Elkton Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and facility environmental rounds, it was determined that the facility failed to 1) provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable homelike environment. This was evident throughout the facility; and 2) protection from loss for a resident's belongings. This was evident for 2 (Resident #3) out of 2 residents reviewed for personal property during the annual survey.The findings include: 1) On 9/28/25 the surveyor observed the following conditions present during the initial tour of the facility: At 9:18AM the surveyor observed an area on the wall which appeared to be missing signage adjacent to the signage for the Northwest 2nd floor sign in the resident hallway which was observed to have letters missing from it. At 9:20AM the surveyor observed white and brown liquids present and pooling on the floor in room [ROOM NUMBER] underneath the window bed and leaking into the door on the bed side of the room along and 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, interviews and review of resident medical records, it was determined that the facility failed to: 1) Ensure that residents received the correct prescribed diet orders and serve the correct diet listed on meal tray tickets; and 2) Ensure resident dietary preferences were honored. This was evident for 6 (#172, #52, #12, #170) residents out of 28 residents reviewed and 2 random observations made during the surveyor's tray line observation as part of the kitchen review and has the potential to affect all residents. The findings include: 1. During observation rounds on 10/08/2025 at 8:15AM resident #172 was found lying in bed with a food tray in front of him/her eating the breakfast that was provided by the facility. The tray was found to have a paper meal ticket with the following printed on it: resident #172 name and room number, current unit number, 10/08/2025, Breakfast, Regular- Diabetic, Thin liquids, 6oz Hot Cereal, 2@ Waffles, 1-each Diet Syrup & Margarine, 2@ Breakfast Sausage Links, Orange Juice Cup – 4oz, Milk 2% - 8oz and Coffee – 8oz. The paper meal…

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

Based on observation, interview, and record review it was determined that the facility failed to ensure the food service department followed the menu and failed to ensure the provided menu met the requirement for the serving size of protein specified for the lunchtime meal. This was evident during a random observation of the serving tray line in the facility's kitchen and during the surveyor's review of the kitchen.Based on observation, interview, and record review it was determined that the facility failed to: 1) ensure the food service department followed the menu and failed to ensure the provided menu met the requirement for the serving size of protein specified for the lunchtime meal and 2) ensure menus and food preferences were followed according to the resident's meal ticket. This was evident for during a random observation of the serving tray line in the facility's kitchen with the potential to affect all residents receiving meals from the kitchen and 2 (Resident #12 and #170) out of 15 residents reviewed for food and nutrition The findings include: 1. During the surveyor's…

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

Based on observation, interview, and record review it was determined the facility failed to ensure safe and appetizing food temperatures. This was evident during the surveyor's review of the kitchen during the facility's recertification survey. The findings include: 1.) On 10/9/25 at 11:56AM the surveyor conducted a review of the written food service temperature log with Regional Dietary Manager (RDM) #55. 10 food items were observed on the steam table which included: 1.) cheese ravioli, 2.) rice, 3.) mixed vegetables, 4.) meat sauce, 5.) cream of rice, 6.) alfredo garlic meat sauce, 7.) plain puree sauce, 8.) pureed meat, 9.) white sauce, 10.) pureed mashed potatoes. Review of the temperature log revealed that only 7 out of 10 hot food items had associated food temperatures recorded and did not identify which specific food items was temperature tested. When the surveyor shared the concern with RDM #55 they stated: I can agree with you on that, yes. When the surveyor inquired as to if it was acceptable food practice to not have food temperatures for all menu items served, RDM #55…

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

Based on observation, interview, and record review it was determined the facility failed to: 1) ensure sanitary practices were followed in accordance with professional standards for food service safety; 2) ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety; 3) ensure food was stored in accordance with professional standards for food service safety; 4) ensure thorough environmental cleaning of the kitchen; 5) ensure food items were labeled and discarded appropriately, 6) ensure the transport of food in accordance with professional standards for food service safety; 7.) ensure the monitoring, oversight, sanitation and maintenance of kitchen 8.) ensure sanitary food prep surfaces were free from personal items. This was evident during observations of the kitchen and has the potential to affect all residents.The findings include:1. On 9/28/25 beginning at 7:43AM the surveyor conducted an initial tour of the facility's kitchen:On 9/28/25 at 7:43AM the surveyor observed the facility's freezer temperature log 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 review of the Facility Assessment and interviews it was determined the facility failed to ensure that all required individuals participate in the Facility Assessment. Additional the facility failed to document, complete and accurately reflect Facility Assessment processes regarding the facility's physical environment, equipment, and other physical plant needs that are necessary to care for its population as well as an evaluation of the facility building maintenance capital improvements, or structures. The findings include the following: During review of the Facility Assessment and interview on 10/08/2025 at 1:00 PM revealed there was no Direct Care Representative involved in completing the Facility assessment dated [DATE]. The Administrator staff #1 and/or staff # 16 were unable to provide or show surveyor that the facility's process to ensure adequate supplies, appropriate maintenance and replacement needs/services by way of plant operational review, established preventative maintenance processes 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 observation, interview and record review it was determined the facility failed to ensure the outside resources utilized for delivery of food and nutrition services to the facility's residents followed professional standards. This was evident for 2 out of 2 contracted companies utilized by the facility for the delivery of food and nutrition services during the facility's recertification survey and has the potential to affect all residents of the facility. The findings include: 1. On 9/30/25 at 3:07PM in response to the surveyor's request for evidence of consultation occurring between the outside contracted dietician services and the outside contracted food and nutrition services which staffed and oversaw the kitchen, Dietary Manager #54 provided the surveyor with the following documentation of correspondence between the two outside contracted companies the facility utilizes for delivery of food and nutrition services for the residents of the facility: a.) Documentation dated 8/12/25 at 2:37PM from RD #13 to DM#54: When was the last time a diet audit was completed? I was able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the dishwashing system was maintained in safe operating condition. This was evident for 1 out of 1 dishwasher present within the facility's kitchen.The findings include:On 9/28/25 at 7:49AM the surveyor observed a large area of pooling water on the floor in the dishwashing area and additionally observed a plastic bucket which was situated under one of the dishwasher's mechanical components which was observed to be catching the dripping of water and was approximately 80% full of cloudy liquid. The surveyor observed an empty plastic jug of sodium hypochlorite chemical attached to the dishwashing machine system which was operating in chemical sanitization mode.On 9/28/25 at 7:49AM the surveyor observed the dish machine's manufacturer guidelines as outlined on the machine's placard which included the following information regarding chemical sanitization: wash tank minimum temperature: 140F and sanitizer required 50ppm available chlorine.On 9/28/25 at 8:02AM the surveyor conducted a dual observation…

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

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 ensure residents' right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This was evident for 7 (Resident #58, #143, #78, #12, #142, #180, #147) residents out of 14 investigated during the the survey.The findings include: 1. On 09/29/2025 at 12:35 PM during observation and interview, Resident #58 shared several concerns: my care plan meetings are at bedside, attended only by the social worker, I receive a care plan report and grievance form, but there are no other staff members to discuss my care or multiple concerns. There is no support for discharge or transfer to return to my home state where I feel I can get access to more community resources. I have missed appointments for over a year due to my lost wheelchair which could fit in the cab for transport, but the current replacement wheelchair is larger and unable to fit in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with residents and staff, it was determined that the facility failed to: 1) maintain all smoking paraphernalia for residents who require supervision with smoking and failed to ensure smoking assessments were reviewed and revised according to the residents' current condition; 2) provide an environment that is free from accident hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents; 3) adequately assess, monitor, and implement facility smoking policy and procedures for residents that smoke. This was evident for 8 (Resident #33, #119, #55, #4, #45, #42, #2, #37) out of 40 residents reviewed for smoking had the potential to affect all residents who smoke. The findings include: 1. On 10/6/2025 at 10:00AM, during an interview with the Director of Nursing (DON) in the presence of the Nursing Home Administrator (NHA) and the Administrator in Training (AIT), the Surveyor was informed that staff can take the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to: 1) ensure secure storage of medications 2) appropriately label and store drugs and biologicals in accordance with currently accepted professional principles (within medication rooms, carts, boxes, refrigerators). This was evident for 2 out of 2 random observations of the facility's second floor supply room, 1 out of 1 shower room on Unit 1, second floor, 1 of 3 medication carts and 1 of 1 Medication refrigerators on Station 2 investigated during the facility's survey.The findings include: 1.) During the surveyor's initial tour of the facility on [DATE] at 8:40 AM the surveyor observed the second-floor biohazard soiled utility room door visibly ajar at which time the surveyor was also able to freely access the 2nd floor supply room. On [DATE] at 8:42 AM the surveyor observed multiple freely accessible boxes and bags of Apomorphine Hydrochloride Injection medication and boxes of needles present within the freely accessible unlocked supply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview with staff, it was determined that the facility failed to ensure a resident receiving a therapeutic mechanically altered diet was given food in the correct consistency based on the physician's order. This was evident for 1 (Resident #100) out of 2 residents observed for accuracy of meal tickets during the revisit survey.The findings include:On 12/18/2025 at 9:00AM, during a tour of the 2nd floor nursing unit, the Surveyor observed Resident #100 sitting in a chair with their breakfast on the bedside table in front of them. During an interview conducted with the resident, the Surveyor was informed that the resident drank some of the supplement shake and was not interested in what was served on their tray. The resident's breakfast tray contained uneaten hot cereal, scrambled eggs, and slice of toast cut in half with margarine. The Surveyor reviewed Resident #100's meal ticket and noted that the tray was to include hot cereal, scrambled eggs (fork mashable), toast (pureed) and jelly and margarine.On 12/18/2025 at 9:18AM, during 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 observations, interviews and record reviews, it was determined that the facility staff failed to implement appropriate infection prevention and control practices. This was evident in observation by surveyors during the environmental tour of the facility including the laundry room, 2 out of 2 hand washing sinks observed by the surveyor on floor 2 of the facility and 5 (#27, #52, #142, and #104, #3) out of 38 residents reviewing during the survey.The findings include:1. On 10/02/2025 at 7:58 AM during medication administration observation of resident #27, LPN staff #21 observed donning and doffing gloves and failing to perform hand hygiene after completing point-of-care testing of fingerstick or administering insulin pen medications. Additionally, staff #21 returned the point-of-care device (glucometer) to the medication cart without cleaning the device. Of note, this was the only glucometer observed in the medication cart.2. On 10/02/2025 at 8:18 AM during medication administration observation of…

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

Based on observation and interview it was determined the facility failed to ensure a safe functional environment. This was evident during 1 out of 1 multi-surveyor observation conducted of the facility's exterior grounds. The findings include: On 9/30/25 at 12:19PM surveyors observed the exterior vent for the laundry room with several inches of grey matter present covering the vent. Overgrown weeds were observed in an area surrounding the facility's generator equipment.On 9/30/25 at 12:20PM surveyors observed from the exterior of the building, an area of ceiling disrepair with peeling paint present extending several feet across the ceiling located within the facility's laundry room.On 9/30/25 at 12:20PM surveyors observed an exterior gutter near the laundry room which was filled with leaves and debris.On 9/30/25 at 12:23PM surveyors observed an area near to the resident dining hall which was observed to have an emergency fire blanket located on the wall with approximately 15 cigarette butts sitting on top of it. At this time surveyors shared the concern with Director of Housekeeping…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with staff and residents, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. This was evident for 2 out of 3 nursing units observed during the annual survey.The findings include: During observation rounds of Unit 1 on 09/28/2025 at 8:55 AM resident #16 room was observed to have 11 black insects flying around near and on resident #16 head, bed and privacy curtain. During an interview on 09/28/2025 at 8:56 AM resident #16 stated, there are flies flying around my head, landing on my food, all over my bed and just everywhere. During an interview on 09/28/2025 at approximately 11:00 AM the Nursing Home Administrator staff #1 was made aware of the observation of insects in resident #16 room. Staff #1 stated that the problem would be addressed. During observation rounds of Unit 1 on 09/30/2025 at 10:00 AM resident #16 room was noted to have 5 black insects flying around near and on resident #16 bed 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, record reviews and interviews, it was determined that the facility failed to ensure reasonable clinical and safety restrictions of the facility's policies, procedures or practices that protect the health and security of all residents and staff by allowing an unvaccinated animal into the controlled environment. This was evident for 1 (#115) resident out of 9 residents investigated during the facility's annual survey.The findings include:On 09/29/2025 at 10:00 AM Surveyors observed a dog in the 1st floor-Dining Room brought in by family; the dog was later identified as belonging to resident #115 and comes for weekly visits.On 09/29/2025 at 10:30 AM during interview with Director of Recreational Therapy staff #10, Surveyor asked about facility Policy & Procedures (P&P) for resident pet visitations on site, pet vaccination records, and front desk check-in process for resident pets. Staff #10 provided the facility P&P and stated that per our policy, all animals, both service animals used for therapy and resident animals are to have vaccination records on file.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 1 (#58) resident out of 9 residents investigated for Advance Directives during the facility's annual survey.The findings include:On [DATE] at 9:03 AM during record review it revealed Resident #58 Code Status:(Advance Directives) as CPR (Full Code) via hyperlink to the document. However, once the hyperlink for Advance Directive was selected, it revealed Resident #58 had two 5 Wishes forms with a DNR preference, dated [DATE] and [DATE] on file. Per the Nursing Home H&P Note signed by Physician staff #52, notes in the 'Advance Directives' section stated The patient has the capacity to make decisions and requests full code including tube feeding, blood transfusion except dialysis. Additionally, there was a history of 5 Maryland Orders for Life Sustaining Treatment (MOLST) forms completed: the most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of medical records, administrative records, interviews, and observations it was determined the facility failed to protect a resident from physical abuse perpetrated by a facility employee. This was evident for 1 (#143) out of 8 residents reviewed for abuse during the recertification survey.The findings include:On 09/28/2025 at 09:30 AM the surveyor observed the Resident #143 in the hallway of the second floor in a wheelchair. The resident denied any remembrance of an employee being physically abusive towards him/her. On 09/28/2025 at 1:00 PM the surveyor reviewed intake #2578157 and the complaint #2578168 related to resident #143. The facility report was directly related to the complaint.On 10/07/25 at 08:15 AM the surveyor continued the review of the resident's hard copy facility incident report. The review revealed that the facility had found the perpetrator (GNA #40) physical abused Resident # 143. The physical abuse consisted of the GNA #40 being observed slapping the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and medical record reviews it was determined that the facility failed to: 1) provide the resident representative with written notification of transfer to the hospital and written notification of the facility's bed hold policy upon transfer to the hospital, and ensure the local Ombudsman was notified timely, on a monthly basis, of a facility-initiated transfer to the hospital; 2) ensure the documentation of the clinical circumstances related to the return of the resident to the hospital as part of the transfer process. This was evident for 3 (Resident #153, #5 and #174) out of 7 residents reviewed for hospitalization during the survey.The findings include: 1. Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 10/1/2025 at 10:38AM, a review of Resident #153's electronic medical record revealed the resident was transferred to the hospital on 9/8/2025 and 9/29/2025. On 10/3/2025 at 10:45AM, a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's status. This was evident for 1 (Resident #5) out of 5 residents investigated for falls during the annual survey.The findings include: The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A comprehensive MDS assessment is completed at admission, annually, quarterly, and with significant change. On 10/2/2025 at 12:05PM, during a review of Resident #5's electronic medical record, the Surveyor discovered that the resident was hospitalized on [DATE] after sustaining a fall with a right femur fracture. The resident received surgical repair and returned to the facility on 8/28/2025. Further review revealed a quarterly MDS assessment completed 9/21/2025. Under Section J-Health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff, it was determined that the facility failed to develop a resident centered activity care plan that addressed the resident's physical, mental, and psychosocial needs with personalized goals with measurable objectives and interventions. This was evident for 1 (Resident #9) out of 4 residents reviewed for activities during the annual survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. Care plans must be person-centered and includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on 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 observations, record reviews and interviews, it was determined that the facility failed to ensure residents right to participate in the development, review and revision of his/her care plan. This was evident for 2 (58 & 14) residents out of 2 residents investigated for care planning. The findings include: On 09/29/2025 at 12:35 PM during observation and interview with Resident #58, resident stated I only have care plan meetings at the bedside with the Social Worker, the most recent was 09/25/25, I receive a copy of my latest care plan and a grievance form and that is it Resident further stated, the Social Worker is unable to answer any of my questions about my medical care and business concerns, I am always told just to fill out a grievance form. The resident shared with Surveyor the copies of the Care Plan related documents they have received from the Social Worker, the items consisted of the Care Plan meeting invitation for 9/25/25-the resident documented on the letter it was received 9/23/25 at 2:56 PM; a Care Plan Report with admission Date: 6/4/25 and Revision Date:…

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

Based on interview and record review it was determined the facility failed to ensure consultations were timely scheduled and wound care was consistently performed. This was evident for 1 (Resident #3) out of 1 resident reviewed for foot care during the facility's recertification survey.The findings include:On 10/1/25 at 9:05AM during an interview with Resident #3 they expressed that dressing changes were not occurring at the frequency they were supposed to occur due to there not being enough nursing staff available to perform the dressing changes and additionally, that their specialist appointments for the care of their foot had not yet been set up by facility staff although staff were expressing to them that they were taking care of the scheduling of the appointments. On 10/3/25 at 9:06AM the surveyor reviewed the medical record of Resident #3 and observed six medical wound care orders having been in place for the care of the resident's foot wounds during September 2025. The surveyor observed the September 2025 Treatment Administration Record which revealed that on the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident medical record review it was determined the facility failed to provide a resident incontinent care and services. This was evident for 1 (Resident #16) out of 11 residents reviewed and observed during the survey. The findings include the following: During observation rounds on 09/28/2025 at 8:55 AM Resident #16 was found sitting in his/her wheelchair near room window wearing a brief that was saturated with urine and stool. Resident #16 bed mattress was observed with no fitted sheet, over 75% of the mattress was saturated with a wet yellow and brown in color substance that had strong odor of urine and stool, was worn and faded, discolored, had lumps, and in poor condition. The flooring around Resident #16's bed and throughout room, was noted to have a thick layer of sticky dark in color spots of dirt accumulation. During an interview on 9/28/2025 at 8:56 AM Resident #16 stated, they came in here and took the sheets off the bed but did not clean the bed. During observation rounds on 09/28/2025 at approximately 10:45 AM Resident #16'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 observations, record reviews and interviews, it was determined that the facility failed to ensure a resident received necessary respiratory care and services that were in accordance with professional standards of practice, the resident's care plan, physician's orders, and the resident's choice. This was evident for 1 (#77) resident out of 9 residents investigated during the facility's survey.The findings include: On 09/28/2025 at 9:22 AM during initial observation, Resident #77 was observed on oxygen(O2) via Nasal Cannula intact with an O2 setting at 1.5L. Per Surveyor interview with LPN Station 2 staff #37 to confirm resident O2 needs, surveyor observe staff #37 review medical orders and stated O2 orders were for 3L.On 09/30/2025 at 9:54 AM during observation and interview, Resident #77 was in bed, restless, O2 tubing laying on the floor, and O2 Concentrator set at 1.5L. This Surveyor notified LPN Station 2 staff #24 of tubing on the floor and Oxygen concentrator set at 1.5L; promptly staff #24 went to Resident #77 bedside, discarded the tubing on the floor and replaced…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This was evident for 3 (#58, #117, and #65) residents out of 9 residents investigated for medically related Social Services. The findings include: 1. On 07/10/2025 Complaint #319266 received to State Agency (OHCQ) regarding multiple concerns related misappropriation of property via misuse of resident personal funds by facility; quality care/treatment and nursing service issues. On 09/29/2025 at 12:35 PM during observation and interview, Resident #58 shared several concerns and stated: my care plan meetings are at bedside, attended only by the social worker, and I receive a care plan report and grievance form; there are no other staff members to discuss my care or multiple concerns. There is no support for discharge or transfer to return to my home state where I feel I can get access to more community resources. I have missed appointments…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview with a resident and staff, it was determined that the facility failed to: 1.) establish a system of records of receipt of controlled drugs 2.) to ensure accurate reconciliation of a controlled medication, 3.) immediately document medication administration of a controlled drug in the accountability record and Medication Administration Record (MAR), and 4.) submit timely requests for a residents controlled drug before it runs out. This was evident for 1 (Resident #39) out of 12 residents review for medications. The findings include:Controlled Drugs (narcotics) are substances that have an accepted medical use, have the potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. 1. On 10/7/2025 at 3:00PM, during a review of the Controlled Substances log book for controlled drugs administered to Resident #39, the Surveyor discovered a controlled medication logs for Diazepam on page 100, 146, and 190; Dilaudid on page 121, 137, 157, 173, and 189; and, Methadone on page 122, 138, 159, and 182;…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure a medication error rate of less than 5 percent for 4 (#27, #52, #170, and #104) residents out of 5 residents observed during 33 medication administration opportunities which resulted in an error rate of 12.12% by 2 of 2 certified medicine LPNs observed during the survey.The findings include: 1. On 10/02/2025 at 8:02 AM during medication administration for resident #27, this Surveyor observed LPN staff #21 dispensed insulin to resident #27 from an unlabeled Insulin Aspart Injection FlexPen, Exp 2027-10-31, Lot RZFSM68. This Surveyor asked about the non-labeled medication; LPN staff #21 replied, 'the label fell off, but this is the only resident on this FlexPen medication'. Surveyor then asked what the facility expectation with this non-labeled medication is; LPN staff #21 replied 'we should have requested another labeled FlexPen from pharmacy for the resident.'2. On 10/02/2025 at 8:27 AM during medication administration for resident #52, this Surveyor observed LPN staff #21 at…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to assist a resident in making transportation arrangements to and from the source of service, when the resident needs assistance. This was evident for 1 (#58) resident out of 1 residents investigated for missed appointments due to transportation services during the facility's survey.The findings include:On 09/29/2025 at 12:35 PM during observation and interview, resident #58 shared I have missed appointments for over a year due to my lost wheelchair which could fit in the cab for transport, but the current replacement wheelchair is larger and unable to fit in with the only cab service that is offered by the facility. I was fitted for a power wheelchair and told I was approved but never received it. When I asked for help from the Social Worker, they just give me a grievance form, but nothing is ever done.On 09/30/2025 at 8:39 AM during interview with Director of Nursing (DON) staff #2, Nursing Home Administrator (NHA) staff #1, and Administrator in Training (AIT) staff #3, this 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.

Based on record review, observation, and interview it was determined the facility failed to ensure staff assigned the supervisory responsibilities for the facility's food and nutrition services was a qualified dietetic service supervisor. This was evident during the surveyor's review of the kitchen during the facility's recertification survey. The findings include:Upon surveyor's initial tour of the facility's kitchen on 9/28/25 at 7:43AM the surveyor conducted an interview with [NAME] #69 who confirmed with the surveyor that Dietary Manager (DM) #54 was the full time supervisor in charge of the kitchen's operations. On 9/30/25 at 2:01 PM the surveyor conducted an interview with Regional Registered Dietitian #12 who stated to the surveyor that they did not provide oversight to the types of diets within the facility and did not provide oversight of the facility's kitchen.On 9/30/25 at 2:12 PM the surveyor conducted an interview of DM #54 who reported that for ten years they have supervised and run the facility's kitchen. During the interview, DM #54 confirmed with the surveyor that…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure each resident received and the facility provides food that accommodates resident allergies, intolerances, and preferences. This was evident for 3 (Resident #58, #117 and #14) residents out of 9 residents reviewed during the survey.The findings include: 1. On 09/28/2025 at 12:39 PM during initial observation and interview, resident #58 was observed in bed with their lunch tray on their lap. Resident #58 stated 'no variety, limited vegetables, too many carbs, and wrong timing'. Surveyor observed the meal ticket; it revealed on the top portion: Regular - Heart Healthy; Thin Liquids. On the mid-portion of the ticket, it revealed: 4oz Baked Pork Chop, 4oz Italian Blend Vegetables, 1@ Dinner Roll, 4oz Diet Ice Cream; Tray Notes:, Instructions and Dislikes: Tomato Products, Tomatoes, Gravy. Surveyor observed the actual tray contents, resident was served the following: approximate 4 inch white meat-like substance, small bowl of green bean-like vegetable, a scoop of mashed potatoes-like…

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

Based on observation, interview and record review it was determined the facility failed to maintain accurate medical records for residents. This was evident for 5 of 38 residents (Resident #109, #3, #4 and #55, #105) reviewed. The findings include: 1.) On 10/3/25 at 2:03PM the surveyor reviewed the medical record of Resident #109 which revealed their care plan sign in sheet listed the resident's family member as being their poa (power of attorney), however, the care conference invitation dated 8/28/25 was observed to be addressed directly to the resident. Review of the resident's face sheet by the surveyor revealed documentation that Resident #109 had a family member listed as their power of attorney and responsible party for their care, medical, and financial decision making. Review of the resident's Maryland Orders for Life Sustaining Treatment form documented the resident had made their own decision as a basis for the orders on 6/23/25. Further review of the resident's power of attorney document by the surveyor revealed the following information regarding the family member listed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, observation of resident rooms, and interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, comfortable interior. This was evident on 2 of 3 nursing units observed during a complaint survey. The findings include: On 6/23/25 at 9:51 AM a review of complaint MD00204546 was conducted. The complaint alleged that the wall behind a resident's bed was falling apart. On 6/23/25 at 7:45 AM a tour was conducted on the second-floor nursing unit. There were ceiling tiles that had brown round stains in the hallways. Outside of room [ROOM NUMBER] there were 5 ceiling tiles with brown stains. From room [ROOM NUMBER] to 260 there were 24 brown stained tiles. By the nurse's stations there were 7 stained tiles. From room [ROOM NUMBER] to the nurse's station there were 38 stained tiles. On 6/25/25 at 12:50 PM observation was made on the second-floor nursing units of the following environmental concerns: room…

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

Based on 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 8 (#11, #41, #19, #34, #17, #4, #9, #26) of 57 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 6/23/25 at 9:55 AM a review of Resident #11's medical record was conducted. Review of the MDS with an assessment reference date (ARD) of 6/11/24, Section K0200 B documented a weight of 70 lbs. Section K0300 Weight Loss 10% or more in last 6 months was documented, no. Review of the vital sign section of the medical record documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaints, medical record review, and interviews, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 5 (#20, #17, #3, #13, #38) of 57 residents reviewed during a complaint survey. The findings include: 1) The facility failed to ensure the resident was transported to the hospital in a safe manner. On 6/26/25 at 2:05 PM a review of complaint MD00208984 alleged that Resident #20 had congestive heart failure and as a result the resident's hands, face, and legs were swollen and painful. It was alleged that the physician wanted the resident to be evaluated by an emergency doctor, however the resident was to go to the hospital as a non-emergency transport. The complaint alleged that the resident was sent to the emergency room in a taxicab and was let out at the front emergency room entrance and had to wait 20 minutes before a security guard assisted the resident into the 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 failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 3 (#40, #34, 17) of 57 residents reviewed during a complaint survey. The findings include: 1) On 6/25/25 at 7:59 AM a review of Resident #40's medical record was conducted. Review of Resident #40's October 2024 Medication Administration Record (MAR) documented the medication Carvedilol Oral Tablet 25 MG (Carvedilol), give 1 tablet by mouth two times a day for hypertension, Hold for HR (heart rate) less than 50. This order was written on 4/4/24. Review of the October 2024 MAR failed to produce documentation that Resident #40's heart rate was monitored prior to the administration of the medication. Review of the vital sign section of the medical record revealed the heart rates were not being consistently taken at 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 flies and gnats seen throughout the facility. This was evident on 2 of 3 nursing units, in resident rooms, the kitchen, the rehab gym, and the conference room during a complaint survey. The findings include: On 6/23/25 at 8:00 AM to 7/2/25 observation was made in the conference room where the surveyors were stationed for the week of flies and gnats consistently flying around the room. Throughout the survey from 6/23/25 to 7/2/25 there were flies and gnats observed in the first-floor hallways and resident rooms. On 6/24/25 at 1:45 PM an interview was conducted with the resident in room [ROOM NUMBER] who stated there have been flies in his/her room for at least a week and that they were annoying. On 6/25/25 at 10:17 AM there was a fly on Resident #12 while lying in bed with the Director of Nursing present. On 6/26/25 at 12:00 PM flies were observed in…

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

Based on observation and staff interview it was determined that facility staff failed to treat each resident in a dignified manner by 1) standing over a resident while feeding the resident, and 2) not placing a urinary catheter bag in a dignity bag. This was evident for 2 (#50, #45) of 57 residents reviewed during a complaint survey. The findings include: 1) On 6/25/25 at 12:25 PM observation was made of Resident #50 sitting in a wheelchair at the end of the hallway on the first-floor nursing unit. Geriatric Nursing Assistant (GNA) #20 was standing in front of Resident #50 feeding the resident his/her lunch. GNA #20 was not sitting next to the resident at eye level while feeding. On 7/2/25 at 1:29 PM the Director of Nursing (DON) was informed of the observation. The DON shook her head. 2) On 6/25/25 at 12:55 PM observation was made from the hallway of Resident #45 lying in bed eating lunch. Resident #45's Foley catheter bag was hanging off the bed frame on the right side of the bed, which was visible from the hallway, as the resident's bed was the closest bed to the door. A Foley…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 representative for a change in condition (Resident #28). This was evident for 1 of 57 residents reviewed during a complaint survey. The findings include: The facility staff failed to notify Resident #28's representative when a new medication was ordered. Review of Resident #28's medical record on 6/23/25 revealed the Resident was admitted to the facility in November 2024 with a diagnosis to include dementia. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Further review of Resident's medical record revealed on 12/18/24 the physician ordered Seroquel 25 mg in the morning for depression and give 2 tablets by mouth at bedtime for depression. Seroquel is an antipsychotic medication used to treat mood conditions. Further review of Resident's medical record revealed no notification to the Resident's representative of the order for Seroquel. Review of Resident #28's December 2024 Medication Administration Record revealed the facility 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 Based on observation and interview, it was determined that facility staff failed to ensure that resident medical records remained private and confidential. This was evident for 1 of 3 nursing units observed during a complaint survey. The findings include: On 6/26/25 at 11:42 AM observation was made of Resident #12's electronic medical record displayed on an opened computer screen that was sitting on top of an unlocked and unattended medication cart on the first-floor nursing unit. The resident's medications were on display and the opportunity to look at additional information was available. The medication cart was sitting in the hallway outside of room [ROOM NUMBER]. On 6/26/25 at 11:44 AM Staff (LPN) #38 walked out of a resident's room and walked up to the medication cart where the surveyor was standing. The surveyor informed Staff #38 of the finding. Staff #38 stated, I made a mistake and left the computer screen open. On 7/2/25 at 1:29 PM the Director of Nursing was informed of the finding.

Based on review of a complaint and interview, it was determined the facility failed to provide the residents with an environment that was free of misappropriation of property. This was evident for 1 (Resident #10) of 57 residents reviewed during a complaint survey. The findings include: On 6/26/25 at 8:00 AM a review of complaint MD00203621 was conducted. The complaint alleged that the facility had either lost or allowed Resident #10's PlayStation 5 to be stolen. The complaint alleged when Resident #10 was transferred to the hospital in December 2023, the facility had packed up the items in his/her room and put the items in storage. Resident #10 alleged that he/she was told everything was locked up in a safe place and now no one knows where the PlayStation was located. On 6/26/25 at 8:17 AM an interview was conducted with Staff #7, the social work director who stated, I heard about it but I'm not sure if a grievance was put in about it. I heard that it was missing, and it was going to be replaced. At that time the surveyor requested a copy of the invoice of when the PlayStation 5…

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

Based on review of a complaint and interview, it was determined the facility failed to report allegations of misappropriation of property to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #10) of 57 residents reviewed during the complaint survey. The findings include: On 6/26/25 at 8:00 AM a review of complaint MD00203621 was conducted. The complaint alleged that the facility had either lost or allowed Resident #10's PlayStation 5 to be stolen. The complaint alleged when Resident #10 was transferred to the hospital in December 2023, the facility had packed up the items in his/her room and put the items in storage. Resident #10 alleged that he/she was told everything was locked up in a safe place and now no one knows where the PlayStation was located. On 7/1/25 at 1:00 PM an interview of Resident #55, Resident #10's roommate, was conducted. Resident #55 stated, the PlayStation was stolen, and [he/she] had to pay for it. [He/she] went through all the channels and the Ombudsman. It has been gone since November. On 7/1/25 at 1:09 AM an…

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

Based on review of a complaint and interview, it was determined the facility failed to conduct a complete investigation for allegations of misappropriation of property and failed to provide an investigation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #10) of 57 residents reviewed during the complaint survey. The findings include: On 6/26/25 at 8:00 AM a review of complaint MD00203621 was conducted. The complaint alleged that the facility had either lost or allowed Resident #10's PlayStation 5 to be stolen. The complaint alleged when Resident #10 was transferred to the hospital in December 2023, the facility had packed up the items in his/her room and put the items in storage. Resident #10 alleged that he/she was told everything was locked up in a safe place and now no one knows where the PlayStation was located. On 7/1/25 at 1:00 PM an interview of Resident #55, Resident #10's roommate, was conducted. Resident #55 stated, the PlayStation was stolen, and [he/she] had to pay for it. [He/she] went through all the channels 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 complaint review, record review, and interview 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 1 (Resident #6) of 57 residents reviewed during a complaint 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. On 6/26/25 at 10:17 AM a review of complaint MD00202545 alleged that Resident #6 was admitted in December 2023 and the RP had requested communication several times and received no return calls. Resident #6's medical record was reviewed and revealed Resident #6 was admitted to the facility in December 2023 with diagnoses that included but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, medical record review and interview, it was determined the facility staff failed to provide needed activities of daily living (ADL) for a resident totally dependent on bathing assistance (Resident #30). This was evident for 1 of 57 residents reviewed during a complaint survey. The findings include: Review of complaint MD00214497 regarding Resident #30's had not received showers on Mondays and Thursdays as scheduled even though the Resident's representative asked the facility staff to give the Resident showers. Review of Resident #30's medical record on 6/26/25 revealed the Resident was admitted to the facility on [DATE] and discharged from the facility on 4/4/25. The Resident diagnosis included hemiplegia and hemiparesis following cerebral infarction. Hemiparesis is a condition characterized by weakness on one side of the body. Further review of Resident #30's medical record revealed the facility staff completed an admission MDS (Minimum Data Set) assessment on 1/28/25 and coded 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, interview and medical record review, the facility staff failed to ensure a resident had glasses (Resident #12). This evident for 1 of 57 residents reviewed during a complaint survey. The findings include: During interview with Resident #12 on 6/25/25 at 10:10 AM, the Resident stated he has been asking staff to get him/her glasses. The Resident stated when he/she went out to the hospital last year and returned his/her glasses have been missing. Observation of the Resident on 6/25/25 at 10:10 AM and 6/30/25 at 8:50 AM the Resident did not have glasses. Review of Resident's medical record revealed the Resident was seen by the eye doctor on 8/16/2024 and the eye doctor documented the Resident had readers assigned. Interview with the Director of Nursing on 6/27/25 confirmed the Resident did not have glasses and the facility staff would assist in getting the Resident glasses.

Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #32). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). Review of Resident #32's medical record on 6/26/25 revealed the Resident was admitted to the facility in October 2022 and had diagnosis to include Stage III…

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

Based on observation, interview and medical record review, the facility staff failed to ensure fall mats were properly in place for a resident with a history of a fall (Resident #38). This was evident for 1 of 4 residents reviewed for falls during a complaint survey. The findings include: Review of Resident #38's medical record on 6/25/25 revealed the Resident was admitted to the facility in March 2025 with a diagnosis to include seizures. Further review of Resident #38's medical record revealed the Resident had a fall on 4/19/25. Review of Resident #38's care plans revealed the Resident had a care plan initiated on 4/20/25 entitled Resident had an actual fall and is at risk for falls with an intervention of fall mats on floor at bedside while in bed. Observation of Resident #38 on 6/25/25 at 11:32 AM revealed the Resident in bed with the fall mat on the Resident's left side of bed was turned and against the wall at the head of the bed and not next to the left side of the Resident's bed. Observation of Resident #38 on 6/25/25 at 1:23 PM with the Unit Manager (Staff #34) present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, it was determined the facility failed to provide the appropriate care and services to prevent urinary tract infections. This was evident for 1 (Resident #45) of 57 residents reviewed during a complaint survey. The findings include: A Foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. On 6/25/25 at 12:55 PM observation was made from the hallway of Resident #45 lying in bed eating lunch. Resident #45 had a Foley catheter that was draining yellow urine. The Foley catheter and the urine was visible from the hallway. Upon entering the room observation was made of the bottom of the catheter bag and the blue tubing touching the floor. On the door there was a sign that stated, enhanced barrier precautions. On 6/25/25 at 1:10 PM a review of Resident #45's medical record revealed a 5/12/25 progress note that documented the resident has had multiple admissions to the hospital and on 4/22/25 was presented to the hospital with fevers, chills and hypoxia. The resident 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, the facility staff failed to assess a resident at risk for malnutrition by the dietitian in a timely manner (Resident #38). This was evident for 1 of 57 residents reviewed during a complaint survey. The findings include: Review of Resident #38's medical record on 6/25/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include malnutrition and gastrostomy. Malnutrition is a serious condition that arises from an imbalance in nutrient intake, either a deficiency or excess, or from impaired nutrient utilization. A gastrostomy is a surgically created opening (stoma) in the abdomen, leading directly into the stomach, used for feeding or administering medications. Further review of the Resident's record revealed the Resident was transferred to the hospital on 4/2/25 and returned to the facility 4/18/25, transferred again on 4/20/25 and returned to the facility on 4/22/25. Further review of the Resident's medical record revealed the Resident…

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

Based on observation, interview and medical record review, the facility staff failed to provide respiratory care to meet the needs of a resident (Resident #12). This was evident for 1 of 57 residents reviewed during a complaint survey. The findings include: Observation of Resident #12 on 6/25/25 at 10:10 AM revealed the Resident in bed with oxygen hooked to a humidified bottle that was empty. Interview with the Resident #12 on 6/25/25 at 10:10 AM at that time stated he/she called to be suctioned about 30 minutes prior and it has not been done. The Resident stated a GNA (geriatric nursing assistant) came in the room but a nurse has not been in to suction the Resident. On 6/25/25 at 10:17 AM the Surveyor brought the Director of Nursing (DON) to the Resident's bedside and the DON confirmed the Resident's humdification bottle was empty. The Resident expressed the need to be suctioned and had been waiting for 30 minutes. The DON at that time advised the Unit Manager (Staff #17) the Resident's request to be suctioned. Staff #17 stated she was doing skin assessments but would return. 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 complaints, medical record review, and interview, it was determined the facility failed to provide timely medications to meet the needs of the residents. This was evident for 1 (Resident #16) of 57 residents reviewed during a complaint survey. The findings include: On 6/24/25 at 10:22 AM a review of complaint MD00210193 alleged that the facility was always running out of Resident #16's pain medication. Review of Resident #16's medical record revealed Resident #16 was admitted to the facility in May 2021 with diagnoses that included systemic sclerosis with polyneuropathy, acquired absence of right and left leg below the knee, phantom limb syndrome with pain, muscle spasms, type 2 diabetes mellitus with diabetic neuropathy and chronic pain. Systemic sclerosis can be associated with peripheral neuropathy, which affects the peripheral nerves. Review of Resident #16's medications revealed the use of Gabapentin 3 times a day, Methadone 3 times a day, hydromorphone (Dilaudid) every 4 hours as needed for pain, and Acetaminophen every 6 hours as needed for pain. On 6/24/25…

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

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 treatment and medication carts locked when unattended, 2) date medication/biologicals when opened and discard medications/biologicals when expired. This was evident on 2 of 3 nursing units observed during a complaint survey. The findings include: 1) On 6/23/25 at 7:50 AM observation was made of an unlocked and unattended treatment cart on the second-floor nursing unit sitting in an alcove. The surveyor opened the top drawer and observed prescription ointments and creams that include: Ketoconazole cream 2% (3) tubes; Todosorb Gel (2) tubes, Betamethasone Dipropionate, Mupirocin ointment (2) tubes belonging to Resident #42, that was dispensed on 9/7/23, Kiclofenac Sodium Gel (1) tube and one Mupirocin ointment tube that had no cap. Licensed Practical Nurse (LPN) #6 was shown the Mupirocin ointments, and she stated if they were dispensed on 9/7/23 they were no good. LPN #6 was informed that the…

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

Based on review of a complaint, medical record review, and interview, it was determined the facility failed to file in the resident's medical record a signed and dated EKG. This was evident for 1 (Resident #34) of 57 residents reviewed during a complaint survey. The findings include: On 6/25/25 at 11:45 AM a review of complaint MD00217108 was conducted and it was alleged that the facility could not obtain an EKG for Resident #34, and the resident had to be sent out to the emergency room for an EKG. An EKG, also known as an ECG, is a test that records the electrical activity of the heart, helping to detect various heart conditions. Review of Resident #34's medical record revealed on 4/25/25 at 11:11 AM a health status note that documented the nurse spoke with the NP (nurse practitioner) regarding increased heart rate and low-grade fever on the previous shift and new orders were received for a stat (immediate) EKG along with a chest x-ray and urinalysis. The note was written by LPN #17. Further review of Resident #34's medical record failed to produce evidence that an EKG was done.…

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

3) The facility failed to obtain a gynecology appointment as requested by the resident. On 6/30/25 at 12:17 PM a review of complaint MD00210037 was conducted. Review of the complaint alleged that the facility failed to arrange and assist Resident #22 to an appointment with the gynecologist. Review of Resident #22's medical record revealed a physician's visit dated 11/22/21 which documented under the diagnosis, assessment and plan, Female perineal bleeding. Suspect vaginal/postmenopausal bleeding from endometrial thickening. Pelvic ultrasound results reviewed. The note documented that the resident would like to follow up with her gynecologist at a specific gynecology clinic. The note concluded, Order to set up appointment with patient's gynecologist placed. Review of physician's orders revealed an order written on 11/22/21 at 10:17 AM that stated to schedule an appointment with the specific name of the gynecology group, along with the phone number for menopausal bleeding, endometrial thickening. Review of the entire medical record failed to produce documentation that the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #12, #35) of 57 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #12's medical record on 6/25/25 revealed the Resident was admitted to the facility in September 2022 with a diagnosis to include Tinea Unguium. Tinea unguium, also known as onychomycosis, is a fungal infection that affects the nails, typically the toenails. It causes the nails to become thickened, discolored, brittle, and may separate from the nail bed. Observation of Resident #12's feet with…

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

Based on documentation review, resident, family, and staff interviews, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 2 of 13 complaints submitted to the Office of Health Care Quality (OHCQ), 2) and 9 of 12 interviewable residents (#316, #26, #61, #5, #58, #366, #417, #64, and #21), and 1 of 3 family interviews (Resident #50's family member) conducted and 5 staff interviews, as well as review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents. The findings include: 1) 2 out of 13 complaints that the Office of Health Care Quality (OHCQ) received and reviewed in this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents who resided there. 1a) A review of complaint MD00194011 on 11/09/23 revealed that an anonymous complaint reported that there was always a low staffing problem on weekends. On 11/08/23 at 2:09 PM, an interview was…

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

Based on Record review and interview with staff it was determined the facility staff failed to have sufficient staff with appropriate training and supervision caring for residents with a history of trauma and/or post-traumatic stress disorder as identified in the facility assessment. This was evident for 1(#21) of 4 residents reviewed for Behavioral-Emotional care. The findings include: Review of the medical record on 11/15/23 at 7:44 AM revealed Resident #21 was admitted to the facility with diagnoses that included but was not limited to PTSD. The facility staff failed to develop and implement person centered care approaches designed to meet individual goals and needs taking into consideration Resident #21's history of trauma. The Director of Nursing (DON) was asked and provided copies of the facility policy(s) and staff training for Trauma Informed Care which were reviewed on 11/15/23 at 2:16 PM. The policy was titled Trauma Informed Care, and indicated it was from the Social Work and Discharge Planning Policies and Procedures Manual. The education included 2 title pages: Social…

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

Based on interviews of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: An initial tour of the facilities kitchen was conducted on 10/30/23 at 9:20 AM. The person in charge of the kitchen (staff #19) at that time was provided with a Nutritional Department Information Request List from the survey team. Copies of the Foodservice Director's credentials and copies of Certified Dietary Managers (CDM) credentials were requested as documented on the request list. As of 11/13/23 the facility did not provide documentation of the CDM's credentials. An interview with the facility's dietary manager (staff #19) was conducted on 11/13/23 at 3:28 PM. The dietary manager revealed that she had been the facility's dietary manger…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and documentation review it was determined that the facility staff failed to: 1) date label and discard expired perishable food products 2) protect food items, dinnerware and cooking utensils from contamination during storage 3) ensure the required sanitation levels of the facility's dishwashing machine, 4) keep vents and ceiling clean and in good repair, and 5) ensure kitchen staff utilized effective hair restraints This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings included. 1). An initial tour of the kitchen was conducted on 10/30/22 at 9:33 AM. In the walk- in freezer the surveyor observed: a cardboard box upside down on the floor. The box was labeled 10 lbs. (pounds) chicken breast and contained 1 blue plastic bag containing several frozen chick breasts. 3 single serving size cups of ice cream were observed on the freezer floor, 1 in front of and under a shelving unit. The walk-in refrigerator revealed: 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 surveyor observation, review of records, and interview with residents and staff it was determined the facility administration failed to employ enough qualified staff, establish systems and implement procedures and protocol to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and failed to maintain documentation related to staff COVID-19 vaccination and failed to ensure an adequate water management plan. This was evident during review of the kitchen and the infection control and antibiotic stewardship programs, five staff (#25, #30, #33, #31, #32) reviewed for immunizations and 2 of 6 residents (#61 and #21) reviewed for Personal Property and has the potential to affect all residents in the facility. The findings include: 1. During the initial observation of the kitchen on [DATE] at 9:33 AM Staff #19 was asked if she was the Dietary Manager of the facility. She indicated no, Staff #79 was. She indicated that she sent him a text and he would be in…

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

Based on observations, review of medical records, facility documentation, and staff interviews, it was determined the facility failed to: 1.) have an effective system in place to ensure infection control precautions were appropriately instituted, maintained, and monitored to prevent potential transmission of infectious disease (Resident #111, #79, #84, #34, #63, #366) and 2.) ensure measures instituted to prevent further spread during a Covid outbreak were being followed by facility staff and monitored (Staff #37, #49, #25, #38 #37, #72, #73, #10) and 3) ensure ice was transported, and stored in a manner that precludes contamination (Staff #65). This was evident during the annual recertification survey and has the potential to impact all residents, staff and visitors. The findings include. 1). Upon surveyor's initial tour on 10/30/23 at 9:24AM an observation was made of one storage bin in the hallway containing personal protective equipment (PPE) located outside of Resident #111's room. The storage bin was observed to contain masks, gloves, and eye shields. The 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 interviews and the review of the facility records and residents' medical records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by the duration of antibiotic use was not accurately completed, and the facility's antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true on 1 (Resident #366) out of 3 residents reviewed for antibiotic use and the facility's antibiotic stewardship program review during the survey. The findings include: 1) On 11/02/23 at 02:00 PM, a review of Resident #366's Medication Administration Record (MAR) for October 2023 revealed that the resident had an order of Azithromycin 500mg for one day for leg wound order date of 10/27/23 and Azithromycin 250mg for leg wounds for six days order date of 10/27/23. Further review of the MAR revealed that Azithromycin 500mg was given on 10/28/23. Azithromycin 250mg was held on 10/28/23, given on 10/29/23, not given on 10/30/23 (documented as Med is not available, as per pharmacist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a review of the facility records, it was determined that the facility failed to designate at least one Infection Preventionist responsible for effectively managing its Infection Prevention and Control Program. This was evident during the Infection Control portion of the recertification survey and impacted the facility's ability to accurately track a current COVID outbreak in the building during the survey and implement, develop, and monitor an antibiotic stewardship program. This deficient practice has the potential to impact all residents in the building. The findings include: During an entrance conference with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 10/30/23 at 09:28 AM, the DON stated that the facility did not have a designated individual as Infection Control Preventionist (ICP) since February 2023. The DON said, Since the vacant ICP position, I have covered it, I do my best so far. Also, she confirmed that the facility did not have a designated assistant for the ICP. On 11/09/23 at 1:35 PM, an interview was conducted with 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 document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents, and failed to maintain documentation related to staff COVID-19 vaccination. This was evident for 3 (Resident #34, #90, and #133) of 5 residents and five staff (#25, #30, #33, #31, #32) reviewed during this survey. The findings include: A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease. 1) On [DATE] at 9:20 AM, during an interview with the Director of Nursing (DON), who also had the role of Infection Control Preventionist (ICP), the DON stated the facility uses the immunization tab under PCC for residents' consent and education for the vaccine. The DON explained that upon residents' admission, she searched their immunization status for COVID-19, with old documentation or Immunet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrative documents, and interviews of residents and staff it was determined that the facility failed to ensure that concerns and suggestions from the resident group were reviewed, and responses provided to the group in writing. This was evident in review of 4 of 4 resident council meeting minutes. The findings include: The president of the resident council was interviewed on 11/2/23 at 12:25 PM to set up a group interview with representatives of the resident council and permission was granted for surveyors to review resident council minutes from recent council meetings. Copies of the previous 4 monthly meetings were obtained and reviewed on 11/6/23. A group interview was conducted with representatives of the resident council on 11/7/23 at 2 PM. The representatives were asked if the facility considered the views of the resident council and acted promptly upon grievance. The answer was an overwhelming no, with one of the resident's stating they don't do anything to show accomplishment. The group proceeded to give comments on two major issues of concern, 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 Based on clinical record review and staff interviews, it was determined that the facility failed to: 1) ensure the resident/responsible party was provided information in a manner easily understood by the resident or resident representative to formulate an advanced directive and offered the opportunity to develop an advanced directive, 2) document/file the resident's advanced directive on their medical record, and 3) failed to inform and document discussions with residents/representatives who did not have an advance directive. This was evident for 4 (Resident #100, #105, #61 and #265) of 6 residents reviewed for Advance Directives. The findings include: A Medical Order for Life Sustaining Treatment (MOLST) form is a medical order form covering options for CPR and other life-sustaining treatments, it is not valid until a physician, nurse practitioner or physician assistant signs and dates it. Per the Maryland Attorney General's office An advance directive speaks for you if you are unable to and helps make sure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and interviews with residents and staff it was determined the facility staff failed to: 1) provide housekeeping and maintenance services necessary to maintain kitchen floors, walls and air vents in a manner to facilitate cleaning, sanitization and prevent harboring of pests and protect dishware 2) exercise reasonable care for the protection of the resident's property by failing to have a system in place to ensure resident's clothing was protected from loss or misplacement for 2 (#61 and #21) of 6 residents reviewed for Personal Property 3) keep the building clean, neat, attractive and in good repair on three nursing units on both floors of the facility, and 4) ensure a sufficient clean linen supply was consistent and readily available for use. The Findings Include: 1) An initial observation of the facility's kitchen was conducted on 9/30/23 at 9:33 AM. The floor of the dry storage room had numerous cracks and chips. 1 floor tile approximately 12 x 12 inches 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 review of resident and facility records and interviews with residents and staff it was determined the facility failed to have an effective process in place to address and ensure prompt resolution of resident grievances by failing to have a Grievance Official who was responsible for overseeing the grievance process. This was evident for 2 (#61 and #21) of 6 residents reviewed for Personal Property. The findings include: Resident #61 was interviewed on 10/31/23 at 10:31 AM. When asked, the resident identified concerns related to staff not answering call bells timely, staff sleeping and missing laundry. He/she indicated that he/she complained to the Administrator, the laundry personnel and during resident council meetings. In an interview on 11/2/23 at 9:35 AM Resident #21 reported his/her brand-new coat went missing in February, he/she bought another in March, and it also went missing. When asked if it was reported, he/she indicated that he/she reported to Staff #64 the Laundry Director and the Administrator, but nothing was done. On 11/2/23 at approximately 1:00 PM, 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 facility staff it was determined the facility staff failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for 2 reports (MD00193602 and MD00193445) of 12 facility reported incidents investigated, and 2 (Resident #111, #11) of 11 residents reviewed for Abuse. The findings include: 1). On 11/15/23 at 11:24 AM a review of the Facility Reported Incident MD00193602 was conducted. The facility report stated that on 6/15/23 Resident #109 was in his/her wheelchair and Resident #10 was in his/her wheelchair being pushed by another resident and was pushed into Resident #109. Resident #109 reached out and hit Resident #10. A review of the facility's investigation file revealed 2 statements. One statement, written by the DON, described the incident but did not include a date or time that the statement was created. A second staff statement by Staff #9 lacked the date and time it was written and the writer's credentials. There were no other witness statements in the investigation file. On 11/15/23 at…

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

Based on medical record review and staff interview it was determined the facility staff failed to have a process to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Resident #221,#127, #157, #267) of 5 residents reviewed for hospitalization. The findings include: On 11/06/23 at 2:38 PM during an interview with the nursing home administrator (NHA) and a group of surveyors, the NHA was a asked how are resident's informed in writing of a facility initiated transfer. He indicated that he was not aware of any documentation of how the facility notifies residents or residents' responsible party when there is a facility-initiated transfer. 1) Review of resident #221's medical record on 11/15/23 revealed resident #221 had an unplanned transfer to a hospital on 9/12/23 at 8:00 PM. Review of the einteract transfer form V5 date on 9/12/2023 written by a LPN/supervisor (staff #24) revealed that resident #221's representative was notified via the telephone of the residents transfer to the…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 5 (#221, #127, #157, #26, #267) of 5 residents reviewed for hospitalization during the recertification/complaint survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) Review of resident #221's medical record on 11/15/23 revealed resident #221 had an unplanned transfer to a hospital on 9/12/23 at 8:00 PM. Review of the medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party was notified in writing of the bed-hold policy. During an interview with the Director of Nursing (DON) on 11/15/23 at 3:26 PM she verified the notice of bed-hold was not provided to the resident. 2) Review of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 8 (Resident #154, #157, #10, #100, #58, #367, #108, #21 ) of 69 residents reviewed during the 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. 1) On 10/31/2023 at 11:49 AM, the surveyor observed Resident #154 lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the right side of the resident's bed. The resident was on oxygen at 2 liters via nasal cannula that was connected to the concentrator. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. A review of resident #154's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for a resident and have care plan meetings with residents and/or resident's representatives. This was evident for 6 (#127, #10, #100, #26, #64, #6) of 69 residents reviewed during a recertification/complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The Minimum Data Set (MDS) is a federally mandated process for clinical assessment of residents in Medicare and Medicaid certified nursing homes. 1). On 11/01/2023 at 12:01 PM, Resident #127 was observed lying in bed, awake, alert, and oriented to person, place, time, 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, interview with residents and staff and medical record reviews, it was determined the facility staff failed to administer medications to the residents in accordance with professional standards of practice by 1) failing to observe that medications were safely taken when administered (Resident #21), 2) follow a medical order and implement an intervention (Resident #108), 3) failed to follow a plan of care for transfer (Resident #50) and ensure residents received care and treatment (Resident #90). This was evident for 4 of 69 residents (#21, #108, #50, #90) during the facility's recertification survey. The findings include: 1). On 11/9/23 at 8:24 AM Resident #21 was observed in his/her room. 2 medication cups containing multiple capsules and tablets were stacked together on the residents overbed table. The resident was asked when the medications were provided. He/She stated, this morning. Staff #49 a Registered Nurse (RN) was in the hallway within a few feet of Resident #21's doorway. She confirmed that she was Resident #21's nurse and was asked to accompany 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 3). Resident #5 was observed on 10/30/23 at 12:51 PM. He/she was receiving oxygen via a nasal cannula (tubing to the nose) from an oxygen concentrator (a machine that concentrates oxygen from the room air) at 3L/min (liters per minute). A humidification bottle connected to the nasal cannula tubing was hand dated 10/28/23. Handwritten numbers 10/(??)/23 were observed written in black marker directly on the cannula tubing. However, the date was illegible. Resident #5 stated sometimes the water runs out and it takes a while to get a refill. Review of Resident #5's medical record on 11/8/23 at 11:40 AM revealed a physician order for oxygen at 3L/min via nasal cannula. Additional physician orders were written on 4/22/21 for: Oxygen Equipment Change Tubing/Nasal Cannula/Mask/Humidifier Bottle and clean filter weekly (when in use) every night shift every Sat. and CHECK AND CHANGE OXYGEN TUBING WEEKLY AND PRN (as needed) every night shift every Sat for PER PROTOCAL DATE THE OXYGEN TUBING AND as needed DATE THE OXYGEN…

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

Based on a review of employee files and interviews, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistant's (GNAs) were competent with their skill sets. This was found to be evident for 3 (#58, #70, and #71) out of 4 GNA employee files reviewed for competencies and skill sets. The findings include: On 11/13/23 at 10:00 AM, GNA employee files were reviewed for GNA #58, #70, and #71. The review of employee files did not reveal documentation that indicated the GNAs had completed their competency skills and techniques to provide care to the residents safely. GNA #70 was hired in August 2017, GNA #71 was hired in October 2021, and agency GNA #58 had been contracted since June 2023. However, none of them had documentation for competencies. During an interview with the Director of Nursing (DON) on 11/14/23 at 9:12 AM, the surveyor requested additional documentation GNA's competencies. The DON said, Since GNA #58's company was one of the agencies whose contract ended by 12/11/23, the company refused to send documentation. We will request…

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

Based on medical record review and interviews with residents and staff it was determined the facility failed to assure that sufficient and appropriate social services were provided to meet the residents needs. This was evident during review of 2 (#61 and #265) of 6 residents for Advance Directives and 1 (#21) of 4 residents reviewed for Behavioral-Emotional care. The findings include: Review of Resident #265's medical record on 10/31/23 at 12:19 PM revealed the resident was admitted to the facility 6/11/20. A Social Service Progress note dated 9/28/20 17:52 indicated Resident #265 had no Advance Directives in place. No documentation was found in the record to indicate that the facility staff informed the resident of his/her right to formulate an Advance Directive, provided education and offered Resident #265 assistance to execute one or more directives. The last line of a Social Service Discharge Planning Note dated 10/23/23 8:53 AM asked Does the patient have an Advanced Directive and indicated Yes however, no Advance Directives were found in Resident #265's medical record.…

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

Based on the review of the resident medical records and interview with facility staff, it was determined that the facility failed to: 1) ensure opioids removed from the resident's supply were administered to the resident, 2) provide medication to meet the needs of the residents timely, and 3) ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed for reconciliation of dispensed and administered medication. This was evident for 4 (Resident #66, #90, #143, and #366) out of 4 residents reviewed for administration of narcotic medication, and 4 (Resident #61, #84, #87, #100) out of 5 residents reviewed for medication administration during the survey. The findings include: Oxycodone hydrochloride is part of a group of drugs known as opioids. Opioids include any drug that acts on opioid receptors in the brain and any natural or synthetic drugs that are derived from or related to the opium poppy. Tramadol is a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines. Tramadol 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.

Based on record review and interviews it was determined that the facility failed to have a system to ensure that monthly Medication Regimen Reviews were completed for facility residents. This was evident for 3 residents (Resident #10, #66, and #90) of 6 residents reviewed for unnecessary medications during the survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review (DRR), is a thorough 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 a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. On 11/06/23 at 12:34 PM the Director of Nursing (DON) provided a list titled No Recommendations Pharmacy Med Reviews for August, September, and October 2023. The surveyor asked the DON if there were any residents for whom the pharmacy had recommendations and she returned with multiple documents of recommendations for individual…

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

Based on observation, interview with facility staff, and review of facility policies, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 4 of 31 medications administered during the observation resulting in a medication error rate of 12.9% for the survey. The findings include: On 11/01/23 at 8:30 AM an observation of Certified Medicine Aide (CMA #27)'s administration of medications was conducted. CMA#27 entered Resident #75's room without performing hand hygiene. CMA#27 was observed on 11/01/23 at 8:40 AM to enter Resident #12's room, take the resident's blood pressure, then return to the medication cart, and access the drawers without performing hand hygiene. In an observation on 11/01/23 at 8:50 AM, CMA#27 went into resident #28's room, gave medications, then returned to the medication cart, opened it, and placed a medication bottle back in the drawer without performing hand hygiene. On 11/07/23 at 4:20 PM, Licensed Practical Nurse (LPN#28) was observed as she walked from…

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

Based on observation, staff interview, and record review it was determined that facility staff failed to 1) properly label medications, 2) remove expired medications and date medication and biologicals when opened, and 3) monitor medication room refrigerator temperatures. This was evident on 3 of 3 nursing units observed during medication storage reviews. The findings include: 1. On 11/07/23 at 4:20 PM during an observation of medication administration to Resident #103 by Licensed Practical Nurse (LPN #28), the surveyor observed that the injector pen of medication lacked the resident's name or a medication label. On 11/7/23 at 4:31 PM, a review of Resident #103's medication orders revealed an order for Apomorphine 30mg/3ml, inject 0.5ml subcutaneously five times a day. This was the only injectable medication ordered for the resident. On 11/07/23 at 5:08 PM an interview with the Director of Nursing (DON), she stated she was not familiar with the medication Apomorphine. When she was informed that the medication was unlabeled, she said that all medications should be labeled and that…

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

Based on resident interviews, and observations of the kitchen services, it was determined that the facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature. Food complaints and concerns were identified for 4 (#48, #139, #61, #316) of 32 residents selected in the final sample. The findings include: Upon initiation of the survey on 10/30/2023 random food complaints from residents included: Resident #48 at 1:14 PM was asked about the food and s/he responded, the food is always cold, I mean ice cold. Resident #48 showed surveyor pictures on his/her phone of grilled cheese sandwich with cheese not melted. Resident #48 added that there was so much cheese on a chicken cheese steak that s/he was unable to eat it because it was served dripping off the plate onto the tray. Resident #48 further showed the surveyor pictures of uncooked chicken and chicken with feathers on it that had been served to them. The resident added that they were served ham that was barely cooked, and coffee that had coffee ground in it: They cannot make a decent cup 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 interview of facility staff it was determined the facility failed to: 1) ensure accuracy of medication side effect monitoring documentation (Resident #108, #32); 2) ensure accurate documentation of an indication of a medication (Resident #32), and 3) maintain complete and accurate medical records in accordance with accepted professional standards (Resident #316, #127, #100). This was evident during a review of unnecessary medications during the facility's recertification survey. The findings include: 1.) On 11/2/23 at 10:56AM the surveyor conducted a review of the medical record for Resident #108 which revealed documentation on the treatment administration record (TAR) for anticoagulant medication side effect monitoring for the month of October 2023. Further review of the October 2023 TAR indicated that on every shift, staff should document the following information: yes if they monitored the resident for side effects and no side effects were observed, or no if they monitored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to document/restore residents' Influenza and Pneumococcal vaccination status, including their education regarding benefits and risk factors for the vaccines, in their medical records. This was evident for 4 (#34, #105, #133, and #366) out of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: The 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 flu, but it is more…

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

Based on observation, staff interview and record reviews, it was determined the facility failed to: keep the tray line plate warmers in operating condition, and failed to ensure a process was in place to address preventative maintenance of Hoyer lift equipment and scales. This was evident during observation of the kitchen and nursing units during the recertification survey and the ability to impact residents receiving food with missing plate bottom insulators and residents who are weighed with facility hoyer lift scales. The findings include: 1. 11/13/23 at 12:15 during tray line lunch observation it was discovered that the plate warmer was not operating as it was only utilized to hold the plates. The power cord to the machine was cut off exposing a approximately 1 inch of the power cord left attached to the plate warmer cart. The dietary manager acknowledged the plate warmer was not in operation she indicated that the metal pellets are utilized. On 11/17/23 at 12:25 PM while observing the tray line the facility ran out of plate bottom insulators. The surveyor asked how many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and facility staff and surveyor observation it was determined the facility failed to ensure all residents were treated with respect and dignity. This was evident for 1 (#61) of 3 residents reviewed for dignity. The findings include: During an interview on 10/31/23 at 10:31 AM Resident #61 was asked if staff treated him/her with respect and dignity. He/she indicated that staff sometimes wore earbuds or headsets and talked to other people on their phones during resident care. He/she indicated that their concerns were reported to the Administrator and at a resident council meeting. Another resident, #139, indicated during an interview on 10/31/23 at 10:33 AM that some of the Aides at night are talking on their phone while providing care. In an interview on 11/9/23 at 9:18 AM the Administrator was asked if staff were permitted to use phones while working. He indicated that they should not have them however, Managers were required to have them as part of their responsibilities. He indicated that he was not aware of any concerns. An interview 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 review of facility records and interviews with facility staff it was determined the facility staff failed to ensure that all allegations of abuse were reported immediately. This was evident for 1 (#11) of 11 residents reviewed for Abuse and 1 report (MD00193445) of 12 facility reported incidents investigated during the annual survey. The findings include: Incidents of injuries of unknown origin and allegations of abuse are required to be reported to State Authorities within 2 hours of serious bodily harm, and within 24 hours for all others. 1a). Review of Facility Reported Incident MD00195150 revealed that on 8/3/23 Resident #11 reported that he/she had been slapped by a staff member on 7/27/23 and 7/30/23. Review of the facility's investigative documentation on 11/20/23 at 10:47 AM revealed a written statement dated and signed on 8/3/23 by Staff #40 a Geriatric Nursing Assistant (GNA). Staff #40 indicated that on 7/26/23 she closed the privacy curtain prior to providing care for resident #11's roommate, that Resident #11 pulled the curtain open, and she closed it again.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document the basis for resident transfer in the medical record, and failed to ensure appropriate information was communicated to the receiving acute care facility to ensure a safe and effective transition of resident care. This was evident for 1 (#267) of 5 residents reviewed for hospitalization during the annual survey. The findings include: Resident #267's medical record was reviewed on 11/15/23 at 6:30 PM and revealed the resident was admitted to the facility on [DATE]. A Hospital Transfer form indicated: completed and reviewed by Staff #24 a Licensed Practical Nurse (LPN) was dated 9/14/23 17:15 (5:15 PM). The form indicated that the resident was transferred to an acute care hospital on 9/14/23 at 18:20 (6:20PM), the section labeled Key Clinical Information included: Reason(s) for transfer Other: A lot secretion/wheezing and included the residents vital signs. The section titled Resident Representative:…

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

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#221, #267) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) Review of resident #221's medical record on 11/15/23 revealed resident #221 had an unplanned transfer to a hospital on 9/12/23 at 8:00 PM. Review of the einteract transfer form V5 date on 9/12/2023 written by a LPN/supervisor (staff #24) did not reveal that resident #221 was informed of the facility-initiated transfer and what was done to prepare the resident for transfer to the hospital. Upon review of an einteract change in condition evaluation V5 and an eINTERACT SBAR Summary for Providers both written by the director of nursing on 9/17/23 for the effective date of transfer 9/12/23 did not reveal documentation related to the resident receiving sufficient preparation and orientation related to the facility-initiated transfer to the hospital. The director of nursing…

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

Based on interviews and medical record reviews, it was determined the facility staff failed to ensure that a resident received care consistent with professional standards of practice to promote the healing of a Pressure Ulcer (PU). This was evident for 1 (Resident #26) of 4 residents reviewed for pressure ulcers during a recertification survey. The findings include: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. On 10/31/23 at 10:15 AM Resident #26 told the surveyor that s/he had a Stage 4 PU and multiple wounds all over their body. The resident also stated that nurses change the wound dressings on days the wound care team were not in the facility. On 11/06/23 at 10:21 AM a review of the quarterly Minimum Data Set (MDS), a comprehensive assessment tool with an Assessment Reference Date (ARD) of 8/5/23 (Date an assessment was due to be completed) documented the presence of multiple pressure ulcer/Injuries, including unhealed pressure ulcers in various stages. A review on 11/06/23 at 11:00 AM 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 review and interview of facility staff it was determined the facility failed to ensure a resident received assistance to maintain their mobility and range of motion. This was evident for 1 (Resident #108) out of 6 residents reviewed for mobility. The findings include: On 11/13/23 at 11:50 AM the surveyor reviewed the medical record of Resident #108 which revealed their current care plan included the following interventions: 1.) get resident out of bed every other day and document, 2.) Hoyer lift (lift equipment utilized to assist with transfer of a resident) for all transfers x2 staff, and 3.) provide assistance with bed mobility, transfers, toileting, and ambulation. Upon further record review, it was revealed that physical therapy had last revised the goal and intervention of getting the resident out of bed every other day on 7/28/23 and the target date for review of the goal was 11/20/23. On 11/13/23 at 1:18PM, the surveyor conducted an interview with Staff #15, Physical Therapist, Director of…

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

Based on observation, interviews, and record reviews, it was determined that the facility failed to provide appropriate care and sufficient services based on the current standard of care for a resident with an indwelling catheter. This was evident for 1 (Resident #26) of 4 residents reviewed for Urinary catheter/Urinary Tract Infection (UTI) during the recertification survey. The findings include: On 10/31/23 at 9:56 AM Resident #26 was observed with a foley catheter, a device that drains urine from the bladder. This was connected to a urinary drainage bag hanging on the lower bed frame. The drainage bag was more than ¾ full. The resident was asked how often staff empty the urinary drainage bag and he stated, every shift. At that time, Staff #44 a License Practical Nurse (LPN) came into the resident's room to medicate the resident. She was shown the Urinary drainage bag that was more than ¾ full of urine and asked who was responsible for emptying it and how often the bags were being emptied. She said that both the nurses and the Geriatric Nursing Assistants (GNA) have the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview of facility staff it was determined the facility failed to have a system to monitor residents' baseline body weight and respond to changes in residents' weights when their weight loss/gain was identified. This was evident for 2 (Resident #108, #6) of 9 residents reviewed for nutrition during the facility's recertification survey. The findings include: 1). On 11/14/23 at 1:51PM, the surveyor reviewed the medical record of Resident #108 which revealed a list of weights obtained for Resident #108, which greatly varied on multiple occasions. Review of the facility's policy for weight monitoring and tracking revealed the following procedures: 1.) all patients will be weighed on admission/readmission and weekly x 4 weeks, or until the interdisciplinary team determines the weight is stable, then monthly thereafter if weight is stable, 2.) weights will be verified within 5 days when a weight variance of 5lbs from last weight and/or when a significant change is identified, 3.) weight…

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

Based on observations, records review, and interviews, it was determined that the facility staff failed to provide care for residents' PEG tube (Percutaneous Endoscopic Gastrostomy) and failed to evaluate for possible continuation or discontinuation of the PEG tube. This was evident for 1 (Resident #6) of 3 residents reviewed for tube feeding during the survey. The findings include: Percutaneous Endoscopic Gastrostomy is: an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. During an interview with Resident #6 on 10/30/23 at 10:32 AM, the resident stated that he/she had a PEG tube for the medication. Also, the resident showed the insertion site of the PEG tube to the surveyor. The surveyor observed that the tube was dark black and that a dressing around the PEG tube insertion site had a dark brown stain on it. In an interview with a Licensed Practical Nurse (LPN #2) on 11/03/23 at 12:28 PM, she stated that residents' PEG tube flushing should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and records reviews, it was determined that the facility staff failed to ensure the resident's pain medication was administered when the resident requested for it. This was evident for 1 (Resident #366) of 5 residents reviewed for pain management during the survey. The findings include: Tramadol is a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines. Tramadol is a synthetic opioid and acts in the brain and spine (central nervous system) to reduce the amount of pain. During an interview with Resident #366 on 10/30/23 at 12:28 PM, the resident reported that she/he had pain in their leg and requested Tramadol several times, but not given for the weekends. Resident #366 also stated that the facility staff informed the resident that they could not give that medication since the physician did not sign the prescription. On 11/02/23 at 2:36 PM, a review of Resident #366 ' s medical record revealed that the resident was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff failed to provide culturally competent, trauma-informed care in order to eliminate or mitigate triggers that may cause re-traumatization for a resident with Post Traumatic Stress Disorder (PTSD). This was evident for 1(#21) of 4 residents reviewed for Behavioral-Emotional care. The findings include: An interview was conducted with Resident #21 on 11/1/23 at 9:31 AM. When asked, the resident confirmed he/she had a history of trauma and PTSD and when asked, expressed that he/she did not feel the facility staff took his/her trauma into account when providing care and services. The resident indicated that he/she was not currently receiving psychiatric/psychological services. Review of the medical record on 11/15/23 at 7:44 AM revealed Resident #21 was admitted to the facility in 2017. His/her diagnoses at the time of admission included PTSD. Additional diagnoses which included but were not limited to Psychotic Disorder with Hallucinations,…

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

Based on review of the medical record and resident interview it was determine the facility staff failed to ensure correct use of bed rails by failing to properly assess the resident and bed for risk of entrapment and proper instillation, obtain the resident's informed consent and ensure a physician's order was in place prior to installation and use of bed rails. This was evident for 1 (#265) of 1 residents reviewed for Physical Restraints. The findings include: On 10/31/23 at 11:59 AM Resident #265 was observed lying in bed. ¼ bedrails were attached to the bed and in the up position. As the surveyor inspected the rails, Resident #265 stated I feel like I'm in a cage. When asked if he/she wanted the rails on the bed he/she stated, I think I requested to have them removed but it wasn't done. Resident #265's medical record was reviewed on 11/2/23 at 2:35 PM. The resident was certified as capable of making informed decisions regarding medical care and was documented as their own responsible party for financial and medical decision making. Further review of the record revealed a Plan of…

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

Based on record review, staff interview, and observation, it was determined that the facility failed to ensure a physician-supervised resident's care, as evidenced by the physician's failure to review a resident's weight loss. This was evident for 2 (#6 and #98) of 9 residents reviewed for nutrition during the survey. The findings include: 1) A review of medical records for Resident #98 on 11/02/23 at 11:08 AM revealed that the resident's body weights were documented 150.1 lb. (pound) on 9/16/23, 130. 2 lb. on 10/8/23, and 126 lb. on 10/25/23. Further review of the progress note revealed that Staff #21 (Dietitian) documented Resident #98's unplanned weight change on 10/25/23. The progress note showed a detailed plan for the resident and said, Nursing notified to inform MD of weight loss. During an interview with a Licensed Practical Nurse (LPN #3) on 11/02/23 at 2:58 PM, he explained that if nursing staff noted residents' weight loss, they reported it to the dietitian and physician. A dietitian would address interventions, and a physician would put the orders under PCC (electronic…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure the service of a charge nurse who was responsible for supervision, emergency coordination, physician liaison, and direct resident care for each unit. This was evident for one unit (unit 3: capacity of 60 beds ) out of three units that had no unit manager (same role as charge nurse). The finding includes: On 10/31/23 at 11:17 AM, observation of unit 3's staffing board indicated that the unit did not have a listed unit manager and the supervisor was [Director of Nursing's name]. During an interview with a Licensed Practical Nurse (LPN #2) on 11/01/23 at 11:34 AM, she confirmed that unit 3 did not have a unit manager. In an interview with the Director of Nursing (DON) on 11/15/23 at 9:30 AM, the surveyor asked if the facility had any licensed nurses with specific responsibilities designated by the facility for unit 3. The DON said, Since the position was vacant, the unit used my name as unit manager. The DON also asked how she could cover the roles of the DON, Infection Control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of Geriatric Nursing Assistant (GNA) personnel files and staff interviews, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 2 out of 2 personnel files reviewed during the annual survey. The findings include: A review of GNA personnel files was conducted on 11/14/23 at 08:00 AM and revealed GNA #70 was hired in August 2021 and GNA #71 was hired in October 2021. On 11/14/23 at 09:12 AM, an interview was conducted with the Director of Nursing (DON). The DON stated, We should do performance review yearly, we tried to do. I have not seen any evidence of yearly evaluations. Also, the DON confirmed that the facility had no designated person for the education. She said, We (HR, QAPI person, and me) worked together to educate staff. During an interview with the DON on 11/20/23 at 10:30 AM, the surveyor shared concerns about the facility's nurse aide performance review.

Based on record review and interviews it was determined that the facility failed to ensure coordination of care for residents receiving hospice care in the facility. This was evident for 1 (Resident #10) of 1 residents reviewed for hospice care. The findings include: A review of Resident #10's medical record in 11/06/23 at 8:17 PM revealed that the resident began receiving hospice services at the facility on 8/14/23. Scanned documentation in the medical record revealed hospice documentation that included the hospice plan of care, hospice staff visit frequencies, and hospice team meeting notes. Further record review revealed no clinical documentation in the resident's medical record by facility staff regarding any hospice care, services, or collaboration between facility and hospice staff. On 11/07/23 at 12:48 PM an interview with the Director of Nursing (DON) was conducted. When asked where facility staff documented Resident #10's collaboration between hospice and facility staff, the DON said she didn't find any, and added that the collaboration was usually just verbal. When asked…

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

Based on facility staff interviews and medical record reviews, it was determined that the facility failed to Include in its policies and procedures how it obtains and uses feedbacks from residents, resident representatives, and staff to identify problem prone issues as well as opportunities for improvement. This was evident during a review of the facilities Quality Assurance/Performance Improvement (QAPI) policies and procedure documents during a recertification survey. The findings include: On 11/20/23 at 12:00 PM, the facility was asked for a copy of their QAPI policies and procedure document. A review of this document revealed that some components related to how the facility obtain and use feedbacks were not included in the document. The Director of Nursing (DON) was asked to provide any missing section. Staff #47 the QAPI coordinator in an interview on 11/20/23 at 1:40 PM was asked how the QAPI committee obtain feedback from residents, their representatives, and the facility staff. She stated that feedbacks are obtained from resident council meetings minutes and that staff or…

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

Based on the interview and documentation review, it was determined the facility failed to ensure that a training program was in place and provided to their staff related to abuse, neglect, exploitation, and misappropriation of resident property along with dementia management and resident abuse prevention. This was evident for 5 (#2, #47, #58, #70, #71) out of 7 employees' training records reviewed during the annual survey. The findings include: 1). The surveyor requested randomly selected employees training records and reviewed them on 11/13/23 at 11:20 AM. The training record review revealed that Staff #70 was hired in August 2017 as a Geriatric Nurse Assistant (GNA). The staff had records for the abuse training completed in September 2021 and October 2023 and yearly dementia training from 2020 to 2023. However, there was no additional training documentation for the staff. A review of training records for Staff #2 revealed that the staff was an agency Licensed Practical Nurse (LPN) hired in December 2021. Staff #2's Relias training record (an online training program 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.

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 2 (#217, #219) of 49 residents reviewed investigated during the annual survey. The findings include: 1. Resident #217 was admitted to the facility on [DATE]. Resident #217's closed medical record was initially reviewed on 11/6/22 in relation to complaint MD00194007. A review of the resident's attending physician (staff #17) documentation revealed a Progress Note with a date of service (DOS) as 4/5/23 that was electronically signed over one month later on 5/8/23 and uploaded to the electronic medical record on 5/9/23. Review of another note written by the resident's attending physician indicated that the resident was seen/visited by the same attending physician on 4/27/23, signed on 5/8/23, and uploaded to the electronic health record on 5/9/23. 2. Resident #219 was admitted to the facility on [DATE]. Resident #219's closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical record and interview with facility staff, it was determined that the facility failed to: 1) ensure that the multidisciplinary team met upon a resident's admission and at least quarterly thereafter to create and revise residents' care plans; 2) invite residents and their family members to participate in those meetings; 3) update a resident's skin care plan based on instructions from a wound care physician; 4) update a resident's respiratory care plan after they no longer required droplet isolation; and, 5) update a resident's fall care plan once interventions are no longer being used. This was evident for 5 (Residents #82, #90, #309, #215, and #94) of 63 residents reviewed during the survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and interview with facility staff, it was determined the facility staff failed to: 1) provide Resident #78 with any liquids at lunch and failed to initiate an antibiotic in a timely manner, 2) extend the administration date to receive medication for 7 days as ordered by the physician for Resident #94, 3) administer medications as ordered by the physicians for Residents #57, #89 and #259, 4) administer medication within a reasonable period of time from when the medication was ordered for Resident #309, and 5) to document the rationale for administering as-needed pain medication for Resident #315. This was evident for 7 Residents (57, 78, 89, 94, 259, 309, and 315) of 63 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to provide Resident #78 with any liquids at lunch. Surveyor observation of Resident #78's lunch on 8/13/21 at 11:50 AM revealed the facility staff served the resident lunch. It was noted 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 2) Review of Resident #123's medical record on 08/12/21 revealed that Resident #123 had his/her medications reviewed by the facility pharmacy consultant on 08/08/21, 07/07/21 and 06/10/21. The recommendations that were addressed by the pharmacy consultant were not in Resident #123's electronic medical record for review. Resident #123 currently receives the antipsychotic medication Haldol orally for nausea and vomiting every 6 hours. In an interview with the facility pharmacy consultant on 08/12/21 at 11:51 AM, the pharmacy consultant stated that he/she works for a totally separate pharmacy then the facility pharmacy that delivers medications to the facility. The pharmacy consultant stated that the documentation program she/he uses to chart on each resident is incompatible with the facility electronic medical record. The pharmacy consultant also stated that she/he has to send all of the facility resident pharmacy reviews and recommendations to the facility Director of Nursing (DON) by email. The pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, surveyor observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order for 1 of 3 nursing units and 1 other resident room. This was evident for 58 of 160 resident call lights reviewed during an annual recertification survey. The findings include: Review of complaint MD00164058 revealed an allegation that the facility staff can take up to 1.5 hours to answer a resident's call for assistance. During an observation of the facility locked dementia care unit, Unit 3, on 08/03/21 at 11:45 AM, the surveyor observed that none of the resident activated call lights were not enunciating at the Unit 3 nurses' station. In an interview with staff member #31 on 08/03/21 at 11:45 AM, staff member #31 stated that he/she has been working on Unit 3 since February 2021 and stated that the Unit 3 call bell system has not enunciated and functioned properly since then. In a second interview with the Unit 3-Unit Manager on 08/03/21 at 11:45…

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 observation and staff interview, it was determined that the facility staff failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. This was evident during a random observation on the facility dementia care unit. The findings include: During an observation of the facility dementia care unit on 08/13/21 at 11:44 AM, the nurse surveyor observed staff member #51 pulling Resident #91 down the hall backwards. Resident #91 was positioned in a Geri chair (medical clinical style recliner). Staff member #51 was observed walking forward with his/her arm extended backwards pulling the Geri chair down the hallway. Resident #51 could not be observed from the staff's position and was not checked on by the staff during this observation. The observation continued with staff member #51 setting up Resident #91 for the lunch meal, outside of his/her room, in the hallway. In an interview with staff member #51 at 08/13/21 at 11:50 AM, staff member #51 stated that it is hard bringing residents back from therapy in wheelchairs or Geri chairs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical record and interview with residents' representatives and facility staff, it was determined that the facility failed to ensure that, 1) laboratory test results were communicated to a resident's attending physician, and, 2) family members were notified of a worsening of a resident's wound. This was evident for 1 (Resident #215) of 3 residents reviewed for urinary catheter and UTI, and 1 (Resident #210) of 10 residents reviewed for pressure ulcers. The findings include: 1) An onsite complaint was received on 08/08/21 at 11:00 AM that revealed an allegation that Resident #215 was not receiving quality of care. Review of Resident #215's closed medical record revealed that Resident #215 had lab work obtained on 07/19/21 that included a complete blood count (CBC) and a basic metabolic profile (BMP). On 07/22/21, the laboratory notified the nurse that there was not enough blood to perform the BMP for Resident #215. Review of the medical record for Resident #215 failed to reveal 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 of tour of the facility with the Maintenance Director (#38) and observations it was determined that the facility staff failed to provide a safe, clean, comfortable homelike environment and failed to provide Resident #102 with a dresser for his/her personal belongings. This was evident for 1 of 63 residents selected for review during the survey process. The findings include: 1. The facility staff failed to provide a homelike environment for the residents. During tour of the facility with the Maintenance Director the following was noted: 1 A. On 8/13/21 at 11:30 AM it was noted rooms [ROOM NUMBERS] with very sticky floors. 1 B. On 8/13/21 at 11:40 AM it was noted rooms 251W, 224W and 219W with holes in the wall behind the head of the beds. Staff #38 stated he was not aware of the holes in the wall and stated that the staff should put maintenance needs in a book and notify him. 1C. On 8/13/21 at 11:45 AM it was noted in rooms [ROOM NUMBERS] a hole in the tile of the floor, exposing the sub-floor. 1 D. 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, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #72, #78 and #94). This was evident for 3 out of 63 residents selected for review during an annual survey. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives the resident's care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. 1. The facility staff failed to accurately document the oral/dental status for a resident. During interview with Resident #72 on 8/3/21 at 9:08 AM, the Resident stated he/she would like to see the dentist. Observation of the resident's mouth at that time revealed no top teeth and the approximately 8 bottom middle teeth that were fragmented and black. At the time the Resident 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.

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 develop a baseline care plan that addressed all of a resident's stated goals and objectives for their stay. This was evidenced by Resident #310's baseline care plan failing to address the resident's pain for a newly amputated great toe, this affected 1 of 61 residents selected for review during an annual survey. The findings include: A baseline 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. A Pain Scale is a communication tool used to measure a patient's pain intensity. It is often performed as part of a larger pain assessment, including details about the pain's duration, severity, and type to help providers make an accurate diagnosis, create a treatment plan and measure the effectiveness of treatment. Amputation is the removal by surgery of a limb (arm or leg) or another body part because of injury or disease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined that facility staff failed to develop and implement comprehensive care plans for residents (Resident #94 and #215). This was evident for 2 of 7 residents reviewed for care plans and 2 of 61 residents selected for review during an annual survey. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. The facility staff failed to initiate a respiratory care plan for Resident #94. Medical record review for Resident…

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

Based on medical record review, observation and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Residents #78). This is evident for 1 of 6 residents reviewed for Activities of Daily Living (ADL) care and 1 of 63 residents selected for review during the annual survey process. The findings include: 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 of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities, and can be used to present a nursing home's profile. One of the section of the MDS is: Functional Abilities and Goals. Some of the components assessed in the Functional Abilities and Goals of the MDS is: bed mobility, transfers, dressing, eating toileting and personal hygiene.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of resident medical records, and interviews with residents' representatives and facility staff, it was determined that the facility failed to: 1) implement recommendations made by the wound care team and the wound clinic regarding the care of residents' pressure ulcers were followed; and, 2) ensure that, when residents have orders to elevate their heels to prevent pressure ulcers, those orders were followed. This was evident for 2 (Residents #210 and #78) of 10 residents reviewed for pressure ulcers. The findings include: 1) Resident #210 was admitted to the facility in September, 2020 and was hospitalized in June, 2021, after developing a blood infection as a result of an infected wound. The surveyor reviewed Resident #210's medical record on 8/4/21 at 2:20 PM. The review revealed that Resident #210 had developed six significant pressure ulcers while at the facility: a pressure ulcer of the right calf that was acquired on 3/26/21; a pressure ulcer of the left calf that was acquired on 4/5/21; a pressure ulcer of the sacrum that was acquired on 5/7/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview it was determined the facility staff failed to ensure residents received proper foot care and treatment (Resident #29 and #72). This was evident for 2 of 63 residents reviewed during the annual survey. The findings include: Podiatrists are health care professionals who have been trained to prevent, diagnose, treat and rehabilitate abnormal conditions of the feet and lower limbs. They can also treat and alleviate day-to-day foot problems, including: toenail problems, such as thickened, fungal or ingrown toenails. corns and calluses. 1. During interview with Resident #29 on 8/3/21 at 9:19 AM, the resident stated he/she would like to be seen the podiatrist. Observation of the resident's toe nails at that time revealed thickened long toenails. Review of Resident #29's medical record on 8/5/21 revealed the resident was admitted to the facility on [DATE] from the hospital. Further review of the resident's medical record revealed no documentation the resident…

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

Based on medical record review, observation and interview, it was determined, the facility staff failed to promote an environment free from potential accidents for Resident (#94) in failure to keep the bed in low position and failed to apply leg rest to the wheelchair for Resident (#123). This was evident for 2 of 63 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to maintain the bed for Resident #94 in low position as ordered by the physician. Medical record review for Resident #94 on 8/5/21 at 9:00 AM revealed on 2/28/21 the physician ordered: Fall precautions: Bed in lowest position to provide a safe environment. Surveyor observation of the resident on 8/5/21 at 10:30 AM revealed the resident in bed; however, the bed was not in the lowest position. It was noted the bed to be approximately 3 feet off the ground. Observation of the resident on 8/6/21 at 8:45 AM and 8/9/21 at 9:30 AM revealed the resident in bed; however, the resident not noted to be in a low bed. The bed was noted to be approximately 2.5 feet 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 medical record review, interview and observation it was determined the facility staff failed to apply a catheter strap for Resident #102's catheter and failed to address a coude catheter recommendations for Resident #211 in a timely manner. This was evident for 2 of 63 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to apply a catheter strap for Resident #102. Medical record review for Resident #102 revealed the resident was re-admitted from the hospital on 3/9/21 with a Foley catheter related to urinary retention. A urinary Foley catheter (a thin, flexible tube) placed in the bladder to drain the urine. Urinary retention is a condition in which the bladder does not empty of urine completely. Surveyor observation of Resident #102 on 8/9/21 at 8:55 AM and 8/10/21 at 11:23 AM revealed the facility staff failed to apply a Foley catheter strap for Resident #102. Staff member #5 and this surveyor observed Resident #102 did not have a catheter strap on 8/10/21 at 11:23 AM. Staff #5 confirmed that Resident #102…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and reviews of a closed and active medical record, it was determined that the facility staff failed to: 1) obtain orders for oxygen and parameters for a resident's BiPAP machine, and 2) document a resident's oxygen usage and treatment in the electronic medical record. This was found to be evident for 2 out of 6 residents (Residents #57 & #215) reviewed for respiratory care during an annual recertification survey. The findings include: 1) 2) An onsite complaint was received on 08/08/21 at 11:00 AM that revealed an allegation Resident #215 was not receiving quality of care. Review of Resident #215's closed medical record on 08/09/21 revealed that Resident #215 was admitted to the facility on [DATE]. Resident #215 was assessed by the facility respiratory therapist (RT) on 07/16/21 at 11:34 AM. The RT made recommendations to obtain orders for Resident #215's BiPAP device to be used at night with 6 liters of oxygen, to use a mask for patient comfort, to clean the mask and oxygen tubing weekly, 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 it was determined the facility staff failed to follow up with recommendations for individual psychotherapy for Resident #94. This was evident for 1 of 5 residents selected for unnecessary medication review and dementia care and 1 of 63 residents selected for review during the survey process. The findings include: Medical record review for Resident #94 on 8/5/21 at 10:00 AM the resident was admitted to the facility that includes but not limited to dementia with behavior disturbances in 4/2020. Further record review revealed on: 2/18/21 the physician ordered: Olazapine Tablet 5 milligrams (mgs.), give 1 tablet by mouth every morning and at bedtime for psychotic disorder. Olanzapine is an antipsychotic medication that is used to treat psychotic conditions such as schizophrenia and bipolar disorders. 2/18/21 the physician ordered: Mirtazapine Tablet 7.5 mgs. give 1 tablet by mouth at bedtime for antidepressant. Mirtazapine is an antidepressant medicine 2/18/21 the physician ordered: Buspirone HCl Tablet 5 mgs, give 1 tablet by mouth three times a day 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 and interview, it was determined the facility staff failed to ensure the safe storage of medications. This was evident for 1 out of 3 nursing units' refrigerators used to store medications. The findings include: On 8/6/21 at 1:02 PM review of the April through August 2021 temperature logs for the refrigerator that is used to store medications on Unit 3 with the Unit 3 Manager present, revealed no temperature readings for the following days: April 12, 13, 22, 23, 24, 25 and 26, 2021 May 4, 5, 6, 15, 16, 19, 23, 24, 28, 29, 30 and 31, 2021 June 15, 20, 25 and 30, 2021 Interview with the Director of Nursing on 8/6/21 at 1:20 PM confirmed the facility staff failed to consistently monitor and document the temperatures on the refrigerators that store medications.

Based on clinical record review it was determined that the facility staff failed to obtain a dental consult for the Resident (#102). This was evident for 1 of 6 residents selected for review of dental services and 1 of 63 residents in the survey sample. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan 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 upon medical record review, observation and interview it was determined that facility staff failed to assist a resident in obtaining routine dental care (Resident #72). This was evident for 1 of 63 residents selected for review during the annual survey The findings include: During interview with Resident #72 on 8/3/21 at 9:08 AM, the resident stated he/she would like to see the Dentist. Observation of the resident's mouth at that time revealed no top teeth and the approximately 8 bottom middle teeth that were fragmented and black. At the time the resident stated the resident stated he/she would like dentures and the dentist to look at his/her remaining teeth. Review of Resident #72's medical record on 8/5/21 revealed the resident was admitted to the facility on [DATE] from the hospital. Further review of the resident's medical record revealed the resident has not seen the Dentist in the 6 months he/she has been a resident at the facility. During observation of the resident with Unit 2 Manager on 8/9/21 at…

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

Based on observation, record review, resident and staff interview, it was determined that the facility staff failed to ensure that residents were given the opportunity to choose meals from a menu in advance of the meal being served, and that the residents received the items of choice from the menu. This was evident for 2 (Resident # 310 and # 316) of 8 residents reviewed for menu choices during the survey. The findings include: During an observation on Unit One on 08/10/21 at 11:56 AM, the surveyor noted resident #310's and # 316's lunch trays were covered and sitting on their bedside tables. Upon interview on 08/10/21 at 11:58 AM, Resident # 310 stated s/he had not received the item that they had requested for the day. Resident # 310 stated s/he requested Homestyle Macaroni Salad with coleslaw for lunch and instead received a cheeseburger on a bun. The resident stated that s/he has no teeth to chew and could not eat the meal served and was going to order food from outside the facility. With the resident's permission surveyor observed the tray that was still in the room 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 review of the tray ticket and observation, it was determined the facility staff failed to provide Resident #94 with food as ordered and failed to provide a liquid to mix a packet of cocoa in. This was evident for 1 of 6 residents selected for review of food and 1 of 63 residents selected for review during the survey process. The findings: 1 A. The facility staff failed to provide Resident #94 with foods per the meal ticket. Surveyor observation of Resident #94's breakfast on 8/6/21 at 8:25 AM revealed the facility staff failed to provide the resident was a banana which is indicated on the meal ticket. The tray ticket is generated in collaboration with the resident and Dietician in reference to likes and dislikes for meals. The tray ticket is used by the dietary staff to ensure the resident receives the foods/liquids as desired and/or ordered by the physician. It was noted on the tray ticket for Resident #94 to have a banana. The Director of Nursing was notified of the finding on 8/6/21 at 10:00 AM and subsequent observations revealed that Resident #94 was provided with 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 observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchen. The findings include: The surveyor conducted an initial tour of the kitchen on 8/2/21 at 11:15 AM. During the tour, the reach in beverage refrigerator was inspected for expired or improperly labeled items. The surveyor found an item labeled, Thick & Easy Cranberry that was opened but had no open date written on it. The label stated keep refrigerated and use within 10 days of opening. The surveyor also found an item labeled, hydrolyte thickened water with an opened date of 7/8/21. This container also had a label that stated, keep refrigerated and use within 10 days of opening. The walk-in refrigerator was next to the reach-in beverage refrigerator. There was a sign on the walk-in refrigerator that stated, Make sure everything is labeled and has a date and used by date before putting away.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of a closed medical record, and staff interview, it was determined that the facility failed to obtain an order from the primary care physician for a resident to be seen by an endocrinology consultant. This was evident for 1 (Resident #215) of 63 residents reviewed during an annual recertification survey. The findings include: An onsite complaint was received on 08/08/21 at 11:00 AM that revealed an allegation that Resident #215 was not receiving quality of care. Review of Resident #215's closed medical record on 08/08/21 revealed a hospital discharge note dated 07/15/21 instructing Resident #215 to follow up with his/her primary care physician regarding the diagnosis of diabetes. Resident #215's attending physician assessed Resident #215 after being admitted on [DATE] and documented a diabetic care plan to continue administering the anti-diabetic medication Metformin and to continue using sliding scale insulin coverage. Resident #215's attending physician did not indicate Resident #215…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to follow infection control standards related to the care of a resident (Resident #29). This was evident for 1 out 63 residents reviewed during an annual survey. The findings include: During observation of medication administration for Resident #29 on 8/6/21 at 9:58 AM with Employee #26, who is a Registered Nurse, revealed a sign on the door for Contact Isolation with personal protective equipment outside the resident's door. Further observation of Employee #26 at the time revealed Employee #26 entered Resident #29's room with no gown and gloves and proceeded to administer medication and a drink to the resident. At the time of the observation Unit 2 Manager was with the surveyor at the entrance to the resident's room. Contact precautions are to help keep staff and visitors from spreading the germs after touching a person or an object the person has touched. Health care personnel caring for patients on Contact precautions must wear a gown and gloves for all interactions that involve contact with the patient 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.