Laurelwood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaints, medical record review, policy review, and interview, it was determined the facility staff 1) failed to notify the physician in a timely manner when a resident had a fall and weight loss and, 2) failed to notify the responsible party when there was a significant change in weight and a change in residents condition. This was evident for 1 (#102) of 8 residents reviewed for accidents and 3 (#247, #125, #133) of 3 residents reviewed for nutrition and significant change in condition The findings include: 1) On 7/31/24 at 8:38 AM a review of complaint MD00204146, that was received by the State Survey Agency (SA), alleged that Resident #102 was unable to walk or move out of bed. The complaint alleged that staff were changing Resident #102 and apparently dropped Resident #102 resulting in a broken hip. On 7/31/24 at 8:38 AM a review of Resident #102's medical record was conducted and revealed a physician's progress note dated 3/25/24 which revealed the physician saw Resident #102 for 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 observation and interview it was determined the facility failed to ensure a homelike environment. This was evident throughout the facility during the surveyor's environmental tour. The findings include: On 7/30/24 at 9:02AM the surveyor observed room [ROOM NUMBER] and observed an area of unpainted spackling felt to be soft and movable on the wall approximately 4.5ft long by 1.5ft tall adjacent to the resident's window. The resident's television was observed to only have one working tv channel with a fuzzy appearance to the screen. The dresser furniture was observed to have a broken drawer handle on the top drawer which was dangling. Upon observation of the shared bathroom, the surveyor noted the following: one ceiling tile containing a plastic air vent with a bowed appearance and 0.5in separation present, approximately a 1ft long by 3in tall brown stain on the ceiling tile containing the light fixture, one missing ceramic wall tile below the toilet paper dispenser with exposed wall board, one broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, interview with staff and facility reported incidents, it was determined the facility failed to ensure that allegations of abuse, neglect, exploitation, injuries of unknown origin, an elopement and unwitnessed fall were reported to the state agency within required timeframe. This was evident for 3 (Resident #101, #27, #129) of 26 residents reviewed for the facility's self-reported incidents and 1 (#102) of 8 residents reviewed for accidents. The findings include: 1) On 7/24/24 at 2:46 PM, a review of facility-reported incident MD00179979 revealed that on 6/23/22 Resident #101 alleged that the resident did not receive care timely when he/she had respiratory issue. Further review of Resident #101's statement for the incident on 7/24/24 at 3:00 PM revealed that the resident pushed the call bell several times for help because his/her oxygen bottle was empty and he/she did not get any oxygen through his/her nasal cannula on 6/23/22 around 5:45 AM. Resident #101 also reported that a nursing staff member approached him/her around 6:23 AM. The review of Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews and a review of facility-reported incident investigations, it was determined that the facility failed to thoroughly investigate allegations of abuse, neglect, injury of unknown origin, unusual occurrence, elopements, and falls. This was evident for 9 (Resident #18, #101, #109, #112, #20, #27, #129 and #102) of 26 residents reviewed for facility self-reported incidents and 1 (#102) of 8 residents reviewed for accidents during a recertification/complaint survey. The findings include: 1)A portion of reviewing the facility reported incident MD00188036 on 7/22/24 at 12:04 PM revealed that Resident #18 exited the facility building without staff knowledge and was found outside of the building by other residents' family member on 1/20/23 around 5:45 PM. Further review of the facility's investigation revealed that the facility's investigation documentation contained that Resident #18 had a wander guard applied after the incident, care plan revised, psychology followed-up, and 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 medical record review, staff interviews and a complaint, it was determined that the facility staff failed to develop, initiate and implement a comprehensive person-centered care plans for residents. This was evident for 7 (Resident #35,#30, #92, #72, #247, #125 and #113) of 87 residents reviewed for care plan during the facility's recertification/complaint survey. 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. Legal blindness is visual acuity less than 20/200, but to fit the definition, the person must not be able to attain 20/200 vision even with prescription eyewear. Normal vision is 20/20. That means you can clearly see an object 20 feet away. If you're legally blind, your vision is 20/200 or less in your better eye or your field of vision is less than 20 degrees. That means if an object is 200 feet away, you have to stand 20 feet from it to see it clearly. The MDS (Minimum Data Set) is part…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, observation, record review, and interview, it was determined that the facility staff: 1) failed to hold care plan meetings for residents and/or their representatives (Resident #38, #35, #14, and #15) and 2) failed to revise and update resident's comprehensive care plan (Resident #14, #15, #72) . This was evident for 5 of 87 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. The Minimum Data Set ( MDS is a complete assessment of the resident, which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and modify the care plan based on the resident's status. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 7/23/2024 at 9:27…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 record review, it was determined that the facility failed to inform the resident of the changes to his/ her treatment plan. This was evident for 1(Resident #21) of 6 residents reviewed for residents' care during the survey. The findings include: Hepatitis C is an inflammation of the liver caused by the hepatitis C virus. The virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness to a serious, lifelong illness including liver cirrhosis and cancer. Brief Interview for Mental Status, BIMS, is a screening tool used to assess basic cognitive function in patients in long-term care facilities. On 7/22/24 at 10:04 AM, in an interview with Resident #21, he/she expressed concern that the facility staff didn't notify him/her of the results every time he underwent laboratory tests. Resident #21 added that one of his/her medications was stopped without notice. On 7/23/24 at 3:09 PM, further review of the medical record indicated that Resident #21's BIMS assessed on 4/29/24 scored 14 of 15, cognitively intact. On 7/24/24 at 2:57 PM, 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 a complaint, observation, interviews, and record reviews, it was determined the facility failed to provide services with reasonable accommodation of resident needs and preferences. This was evident for 2 (#6, #134) of 87 residents reviewed during a recertification and complaint survey. The findings include: A Hoyer lift is an assistive device used to help persons with mobility challenges get in and out of bed. It allows a person to be lifted and transferred with a minimum of physical effort between a bed and a chair and vice versa. 1) On 7/23/2024 11:22 AM, surveyor observed Resident #6 sitting in a bariatric wheelchair and working with therapy in their room. On 8/6/2024 at 12:40 PM, an interview was conducted with the Area Manager for Therapy (Staff #35). Staff #35 stated that Resident #6 was currently on PT (physical therapy) case load and PT has been working with the resident since January 2024 for bed mobility and transfers. Staff #35 further stated that the resident required standby assist for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to convey resident funds to a resident at discharge (Resident #104). This was evident for 1 of 3 residents reviewed during an annual survey. The findings include: Review of Resident #104's medical record on 8/1/24 revealed the Resident was admitted to the facility on [DATE] from another facility and discharged to the hospital on 3/6/24. The Resident did not return to the facility after discharge. Further review of Resident #104's medical record revealed on 3/4/24 the previous facility the Resident resided in sent a check to the facility for $2132.12 payable to the Resident and evidence the Resident's RFMS (Resident Fund Management Service) account was closed by the previous facility on 3/4/24. Further review of Resident #104's medical record revealed on 3/14/24 the facility staff sent back a check to the previous facility for $2132.12 even though Resident #104 was not a resident at that facility. During interview with the Business Office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined the facility failed to ensure that resident/resident's representative was offered the opportunity to develop advance directives and/or provided information regarding advance directives. This was evident for 2 (Resident #14, #15) of 4 residents reviewed for advance directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other…

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

Based on record review and interview it was determined the facility failed to ensure advance written notification to residents was issued when the facility determined that residents no longer qualified for Medicare part A skilled services. This was evident for 3 out of 3 residents (#46, #25, and #248) reviewed during the surveyor's beneficiary protection notification review during the facility's recertification survey. The findings include: On 7/26/24 at 2:55PM the surveyor provided three Skilled Nursing Facility Beneficiary Protection Notification Review forms and requested them to be completed for Residents #248, #46, and #25 to Registered Nurse #30. On 7/29/24 at 9:08AM the surveyor requested to the facility's Director of Nursing, that the forms be completed and returned to the surveyor. On 7/29/24 at 9:15AM the surveyor notified the facility Administrator that the forms had not been completed or returned. At this time, the surveyor conducted an interview with the facility Administrator who provided the following response regarding notices issued to residents: We don't have them.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 ensure secure storage of resident records and personal information. This was evident during the surveyor's exterior environment tour of the facility's grounds during the facility's recertification survey. The findings include: On 7/30/24 at approximately 11:20AM the surveyor conducted an exterior environmental tour of the facility's grounds and observed two exterior doors to the facility which were ajar, unlocked, and able to be opened. One out of two openly accessible areas was found to be a storage area with therapy related medical equipment in disarray, with a two drawer metal filing cabinet present, and two oversized cardboard banker boxes stacked on top, observed to be completely filled with various medical documents with resident personal information present. The surveyor observed and noted the following was present: bad medicare debt documents, resident information including names, admission dates, and lists with social security numbers present, room numbers, letters from the facility…

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

Based on the facility's self-reported incident, residents' medical record review, and interview, it was determined that the facility failed to prevent incident of abuse that was related to a resident kissing an opposite-gender resident who did not want to. This was evident for one (Resident #16) of 13 abuse investigations, including complaints and facility-reported incidents. The findings include: A review of the facility reported incident MD00205715 on 8/01/24 at 9:00 AM revealed that a sexual abuse alleged on 5/14/24 by Resident #98 kissed Resident #16 (an opposite gender resident) on his/her lip, which Resident #16 did not consent to. On 8/01/24 at 9:27 AM, the surveyor reviewed the medical record of Resident #98 and #16. Resident #98's medical records revealed the resident was alert and oriented. BIMS (Brief Interview for Mental Status: an assessment used in nursing homes and other long-term care facilities to monitor cognition) was 12 out of 15 on 3/26/24. Also, Resident #98's records showed that a social worker ( Staff #5) wrote a progress note on 5/15/24 (late entry; the note…

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

Based on policy review, facility investigation review, medical record review, and staff interview, it was determined that the facility failed to implement the abuse policy by failing to timely report and conduct a thorough investigation of alleged abuse and a documented unwitnessed fall with injury. This was evident for 1 (#129) of 26 facility reported incidents reviewed and 1 (#102) of 8 residents reviewed for accidents. The findings include: On 7/22/24 at 9:25 AM an entrance conference was conducted with the Director of Nursing (DON), the Nursing Home Administrator (NHA) and the [NAME] President of Clinical Operations. The entrance conference sheet was provided which included a request for a copy of the Abuse Policy. Review of the Abuse, Neglect and Misappropriation Policy revealed, IV. Identification of incidents and allegations 2. The following procedure will assist the staff in the identification of incidents and direct them to appropriate steps of intervention. A. Each occurrence of resident incident, bruise, abrasion or injury of unknown source; or report of alleged abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#38, #4) of 4 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: 1) During an initial screen of Resident #38 on 7/23/2024 at 9:37 AM, the resident stated that s/he was sent out to the hospital on 6/28/2024. On 7/23/2024 at 1:48 PM a review of nurses' progress notes and change in condition documentation revealed Resident #38 was sent to the ED (emergency department) on 6/28/2024 at 2206H (10:26 PM) via 911. On 7/24/2024 at 12:17 PM an interview was conducted with Licensed Practical Nurse (LPN #3). Regarding written notification of reason for transfer to the hospital, LPN #3 stated that s/he was not aware that they had to give the resident and/or family written notification of reason for transfer to the hospital.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, resident interview, and staff interviews, it was determined that the facility failed to offer a Bed-hold notice to the resident or resident's representative before the facility transferred a resident to the hospital. This was evident for 1 (Resident #72) of 4 resident records reviewed for hospitalization during a recertification/complaint survey. The findings include: Bed hold notice includes providing written information to the resident and bed charges, including the duration of the bed hold until the resident is permitted to return to the nursing facility. On 07/23/24 at 10:44 AM, an interview with (resident #72) revealed that he/she went to the Hospital unplanned, recently in January and April of 2024. The resident further confirmed that no one at the facility informed him/her about the bed hold policy. On 07/26/24 at 11:16 AM, medical record review of the INTERACT transfer assessment and the resident's progress notes revealed that the behold policy was not discussed with the resident or given a copy, prior to sending the resident to the hospital. 07/29/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#38, #125) of 82 residents reviewed during a recertification/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. Ventilator (Vent) /Ventilator support: A ventilator (Vent) is a machine that helps you breathe or breathes for you. Oxygen therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from…

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

Based on record review and interview it was determined that the facility to refer residents to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This was evident for 1 resident (Resident #30) of 2 residents reviewed for PASSAR during the annual survey. The findings include: Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. On 7/24/24 at 9:02 AM a review of Resident #30's records revealed a PASSAR Level I screening form dated 3/10/22 which indicated that the resident should have been referred for a Level II evaluation. No Level II PASSAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 meet professional standards of practice by failing to ensure staff followed physician orders for administration of medications and documentation. This was evident for 2 (Resident #41, #66) of 4 residents observed for medication administration during a recertification/complaint survey. The findings include: On 7/31/2024 at 9:48 AM, surveyors met the nurse, Registered Nurse, RN #8, at a medication cart on the A-Wing Unit. RN #8 reported he was preparing medications for Resident #41. Surveyors observed RN #8 remove from the medication cart and give Resident #41 their morning meds including the following: 1 tab Senna Plus and 1 Acidophilus (probiotic). On 7/31/2024 at 10:55 AM, surveyors observed RN #8 pulled administer Resident #66 their morning meds including the following: 1 tab Metformin 500 mg. The medication Topiramate 25 mg was not available. RN #8 informed Resident #66 that they were going to follow up with the doctor. He stated that the medication was re-ordered but not delivered by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, it was determined the facility failed to implement an ongoing program of activities based on the abilities, interests and treatment needs of a resident that resided in the facility. This was evident for 1 (#38) of 82 residents reviewed during a recertification/complaint survey. The findings include: Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. The MDS (Minimum Data Set) 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide medication and treatment in accordance with professional standards of practice (Resident #110, #120 and #134) and 2) failed to have an order for the management of oxygen for a resident on oxygen therapy (Resident #133). This was evident during a recertification/complaint survey. The findings include: 1) The facility staff failed to monitor Resident #110's blood sugars per hospital's nursing report. Review of Resident #110's medical record on 7/30/24 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include uncontrolled diabetes. Diabetes is a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels. Review of Resident #110's May 2023 Medication Administration Record (MAR) revealed the facility staff was monitoring the Resident's blood sugar before meals and at bedtime prior to the administration of insulin, 4 times a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to change a resident's urinary catheter and drainage bag and failed to follow discharge orders from an acute care facility to arrange for a resident with a foley catheter to be seen by an outpatient urologist (Resident #48), and 2) failed to monitor and empty a urinary drainage bag as ordered (Resident #70). This was evident for 2 of 2 residents reviewed for urinary catheter during a recertification/complaint survey. The findings include: A urologist is a doctor that specializes in the study or treatment of the function and disorder of the urinary system. A urinary (foley) catheter is a flexible tube that is inserted into the bladder to drain urine. 1) On 7/22/2024 at 1:49 PM, Resident #48 was observed in bed with a urinary catheter bag hanging on the right side of their bedframe. In an interview with the resident s/he stated that the urinary catheter was placed a long time ago and has not been changed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review and staff interview it was determined the facility failed to have a process in place to address weight loss in a timely manner (Resident #247, #125). and 2) failed to monitor a resident's nutritional status by documenting their eating amount every shift and developing a care plan (Resident #103). This was evident for 3 of 4 residents reviewed for nutrition during a recertification/complaint survey. The findings include: 1) On 7/30/24 at12:30 PM review of complaint MD00186837 revealed a concern that Resident #247 entered the facility at a much higher weight and that the facility failed to monitor the resident's nutritional needs. On 7/30/24 at 12:30 PM Resident #247's medical record was reviewed and revealed the resident was admitted to the facility in November 2022 for rehabilitation following hospitalization. The resident was in the facility for 37 days until discharge home in December 2022. Review of the weight section of Resident #247's medical record revealed 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 a review of employee records and interviews, it was determined that the facility failed to ensure that nursing staff had competency evaluations upon hire. This was evident for 5 (Registered Nurse #50, #51, Geriatric Nursing Assistant #16, #48, and #49) of 5 randomly selected nursing staff reviewed for competencies. The findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 7/26/24 at 11:08 AM, a telephone Interview with the staffing coordinator (Staff #13) revealed that the facility had no official educator. Staff #13 explained that training was conducted by the staffing coordinator, Director of Nursing (DON), or Human Resources (HR). Staff #13 stated that an orientation packet, including their skills checklist, was provided to the new hires and then given to the DON once completed. He/she added that after the orientation, competency training is done yearly. On 7/26/24 at 12:50 PM, a review of nursing employee records revealed the following: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 records and interviews, it was determined that the facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs)at least once every 12 months. This was evident for 3 ( GNA #16, #48, and#49) of 3 randomly selected GNAs' records reviewed for annual training requirements during the recertification/complaint survey. The findings: On 7/26/24 at 12:50 PM, a review of randomly selected 3 GNAs' records revealed the following: 1. GNA #16 was hired in January 2022- no annual performance review found. 2. GNA #48 was hired in March 2013. no annual performance review was found. 3. GNA #49 was hired in May 2020- no annual performance review found. On 7/29/24 at 1:53 PM, in an interview with the Assistant Director of Nursing (ADON), who is also a staff educator (RN #14), she stated that the nursing staff are evaluated annually by the Director of Nursing (DON). On 7/30/24 at 10:35 AM, during an interview with the DON, the surveyor shared concerns that the employees' personal files did not contain annual performance reviews. The surveyor…

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

Based on observation, medical record review, and interview, it was determined the facility failed to ensure that its medication error rates are not 5 percent or greater. This was found to be evident based on errors identified during medication administration for 2 (Resident #41, #66) of 4 residents observed. The observations were made on two of two nursing units and involved one of three different nurses. The findings include: On 7/31/2024 at 9:48 AM, surveyors met the nurse, Registered Nurse, RN #8, at a medication cart on the A-Wing Unit. RN #8 reported s/he was preparing medications for Resident #41. RN #8 was observed removing the following medications from the medication cart: 1 Acetaminophen 650 mg 1 Senna Plus 1 Eliquis 2.5 mg 1 Amlodipine 5 mg 1 Acidophilus (probiotic) 1 Metoprolol ER 25 mg, and Med Plus 2.0 Vanilla nutritional drink, 120 ml (supplement). RN #8 then gave the medications to resident #41. On 7/31/2024 at 10:55 AM, surveyors observed RN #8 pulled out from the medication cart the following medications and administered them to Resident #66: 1 Carvedilol 12.5 mg,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 facility staff failed to remove expired medications and patient supplies. This was evident on 1 of 2 nursing units and a central supply room observed during a recertification/complaint survey. The findings include: On 7/31/2024 at 11:45 AM, A-Wing Unit CMA (Certified Medicine Aide) medication cart was reviewed for medication storage and labeling in the presence of RN #8: Surveyor found in the overflow drawer of the med cart one blister pack of Mirtazapine 15 mg tabs that expired on 7/16/2024 for Resident #49. RN #8 confirmed the findings and showed the expired drugs to the Regional Director of Clinical Operations (Staff #33), who immediately removed them from the med cart. On 8/1/2024 at 10:10 AM, observation was made of the Central Supply room, in the presence of the Central Supplies staff (Staff #9) and A-Wing Unit Manager (UM #23): The following items were found expired: A box of BD vacutainer eclipse blood collection needles expired on 12/06/2017 A Nipro Box of 22 Gauge needles expired on 4/30/2022 A Nipro box of three (3) 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#102) of 2 residents reviewed for Hospice care and one facility self report (Resident #131) during a recertification/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) On [DATE] at 8:38 AM a review of Resident #102's medical record was conducted and revealed Resident #102 was admitted to the facility in [DATE] with diagnoses that included heart disease, chronic obstructive pulmonary disease (COPD), and chronic pain. The medical record further revealed that Resident #102 was admitted to hospice care in [DATE] due to heart…

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

Based on record review and interview it was determined that the facility failed to ensure that residents understood the arbitration agreement. This was evident for 1 signed agreement (for Resident #14) of 3 signed agreements reviewed during the recertification/complaint survey. The findings include: On 7/22/24 during the entrance conference a request was made for arbitration agreements. On 7/24/24 at 9:08 AM a review of the binding arbitration agreement for Resident #14 revealed that the document was electronically signed by the resident on 9/22/23. On 7/24/24 at 10:41 AM a review of Resident #14's clinical records revealed a certification of capacity form dated 7/24/22 that indicated the resident lacked capacity to make decisions or sign documents due to cognitive impairment. A second capacity form was present in the resident's record that also indicated the resident lacked the ability to make decisions. On 7/24/24 at 12:04 PM an interview with the Admissions Director (Staff #40) regarding arbitration agreements was conducted. Resident #14's arbitration agreement was reviewed 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 that the facility failed to 1) use proper hand hygiene and 2) use proper personal protective equipment, evident for 1 resident (Resident # 73) of 23 residents reviewed for Enhanced Barrier Precaution (EBP). The facility also failed to 3) perform annual revision of Infection Prevention and Control Policies and Procedures, which was evident for 4 of 5 policies and procedures reviewed during the infection control task. The findings include: 1).On 8/05/24 at 10:50 AM an observation of Resident #73's dressing change was conducted. After Wound Nurse (Staff #29) removed the resident's soiled dressing, she removed her dirty gloves and put on clean gloves without performing hand hygiene. On 08/05/24 at 1:03 PM an interview with Staff #29 was conducted. Staff #29 failed to state that handwashing should be performed before and after changing gloves. On 08/06/24 at 10:00 AM an interview with the Director of Nursing (DON) was conducted. He was informed that Staff #29 did not perform hand hygiene before she put on clean gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 records and an interview, it was determined that the facility failed to provide evidence that nursing staff had received annual education on abuse, neglect, exploitation prevention, and misappropriation of resident property along with dementia management and resident abuse prevention . This was evident for 5 (Registered Nurse #50, #51, Geriatric Nurse Assistant #16, #48, and #49) of 5 randomly selected nursing staff reviewed for annual training requirements during the recertification/complaint survey. The findings include: Relias is an online training provider that offers continuing education (CE) for healthcare, senior care, and disabilities professionals. Relias's CE library covers a wide range of topics and is accredited by many national and state licensing boards. Relias's courses are designed to help healthcare workers improve patient care, grow, and provide high-quality care. 1) On 7/26/24 at 11:08 AM, a telephone Interview with staffing coordinator (Staff #13) revealed that the facility had no assigned staff development personnel. Staff #13 added…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a closed medical record, and staff interview, it was determined that the facility staff failed to notify a resident, the resident's representative, and the Long-Term Care State Ombudsman's Office in writing after the facility decided to refuse to readmit a resident that was sent to the hospital. This was evident for 1 (Resident #1) of 3 residents reviewed for discharge during a complaint survey. The findings include: Review of complaint MD00203468 on 03/13/24 revealed an allegation that Resident #1 was sent to the emergency room under emergency petition due to being uncooperative, aggressive, and combative with staff. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 03/06/24. The facility refused to have Resident #1 return from the hospital on [DATE]. A review of Resident #1's transfer documents on 03/13/24 revealed that Resident #1 was admitted from another long-term care facility on 03/01/24. The new long-term care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of 2 closed medical records and all pertinent administrative policies and procedures, and staff interview, it was determined that the facility staff failed to provide a resident nor the resident's representative with written information regarding the facility bed-hold policy. This was evident for 2 (Residents #2 and #3) of 3 residents reviewed for receiving a bed hold policy upon emergent discharge to the hospital. The findings include: A review of the facility policy entitled, Transfer and Discharge policy on 03/14/24, revealed under section C. Acute Transfer, #4: the resident's bed will be held while the facility representative contacts the resident or responsible party to discuss the bed hold. A letter containing admission/discharge/transfer and appeal rights will be discussed with the resident or responsible party and will be mailed to them as soon as practical. The resident or responsible party will be given the opportunity to continue to hold the bed. The resident's bed will 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 reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to permit a resident to return to the facility after a brief hospitalization. This was evident for 1 (Resident #1) of 3 complaints reviewed during a complaint survey. The findings include: Review of complaint MD00203468 on 03/13/24 revealed an allegation that Resident #1 was sent to the emergency room under emergency petition due to being uncooperative, aggressive, and combative with staff. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 03/06/24. The facility refused to have Resident #1 return from the hospital on [DATE]. A review of Resident #1's transfer documents on 03/13/24 revealed that Resident #1 was admitted from another long-term care facility on 03/01/24. The new long-term care facility received transfer documents on 03/01/24 that included diagnoses that included: unspecified personality and behavior disorder, a history 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 surveyors observations and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect multiple residents. The findings include: 1. On 9/17/2019 at 8:09 AM the men's bathroom in the main dining room was observed with brown stains and cobwebs on the ceiling tiles. The Administrator and Director of Nursing were made aware of these findings on 9/18/2019 during the exit conference. 2. During an observational tour on 9/11/19 the following items were identified: An observation of Resident #40's room on 9/11/19 at 12:15 PM revealed Resident #40's wheelchair arm rests were noted to be in disrepair. An observation of Resident #5's room on 9/11/19 at 2:18 PM also revealed wheelchair arm rests were also in disrepair with missing covers and duct tape being applied. In an observation of Resident #68's room on 9/11/19 at 2:47 PM revealed a set of drawers being in disrepair with broken handles and missing screws.

Based on review of the medical record and interviews with staff, it was determined that the facility staff failed to develop comprehensive care plans for residents (#94 and #93). This was evident for 2 of 51 residents reviewed during the annual survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect, or inaccurate care. 1. Resident #94 was admitted to the facility for dementia and pressure ulcer care. On 7/23/19 a urinary drainage catheter was placed in Resident #94's bladder to prevent urine from infecting the healing sacral wound. A care plan meeting was held on 7/30/19. During the care plan meeting the facility failed to develop a care plan for dealing with the urinary drainage catheter. On 9/17/19 at 9:55 AM the Director of Nursing (DON) confirmed that the urinary drainage care plan had not been developed. The…

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

Based on staff interview, review of 3 previous surveys, and the facility Quality Assurance Performance Improvement (QAPI) plan, it was determined that nursing home administration failed to continuously monitor the effectiveness of the interventions required to correct cited deficiencies resulting in 5 repeated citations since 2017. The findings include: The facility QAPI plan has a committee which includes but is not limited to the Administrator, Director of Nursing, and Medical Director. The committee also includes Regional and Corporate staff as needed. The QAPI committe duties include identifying and undertaking systematic change to eliminate problems after the root cause is determined and develop a feedback and monitoring system to sustain continuous improvement. The following deficiencies were identified and again cited in the 3/30/2017 & 5/24/18 annual surveys, the 3/30-/9 complaint survey, and in the 9/18/2019 annual survey: F684 - Quality of Care - residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, review of annual surveys for 3/30/2017 & 5/24/018, complaint survey of 3/29/2019, and interviews with facility staff, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) Plan failed to effectively implement plans of action and monitor effectiveness to correct identified quality deficiencies. This was for 5 of 36 deficiencies from the 9/18/2019 annual survey that had been previously cited. The findings include: QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of flies. This deficient practice has the potential to impact all residents. The findings include: During surveyor tour of the facility on 9/10/2019, a fruit fly was observed in room [ROOM NUMBER] at 12:11 PM and in room [ROOM NUMBER] at 1:44 PM. During a tour of the facility's main kitchen on 9/16/2019 at 10:10 AM, two fruit flies were observed in the dry goods room and one housefly was observed hovering over a hotel pan containing ground meat and breadcrumbs on the tray line. Additionally, on 9/17/2019 at 11:13 AM two fruit flies were observed in the B Wing hallway. The Administrator and Director of Nursing were made aware of these findings during the exit interview on 9/18/2019.

Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#35) with a lip plate as indicated on the meal ticket. This was evident for 1 of 51 residents selected for review during the survey process. The findings include: Surveyor observation of Resident #35's breakfast on 9/11/19 at 8:45 AM, lunch on 9/12/19 and 9/13/19 at 12:30 PM revealed the resident eating his/her meals off a flat white plate. Review of the meal ticket which accompanied the meals revealed Resident #35 was to have a lip plate due to tremors. The tray ticket accompanies the resident's meals from the kitchen to the resident. The tray ticket revealed the type and amount of food to be provided as well as any individualized needs. The tray ticket for Resident #35 revealed the resident needing: lip plate, left angled spoon and fork and sippy cup. The lip plate is designed to assist people with limited muscle control. The deep inner lip keeps food from sliding off the plate as the user brings the fork or spoon to the edge of the plate and pushes the food…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to promote self-determination for Residents (#56 and #57). This was evident for 2 of 5 residents in the survey sample for choices and 2 of 51 residents selected for review during the survey. The finding includes: 1 A. The facility staff failed to promote self-determination for Resident #56. Medical record review for Resident #56 revealed on 8/1/19 the resident entered Hospice. Hospice care enhances the end of life by providing care that allows people to live their final days to the fullest, in peace and without pain. At that time, the physician ordered: discontinue weights. Further record review revealed the facility staff obtained a weight on Resident #56 on 9/5/19. 1 B. The facility staff failed to promote self-determination for Resident #56. Medical record review for Resident #56 revealed on 8/1/19 the resident entered Hospice. Hospice care enhances the end of life by providing care that allows people to live their final days to the fullest, in peace and without pain. At that…

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

Based on medical record review and interviews with staff, it was determined the nursing staff failed to notify the responsible party of a resident's change in condition requiring hospitalization (Resident #94). This was evident for 1 of 1 residents reviewed for notification of change during this survey. The findings included: Resident #94 was admitted to the facility with dementia and other diagnoses. Resident #94 had a spouse who was the responsible party to be notifiied in case of any changes in condition. On 8/18/19 Resident #94 had a change in condition requiring transfer and subsequent admission to the hospital. The facility notified the physician and attempted to call the spouse one time. No other attempt to notify the spouse was recorded in the medical record. On 8/19/19 Resident #94's spouse came to the facility to visit him/her and discovered that he/she had been admitted to the hospital the previous day. A nursing note of 8/19/19 at 3:00 PM states Resident #94's spouse expressed concern over not being notified of the husband/wife's transfer to the hospital and admission.…

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

Based on medical record review, facility investigation review, and staff interview it was determined that the facility staff failed to thoroughly investigate an injury of unknown origin for a resident (#301). This was evident for 1 of 8 residents reviewed for pain management. The findings include: Resident #301 was admitted to the facility with multiple diagnoses including osteoporosis (brittle bones). On 2/5/19 the geriatic nursing assistant (GNA) #23 documented in the medical record that Resident #301 had pain with walking on 2/4/19 and 2/5/19 and the resident refused to walk in the halls due to pain. The facility obtained an X-ray of the left hip that showed a hip fracture. Resident #301 was transported to the hospital for treatment. The facility determined the fracture was an injury of unknown origin and reported the incident to the Office of Health Care Quality (OHCQ) stating staff members were interviewed. The final report to OHCQ stated the cause of the fracture was osteoporsis. The completed facility investigation given to this surveyor did not include any interviews with…

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

Based on medical record review and interview with staff it was determined that the facility staff failed to have a system in place to ensure that the transfer of the resident's medical record and appropriate information is communicated to the receiving health care provider. This was found to be evident for 3 out of 5 (#44, #84 and #92) residents reviewed for hospitalization during the investigative portion of the survey. The findings include: The facility staff failed to meet the requirement for transfer information. If the resident is being transferred, and return is expected, the following information must be conveyed to the receiving provider: 1. Resident representative information, including contact information. 2. Advance directive information. 3. The resident's comprehensive care plan goals. 4. Medications (including when last received) 5. Most recent relevant labs, other diagnostic tests. The facility must ensure that the transfer or discharge is documented in the resident's medical record and, who is responsible for making the documentation. A medical record review for…

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

Based on medical record review and staff interview, it was determined the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy before transferring them to the hospital. This was evident for 3 (Residents #44, #84 and #92) of 5 residents sampled for investigations. The findings include: 1. Review of the medical record for Resident #44 documented that the resident was transferred to an acute care facility on 6/6/19, and 6/21/19. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 2. Review of the medical record for Resident #84 revealed the resident was transferred to an acute care facility on 6/21/19. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 3. Review of the medical record for Resident #92 revealed the resident was transferred to an acute care facility on…

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

Based on medical record review, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#77 and #101) of 51 residents reviewed during an annual recertification 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. Review of the medical record for Resident #77 on 9/11/19 revealed Resident #77 was receiving the antipsychotic medication Zyprexa 5mg twice a day for anxiety. Review of the quarterly MDS assessment with an ARD of 5/12/19, Section N, failed to capture Resident #77 was receiving the antipsychotic medication for 7 days during the review period. 2. The facility staff failed to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to develop and then provide Resident (#44 and #300) and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 2 of 5 resident reviewed for dementia care during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #44's medical record on 8/13/19 revealed Resident #44 was admitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a baseline care plan was developed within 48 hours of admission and a copy was provided to the resident/resident representative. The facility failed to develop a baseline care plan and provide the resident/resident representative with a copy within 48 hours of admission to the facility. Interview 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.

Based on medical record review and interview, it was determined the facility staff failed to administer a medication to Resident (#53) in accordance with the standard of practice. This was evident for 1 of 51 residents reviewed of medication administration during the survey process. The findings include: Medical record review for Resident #53 revealed on 10/18/18 the physician ordered: Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol)--1 Inhalation every day. Breo Ellipta 100/25 is a prescription medicine used long term to treat chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema, or both, for better breathing and fewer flare-ups. Breo is not used to relieve sudden breathing problems and won't replace a rescue inhaler. Breo can cause serious side effects, including fungal infection in the mouth or throat (thrush). Rinse the mouth with water without swallowing after using Breo to help reduce the chance of getting thrush (fungal infection of the mouth): https://www.mybreo.com > copd > about-breo >…

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

Based on observation, medical record review and interview it was determined the facility staff failed to provide grooming and personal hygiene services for Residents (#57 and #16). This is evident for 2 of 51 residents selected for review for ADL care reviewed during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. 1. The facility staff failed to provide grooming and personal hygiene services for Resident #57. Observation of Resident #57 on 9/10/19 at 9:45 AM and 9/11/19 at 12:45 PM revealed…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain abdominal girths as ordered for Resident (#35), failed to obtain a cardiology consultation as ordered for Resident (#53), failed to obtain weekly weights as ordered for Resident (#57) and failed to ensure Resident (#56) was deemed capable to sign consents. This was evident for 4 of 51 residents selected for review during the survey process. The findings include: 1. The facility staff failed to obtain abdominal girths as ordered for Resident #35. Medical record review for Resident #35 revealed on 9/25/18 the physician ordered: abdominal girth every month on the 28th. Abdominal girth is the measurement of the distance around the abdomen at a specific point. Measurement is most often made at the level of the belly button. Further record review revealed the facility staff failed to obtain the abdominal girth as ordered by the physician. Interview with the Director of Nursing on 9/18/19 at 1:00 PM confirmed the facility staff failed to obtain abdominal girths as ordered for Resident #35.…

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

Based on medical record review, observation and interviews, it was determined the facility staff failed to provide an environment free from potential accidents for Resident (#53). This was evident for 1 of 2 residents selected for accident review and 1 of 51 residents selected for review during the annual survey process and observations noted by surveyors. The findings include: 1. The facility staff failed to remove straws from Resident #53. Medical record review for Resident #53 revealed on 3/31/18 the physician in collaboration with the dietician and Speech Language Pathologist (SLP) revealed: no straws. Surveyor observation of Resident #53 on 9/11/19 at 12:30 PM and 9/12/19 at 7:53 AM, 12:00 PM and 12:35 PM and AM and 9/13/19 at 11:00 AM revealed the resident with a water pitcher in the room; however, there was a straw in the water. The Director of Nursing was made aware of the same. (Of note, the facility staff assessed the resident to be alert, oriented and cognitively intact and has refused the facility staff to remove straws; however, the facility staff failed to address 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 staff failed to follow a Physician's order for Resident (#1) for tracheotomy care in accordance with the standard of practice. This was evident for 1 of 1 resident selected for review of tracheotomy care during the annual survey process. The findings include: Surveyor observation of Resident #1 on 9/10/19 at 10:00 AM revealed the resident lying in his/her bed with a tracheostomy tube connected to oxygen. A tracheotomy, or tracheostomy, is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. Review of the medical record revealed Physician orders written on 6/30/19 to change trach ties daily on day shift for hygiene. Trach ties are the bands that go around the neck. They hold the trach tube in place. The Physician orders written on 6/30/19 also included for the inner cannula to be change/clean every shift for hygiene. The inner cannula fits inside the outer cannula. It has a lock to keep it from being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 the clinical records and staff interview it was determined that the facility staff failed to document the administered of pain medication, assess the need for pain medication and thoroughly monitor the effectiveness. This was true for 2 (#92 and #35) out of the 8 residents reviewed for pain management during an annual recertification survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. 1. The facility staff failed to document the administered of pain medication, assess the need for pain medication and thoroughly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure a physician visited a resident (#101) the required number of times during their admission and the physician failed to ensure 2 certifications of inability to make medical decision were provided for Resident (#93). This was evident for 1 of 5 residents reviewed for hospitalization during the annual survey and 1 out of 10 residents selected for review of advance directives and 2 out of 51 residents selected for review during the annual survey process. Findings include: 1. The facility staff failed to ensure a physician visited a resident (#101) the required number of times during their admission Physicians are required to see a resident once every 30 days for the first 90 days of admission and then once every 60 days thereafter. Resident #101 was admitted to the facility on [DATE] and signed out against medical advice on 6/15/19 after a 9-day stay. Resident #101's physician saw him/her on 3/12/19 and not…

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

Based on medical record review and interview, it was determined the facility staff failed to complete an ordered consult (Resident #94) for 1 of 2 residents reviewed for dementia care. The findings include: Resident #94 was admitted to the facility for dementia care and on 7/15/19 the physician ordered a psychiatric consult for hallucinations. A copy of the consultation was not a part of the medical record when reviewed on 9/16/19. On 9/17/19 at 9:55 AM the Director of Nursing confirmed the physician order for a psychiatric consult had not been requested by the nursing staff.

Based on medical record review and staff interview, it was determined that a resident's physician failed to take steps to address irregularities in the resident's drug regimen. This was evident for 1 (Resident #77) of 4 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: Review of Resident #77's medical record was conducted on 9/12/19. Resident #77's medical record listed 6 pharmacy reviews. 5 out of 6 pharmacy reviews noted irregularities to Resident #77's medication regimen. These irregularities were noted by the facility pharmacist on the following days: 6/19/19, 5/15/19, and 4/17/19. Further review of Resident #77's medical record failed to reveal these pharmacy irregularities were located in Resident #77's medical record and had been been addressed by Resident #77's physician. On 4/17/19 and again on 5/15/19, the facility pharmacist made a recommendation that Resident #77's physician please evaluate the administration of Resident #77 receiving the antipsychotic medication, Olanzapine, for anxiety. On 6/19/19, 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 interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication had an adequate indication for use. This was evident for 1 (Resident #77) of 4 residents reviewed for unnecessary medications during an annual recertification. The findings include: A review of Resident #77's monthly pharmacy review for April 2019 revealed a recommendation or request for an indication for the continued use of the psychotropic medication Zyprexa. Resident #77 was receiving Zyprexa twice daily for anxiety. The pharmacist requested a reevaluation of Resident #77's antipsychotic therapy and documentation for the continued use. Resident #77 was seen by the facility psychiatric consultants on 8/8/19 when Resident #77's administration of Zyprexa was addressed. In an interview with the facility psychiatric nurse practitioner on 9/13/19 at 9:46 AM, the psychiatric nurse practitioner stated s/he first was asked to assess Resident #77 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 medical record review and staff interview, it was determined that a resident's physician failed to take steps to address irregularities in the resident's drug regimen (Resident #77) and the facility staff failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident (#93) and the facility staff failed to document the administered of as needed psychotropic medications for Resident (#44) and thoroughly monitor the effectiveness. This was evident for 3 of 5 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: 1. A resident's physician failed to take steps to address irregularities in the resident's drug regimen. Review of Resident #77's medical record was conducted on 9/12/19. Resident #77's medical record listed 6 pharmacy reviews. 5 out of 6 pharmacy reviews noted irregularities to Resident #77's medication regimen. These irregularities were noted by the facility pharmacist on the following days: 6/19/19,…

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

Based on observation, it was determined the facility staff failed to properly store medications. This was observed twice during an annual recertification survey. The findings include: 1) An observation was made on 09/11/19 at 9:12 AM on the B wing at the nursing station. The surveyor observed an unattended and unlocked medication cart. The medication cart held medications for the resident's residing on the B wing. No nursing staff members were attending the medication cart at the time of the observation. The charge was immediately made aware of finding. Based on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when the medication was open. This was evident for 2 of 3 medication carts observed during the annual survey process. The findings include: Observation of the medication cart on 9/17/19 9:11 AM revealed the following observation: 1. The medication cart A on Top Unit had the following: insulin medications with no open dates, 2 Humalog vial, Novolog pen, Humalog pen and two…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain a diagnostic test as ordered for Resident (#57) in a timely manner. This was evident for 1 of 51 residents selected for review during the survey process. The findings include: Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Most deep vein clots occur in the lower leg or thigh. Some warning signs of a DVT are pain, swelling and warmth. Flowing blood changes the sound waves by the Doppler effect. The ultrasound machine can detect these changes and determine whether blood within a vein is flowing normally. Absence of blood flow confirms the diagnosis of DVT. Medical record for Resident #57 revealed on 5/17/2019 Nurses Note revealed: New order received for an ultrasound (doppler study) right lower extremities to R/O DVT /RT (rule out deep vein thrombosis right leg) due to complaint of pain and swelling. This nurse called to Mobilex to place the order and they did not accept the order as further clarification is needed (Arterial or venous). Left a voice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, reviews of a medical record, and staff interview, it was determined that the facility staff failed to 1. document an Occupational Therapy screen, and 2. initiate nursing restorative care and plan. This was evident for 1 (Resident #4) of 51 residents reviewed during an annual recertification survey. The findings include: In an interview with Resident #4 on 9/11/19 at 3:50 PM, Resident #4 complained that s/he was recently discharged from the hospital and has not received any therapy services since being readmitted . Review of Resident #4's medical record on 9/11/19 failed to reveal any therapy notes that indicated Resident #4 had been receiving therapy since being readmitted back to the facility on 9/3/19. In a telephone interview with the facility occupational therapist on 9/13/19 at 1:55 PM, the facility occupational therapist stated that s/he recalled assessing Resident #4 on the day after Resident #4 was readmitted back to the facility on 9/3/19. The facility occupational therapist stated Resident #4 wanted to work on his/her upper body strength and the plan…

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

Based on review of employee health records and staff interview the facility staff failed to thoroughly screen for Tuberculosis and failed to have 2nd step Tuberculosis (PPD) completed to those newly hired employees (Employee #22, #23 and #24). The findings include: Bacteria are the cause of Tuberculosis that affects the lungs. Tuberculosis is spread from person to person through the air. When people with Tuberculosis cough, sneeze or spit, they propel the germs into the air. 1. Review of the health record for Employee #22 with the date of hire of 5/7/18 revealed that facility staff failed to thoroughly, screen for Tuberculosis. 2. Review of the health record for Employee #23 with the date of hire of 2/28/19 was screened for Tuberculosis on 9/5/19 as step one of a 2-step screening. No action was taken by the facility staff to ensure immunity by screening to prevent possible exposure to residents and employ 3. Review of the health record for Employee #24. with the date of hire of 6/18/19 was screened for Tuberculosis on 9/6/19 as step one of a 2-step screening. No action was taken by…

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