Ellicott City Healthcare Center

Based on resident and staff interviews, record review and observation, it was determined that the facility failed to demonstrate prompt action in response to residents' grievances; provide a written response to residents of the grievance outcome; ensure an anonymous means to submit grievances; and post the Grievance Official name and contact information. This was evident for six of six Activities Team's grievances that were reviewed during this survey. The findings include: On 2/12/26 at 10:01 AM in an interview with the Resident Council President (Resident #129,) the following was reported: Resident Council meetings held every second Tuesday of each month at 3:00 PM On average 25 residents attend Staff are invited to the meetings, but often they don't attend, especially nursing leadership Minutes are recorded by me (Resident #129) and kept in my personal journal On the day before the meeting, I (Resident #129) personally and physically go throughout the building via wheelchair to verbally invite residents to the meeting. It was stated; the facility won't allow posted signs 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 interview and medical record review it was determined that the facility failed to inform the resident's responsible party (RP) of a change in condition. This was found to be evident for one (Resident #12) out of one resident reviewed for notification of change.The findings include:Resident #12 has resided at the facility for more than one year. Review of the medical record revealed the resident has moderate cognitive impairment as evidenced by a brief interview for mental status score of 10 out of 15. Review of the 9/22/25 Minimum Data Set (MDS) assessment revealed the resident reported that it was very important to have family or a close friend involved in discussions about his/her care. Review of the resident's medical record revealed two family members were listed as contacts.On 2/11/26 at 2:47 PM the resident's family member reported that they were not sure if the facility always contacted them when there were changes in the resident's condition.Review of the medical record revealed a change in condition note dated 1/10/26 that indicated the nurse practitioner had…

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

Based on review of pertinent records and interview it was determined that the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) were provided to residents prior to the end of skilled services. This was found to be evident for two (Resident #89 and #115) out of three residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification Review.The findings include:Review of the list of residents, provided by the facility, of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months revealed Resident #89 and Resident #115 were discharged from services and remained in the facility for long term care. If a resident remains in the facility long term care they are expected to be issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and a Notice of Medicare Non-Coverage (NOMNC).Notice of Medicare Non-Coverage (NOMNC) The NOMNC, Form CMS-10123, is given by the facility to all Medicare…

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

Based on interviews and pertinent document review, it was determined that the facility failed to promptly respond to and resolve a resident grievance. This was evident for one (Resident #100) of one resident reviewed for general concerns during the survey.The findings included:On 2/10/26 at 12:46 PM, Resident #100, a long-term resident of the facility, was interviewed. During the interview, Resident #100 reported that while at the facility, there was a plumbing water emergency in their room. This resulted in a short-term transfer for the resident to another facility. Resident #100 reported that upon return there were items missing. They reported the missing items of clothing and personal documents (including an ID card, Social Security card, and a birth certificate), to social services. On 2/13/26 at 11:30 AM, a second interview was conducted with Resident #100 in their room. The resident reported that when transferred to another facility, the ID card, birth certificate, and Social Security card were left in their drawers. Resident #100 stated that the missing items were reported to…

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

Based on record review, observations, and interviews, it was determined that the facility failed to protect residents from verbal abuse. This was evident for two (Residents #90 and #111) out of six residents reviewed for abuse allegations.The findings include:1) Resident #90 has a medical history of heart failure, depression, and post-traumatic stress disorder.On 1/28/26 at 5:26 PM, the facility submitted a facility-reported incident to the Office of Health Care Quality (OHCQ) stating that an Activities Assistant (AA #29) had a verbal altercation with Resident #90 (Incident #2729623).On 2/12/26 at 4:22 PM, the surveyor reviewed the facility's investigation regarding the allegation of verbal abuse. The report indicated that Resident #90 informed Unit Manager (UM #10) that AA #29 had delivered cigarettes to another resident. When Resident #90 asked to borrow one, the other resident stated that AA #29 had told them Resident #90 takes advantage of other residents and declined to share. Upset by this accusation, Resident #90 approached AA #29 to ask why this was said. Resident #90…

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

Based on medical record review and interview it was determined that the facility failed to ensure discharge planning was updated and facilitated by staff. This was found to be evident for one out (Resident #12) of two resident's reviewed for disharge.The findings include: Resident #12 has resided at the facility for more than one year. Review of the medical record revealed the resident has moderate cognitive impairment as evidenced by a brief interview for mental status score of 10 out of 15. Review of the 9/22/25 Minimum Data Set (MDS) assessment revealed the resident reported that it was very important to have family or a close friend involved in discussions about his/her care. Review of the resident's medical record revealed two family members were listed as contacts.During an interview on 2/11/26 at 2:47 PM the resident's family member reported that the facility was too far away, s/he is often unable to get a ride to the facility, and they want to have the resident transferred to a facility nearby. The family member also reported that the social worker claims she is working on…

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

Based on medical record review and interview it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to the facility. This was found to be evident for one (Resident #2) out of two residents reviewed for PASARR.The findings include: 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. Review of Resident #2's medical record on 2/11/26 revealed the resident was originally admitted to the facility in January 2026. No documentation was found to indicate a PASARR screen was completed for this resident prior to, or after, the admission to the facility. Interview with the Director of Social Services (DSS)…

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

Based on medical record review and interview it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident. This was found to be evident for one (Resident #2) out of one reviewed for urinary catheter use; two (Resident #2 and #89) out of four reviewed for activities; and one (Resident #14) out of one reviewed for the use of side rails. The findings include:1) Review of Resident #2's medical record revealed the resident was admitted in early January 2026. Review of a 1/4/26 history and physical note revealed a diagnosis of neurogenic bladder requiring intermittent catheterization.Urinary catheterization involves inserting a tube into the bladder via the urethra to drain the urine from the body. Catheterization can be performed by nursing staff, or a resident can perform this procedure themselves. If performed by the resident the procedure is called self-catheterization (or just self-cath). Self-catheterization is usually performed 4 to 6 times per day.On 2/12/26 at 12:47 PM during an interview the resident reported…

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

Based on medical record review and interview it was determined that the facility failed to ensure the interdisciplinary team, including the resident's responsible representatives, participated in care conferences to review and revise a resident's care plan following Minimum Data Set (MDS) assessments. This was found to be evident for one (Resident #12) out of four residents reviewed for care planning.The findings include:Care Conferences, also known as care plan meetings, are interdisciplinary team meetings that are to occur following the completion of Minimum Data Set (MDS) assessments. The MDS is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. Review of Resident #12's medical record on 2/12/26 revealed the resident has resided at the facility for more than one year, has moderate cognitive impairment as evidenced by a brief interview for mental status score of 10 out of 15. Review of the 9/22/25 Minimum Data Set…

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

Based on observations, interviews, and medical record review, it was determined that the facility staff failed to adhere to professional standards of nursing practice for timely and accurate documentation of medication administration in the medical record. This deficient practice was identified for four of 32 medications reviewed during the medication administration task and affected two (Resident #122 and #129) of the five residents observed.The findings include:On 2/13/26 between 8:16 AM and 8:55 AM, the surveyor observed Licensed Practical Nurse (Nurse #41) perform medication administration for Resident #122 and Resident #129. The surveyor observed the nurse administer medications to Resident #122 and #129. On 2/13/26 at 12:34 PM, the surveyor reviewed the residents' Medication Administration Records (MARs). Review revealed Nurse #41 had not documented administration of Oxycodone 5 mg to Resident #122, despite the surveyor directly observing the medication being administered. Review of Resident #129's MAR further revealed three ordered morning medications — loratadine,…

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

Based on interviews, observations, and record review, it was determined that the facility failed to provide ADL (activity of daily living) care to residents. This was evident for two (Resident #6 and Resident #10) out of three residents reviewed for ADL care.The findings include:Activities of Daily Living (ADL) care refers to support provided to individuals who struggle with essential, routine self-care tasks necessary for basic health, safety, and hygiene.1) Resident #6 has a medical history of diabetes, end-stage kidney disease requiring dialysis, and abnormalities of gait and mobility requiring assistance with ADL care.On 2/10/26 at 4:45 PM, the surveyor interviewed Resident #6 and observed that s/he looked disheveled with greasy hair and body odor. The resident mentioned that s/he often waits up to five hours without incontinence care and stated that they get a little wet towel bath but no real cleaning. The surveyor noted that the bedding was disheveled, the resident was only wearing an incontinence brief, and a dressing on the chest was falling off.On 2/17/26 at 2:27 PM, the…

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

Based on interview, observation and record review, it was determined that the facility failed to develop, or update, activity care plans to address and facilitate residents' activity interests. This was evident for 3 (Resident #12, #2 and #89) of 4 residents reviewed for activities during the survey. The findings included:A care plan was a guide that addressed the unique needs of each resident. It was used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of Resident #12's medical record revealed the resident has resided at the facility for several years, is dependent on staff for mobility, has some cognitive impairment, and prefers family involvement in care discussions. Review of the 9/22/25 MDS assessment, Section F, revealed it was somewhat important to the resident to get fresh air when weather is good. Review of the 9/23/25 Care Conference note revealed the following statement in the Activities section: I need to go outside. On 2/13/26 review of the resident's care plan addressing activities failed to reveal interventions related to taking the…

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

Based on observation, record review, and interviews, it was determined that the facility failed to implement medical recommendations for a resident to wear a splint. This was evident for one (Resident #111) of two residents reviewed for rehabilitative services.The findings include: A hand contracture in a long-term care (LTC) resident is a permanent or semi-permanent, often painful stiffening of the joints and tightening of muscles, tendons, or skin in the hand and wrist, which reduces range of motion. This condition is often due to prolonged immobility, muscle disuse, or neurological conditions such as stroke. Resident #111 has a history of stroke that has impacted function on their left side. On 2/10/26 at 4:23 PM, the surveyor observed that Resident #111 had a contracture of the left hand and was not wearing a splint. When asked, the resident stated that s/he did not have one and reported that their left hand gets very red and smelly. On 2/18/26 at 9:58 AM, the surveyor interviewed the Rehab Director (RD #20), who reported that Resident #111 had received Occupational Therapy…

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

Based on medical record review and interview it was determined that the facility failed to accurately assess, plan and provide for a resident's urinary catheterization needs. This was found to be evident for one (Resident #2) out of one resident reviewed for urinary catheterization.The findings include: Review of Resident #2's medical record revealed the resident was cognitively intact and their own responsible party.Urinary catheterization involves inserting a tube into the bladder via the urethra to drain the urine from the body. Catheterization can be performed by nursing staff, or a resident can perform this procedure themselves. If performed by the resident the procedure is called self-catheterization (or just self-cath). Self-catheterization is usually performed 4 to 6 times per day.On 2/12/26 at 12:47 PM during an interview the resident reported that s/he performs self-catheterization and is supposed to have 6 catheters per day but was only being provided four per day. The resident also reported having to ask each day for the needed supplies and that they only provided three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined that the facility staff failed to follow proper tube feed management; to secure a feeding tube free from pulling to prevent dislodgement. This was evident for 1 (Resident # 13) out of 2 residents reviewed for tube feed management during the annual survey. The findings include: Percutaneous Endoscopic Gastrostomy (PEG)tube is a surgical procedure where physicians use an endoscope to insert a plastic flexible feeding tube through the upper abdominal wall directly out of the stomach. Proper care of the PEG tube is necessary to prevent infections, pulling, and clogging of the tube. The external fixation plate of a PEG tube should be positioned 0.5 cm to 1 cm roughly a finger's width away from the skin to avoid pressure necrosis (Necrosis is the death of the cells in one's body tissues. Necrosis can occur due to injuries, infections or diseases). A light dressing normally applied around the PEG tube side and changed daily. Contractures are…

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

Based on observation, interview and medical record review it was determined that the facility failed to ensure informed consent was obtained from a resident/responsible representative prior to the initiation of side rails; to obtain a physician order ; or develop a care plan related to side rail usage. This was found to be evident for one (Resident #14) out of one resident reviewed for use of side rails.The findings include:Review of Resident #14's medical record revealed that as of 9/25/25 the resident was determined to be incapable of making informed decisions regarding the provision, withholding or withdrawing of all treatments due to vascular dementia. Review of the 1/28/26 Minimum Data Set Assessment revealed the resident was severely cognitively impaired based on a Brief Interview for Mental Status (BIMS) score of 6 out of 15. There are family members involved in the residents care planning.On 2/11/26 at 1:11 PM the resident was observed in bed asleep, grab bars (small side rails) were noted to be in the up position on both sides of the bed.Even when bed rails are properly…

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

Based on interviews, observations, and record review, it was determined that the facility failed to ensure ordered medications were maintained in stock and available for administration as prescribed. This deficient practice was identified for one (Resident #8) of three residents reviewed for pain management and for one (Resident #129) of five residents observed during the medication administration task.The findings include:1) Resident #8 has a medical history of chronic pain. On 2/10/26 at 1:14 PM, during the initial screening of residents, Resident #8 reported that the facility runs out of their pain medication approximately every eight days and that s/he must wait several days for the medication to be refilled. The resident stated they experience pain daily and require the medication consistently. The resident further stated that staff are aware of this need but do not ensure the medication is always available.Medical record review revealed Resident #8 is prescribed Oxycodone, two tablets by mouth as needed for moderate to severe pain, scheduled to be available at 5:30 AM and 1:30…

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

Based on record review and staff interviews, it was determined that the facility failed to acknowledge a pharmacist's recommendation with a physician signature and define timely manner by which the consulting pharmacist's recommendations must be reviewed. This was evident for one (Resident #150) of five residents reviewed for unnecessary medications during the survey.The findings include:On 2/13/26 at 10:13 AM a record review of Resident #150's Pharmacy monthly review revealed the following:On 9/12/25- irregularities, clinically significantA record review of the paper chart revealed no physician signed hard copy of pharmacist recommendations. A review of the Medication Regime Review Policy revealed, in part:Clinically significant irregularities will be addressed with the Medical Director and Director of Nursing the day the notification is received or communicated from the Consultant Pharmacist.If the medical practitioner fails to address the irregularity in a timely manner the Director of Nursing will escalate the concern to the Medical Director.On 2/13/26 at 2:34, in an interview,…

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

Based on medical record review and interview it was determined that the facility failed to ensure social service notes were completed in a timely manner and readily accessible. This was found to be evident for one (Resident #12) out of four residents reviewed for care planning.The findings include: Resident #12 has resided at the facility for more than one yearOn 2/12/26 review of Resident #12's Care Conference notes for meetings held in March, June and September 2025 revealed each note was entered as a LATE ENTRY, indicating the notes were not completed on the date the meetings occurred.Further review of the details of the note written for the meeting held 9/23/25 revealed it was created (i.e. written) by the Social Service Director (SSD) #21 on 1/16/26.Care Conferences are interdisciplinary team meetings that are to occur following the completion of Minimum Data Set (MDS) assessments. The MDS is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan…

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

Based on record review and interviews, it was determined that the facility failed to ensure that employees received the mandatory training for quality assurance and performance improvement. This was evident for one employee (LPN #35) out of five employee files reviewed during this survey.Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving.The findings include:During the survey, a review of Licensed Practical Nurse (LPN #35) employee file revealed a hire date of 6/30/22. The facility provided required training via an online service called Relias. On 2/13/26 at 2:25 PM a review of LPN #35's Relias transcripts revealed a lack of Quality Improvement training. The Director of Nursing was made aware of the…

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

Based on observation, record review, and interview, it was determined that the facility failed to ensure medications were administered based on professional standards of practice. This was evident for 1 of 1 medication administration observed during a complaint survey. The findings include: On 11/03/2025 at 8:01 AM, review of Complaint #2656373 revealed an allegation that medications were not administered as ordered.On 11/04/2025 at 9:00 AM, a random observation of Licensed Practical Nurse (Staff #13) administering medications to Resident #11 revealed several medications administered, two of which being Fluticasone-Salmeterol and Albuterol (both are inhalers which are medications given through the mouth by taking a deep breath to help breathing).Further observation revealed that Staff #13 administered one puff (one breath) of Fluticasone-Salmeterol and one puff of Albuterol. On 11/04/2025 at 9:40 AM, review of the medication administration record revealed that Fluticasone-Salmeterol and Umeclidinium Bromide (another type of inhaler) were signed off as administered during the 9:00 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint #2593162, observation, interview, and record review, it was determined that the facility failed to provide nail care to dependent residents. This was evident for 1 out of 1 resident (Resident #2) reviewed for Activities of Daily Living (ADL) care during the survey process.The findings include:The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment.Minimum Data Set (MDS) or MDS assessment, is a standardized, federally mandated clinical and functional assessment of residents in Medicare and Medicaid-certified nursing homes. The assessment helps nursing home staff understand a resident's strengths and needs to create an individualized care plan, monitor quality of care, and determine reimbursement. It is conducted upon admission, periodically (quarterly and annually),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 #2593162, observations and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 test tray temperature observations conducted during survey process. This deficient practice has the potential to affect all residents who receive meals prepared and delivered by the facility. The findings include:On 10/30/2025 at 8:41 AM, a review of complaint #2593162 alleged that Resident #2's food was always cold. On 10/30/2025 at 9:53 AM, during an interview with Resident #2, who resided on the Cedar Unit, the resident stated that meals always come very cold regardless of the meal and added that foods expected to be warm were cold by the time the tray arrived. On 11/03/2025 at 7:48 AM, the surveyor observed that it was only one Geriatric Nursing Assistant (GNA #6) passing the tray out on Cedar unit and there were several times the meal cart was left open and unattended to. On 11/03/2025 at 7:53 AM, during an interview 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 interview, record review, facility document review, and facility policy review, the facility failed to immediately inform the resident's legal representative of an accident involving 1 (Resident #9) of 3 residents reviewed for notification of change in condition. Findings included: An undated facility policy titled, Notification of Change in Condition, revealed, The purpose of this policy is to provide guidance for notifications made to residents, resident representatives, and authorized family members for resident changes in condition. Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, therapy services changes, transfer, hospitalizations, or death. The policy revealed, Compliance Guidelines: The center must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification including but not…

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

2. An admission Record revealed the facility admitted Resident #10 on November 2023. According to the admission Record, Resident #10 had a medical history that included a diagnosis of unspecified Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/19/2025, indicated Resident #10 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment for Mental Status (SAMS). Resident #10's Care Plan Report included a focus area, revised 02/19/2024, that indicated the resident had impaired cognitive function related to Alzheimer's dementia. An email, dated 04/17/2025, sent by Resident Representative (RR) #4 to the Director of Social Services (DSS) on behalf of Resident #10, indicated RR #4 wanted to know what the DSS had planned to do about Resident #10's missing property, and RR #4 requested that the plan for finding the property be submitted back to them in writing. The DSS replied to the email that RR #4's concerns had been placed on a grievance form and given to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility document and policy review, the facility failed to thoroughly investigate an allegation of abuse for 1 (Resident #6) of 3 sampled residents reviewed for abuse. Findings included: An undated facility policy titled, Maryland Abuse, Neglect & Misappropriation, revealed, Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. The policy revealed the section titled, Procedure, included, V. Investigation of Incidents, 2. A Suspected Abuse d. Statements will be obtained from staff related to the incident, including victim, person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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, record review, and facility policy review, the facility failed to provide necessary care and services to maintain proper grooming and personal hygiene related to fingernail care and bathing for 1 (Resident #2) of 4 residents reviewed for activities of daily living (ADLs). Findings included: An undated facility policy titled, Resident Rights, indicated, Definitions: Dignity: a state worthy of honor or respect; includes but not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing, sanitary food and hydration; respecting resident choice and attending to needs in a timely fashion. An admission Record revealed the facility admitted Resident #2 on December 2024. According to the admission Record, Resident #2 had a medical history that included unspecified osteomyelitis (bone infection), necrotizing fasciitis (flesh-eating disease), unspecified local infection of the skin and subcutaneous tissue, an unspecified pressure ulcer of the sacral region, and complete paraplegia. A quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaint MD00213109, observation of resident rooms and equipment, and resident and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 3 of 4 nursing units observed. The findings include: On 2/25/25 at 10:15 AM a review of complaint MD00213109 revealed complaints of a section of the ceiling by the window leak had crumbled back in late September 2024 along with mold and peeling paint in room [ROOM NUMBER]-B. The complainant alleged that some work was done on the ceiling to repair it, however the room was still not completely finished and remained not homelike. On 2/25/25 at 10:28 AM a tour was conducted of the facility. The following observations were made of disrepair: room [ROOM NUMBER]: There was a board with nails hanging out of the board that was over the top of the window. Resident #29 said that the sheet rock fell down, and they have not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 2/27/25 at 10:15 AM a review of complaint MD00213453 alleged that Resident #23 was admitted with a wound on the buttocks and now had acquired wounds on the legs. It was alleged that the bandage on the wound on the worst leg had not been changed since 1/10/25. The complaint also alleged that the barrier used for the wound was not being applied to the resident's wound on the buttocks. Review of the January 2025 Treatment administration record (TAR) had an order, cleanse sacrum with wound cleanser, pat dry, apply Medi honey and calcium, and cover with dry dressing every day shift, Left Lower Leg: Cleanse with 0.25% Dakin's solution, pat dry apply Santyl and calcium alginate and cover with Bordered Gauze. every day shift, and Resident is on a pressure reducing/relieving mattress every shift for Pressure reducing/relieving, elevate BLE (bilateral lower extremities) every shift and low air loss mattress, check function and status every shift, and turn and reposition every 2 hours every shift for pressure relief.…

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

Based on interview and review of pertinent documentation, it was determined that the facility failed to treat residents with respect and dignity by attempting to restrict a resident access to a family member which was inconsistent with the resident's wishes. This was evident for 1 (#4) of 37 residents reviewed for complaints. The findings include: On 2/26/25 at 10:30 AM, a review of complaint MD00210366 was conducted. In the complaint, the complainant stated that on 9/20/24, at approximately 8:00 PM, while a family member was visiting, Resident #4 called for nursing assistance because his/her ileostomy bag was leaking and needed incontinent care. At approximately 9:00 PM, Staff #21, geriatric nursing assistant (GNA) and Staff #30, GNA, entered the resident's room. Staff #30 asked Resident #4's family member to leave the room while they provided care to the resident, and the family member, who was authorized by Resident #4 to stay in the room when s/he received care, declined to leave the room. The complainant alleged that Staff #30 refused to provide the resident's care when 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 ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#18) of 28 residents reviewed for complaints during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A nephrostomy tube is a thin tube inserted into the kidney to drain urine when the urinary tract is blocked. Proper care is essential to prevent infection and ensure optimal drainage. On 2/26/25 at 1:33 PM a review of Resident #18's medical record revealed a discharge summary that documented one of the resident's discharge diagnoses was R (right) hydroureteronephrosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility staff failed to ensure a resident's plans of care included individual resident care needs and interventions to assist each resident in reaching their highest practicable level of wellbeing (Resident #8). This was evident for 1 of 35 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #8's medical record on 2/25/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include neuromuscular dysfunction of the bladder and the Resident had a suprapubic catheter. A suprapubic catheter is a tube inserted directly into the bladder through a small incision in the lower abdomen. It is used to drain urine when individuals are unable to urinate themselves. Further review of Resident #8's medical record revealed the facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, medical record review and interview, it was determined that the facility staff failed to provide needed activities of daily living for a resident dependent on assistance with care (Resident #8, #18, #24). This was evident for 3 of 28 residents reviewed for complaints during a complaint survey. The findings include: 1) On 2/25/25 review of complaint MD00214802 revealed an allegation that Resident #8 was left in feces for hours on 2/14/25. Review of Resident #8's medical record on 2/25/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include neuromuscular dysfunction of the bladder and the Resident had a suprapubic catheter. A suprapubic catheter is a tube inserted directly into the bladder through a small incision in the lower abdomen. It is used to drain urine when individuals are unable to urinate themselves. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer treatments as ordered by the physician (Resident #8, #16) and failed to accurately assess a resident who was admitted with a nephrostomy tube and failed to monitor the nephrostomy tube while the resident resided at the facility (Resident #18). This was evident for 3 of 35 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to administer flushes to Resident #8's suprapubic catheter from 1/28/25 until 2/8/25. Review of Resident #8's medical record on 2/25/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include neuromuscular dysfunction of the bladder and the Resident had a suprapubic catheter. A suprapubic catheter is a tube inserted directly into the bladder through a small incision in the lower abdomen. It is used to drain urine when individuals are unable to urinate themselves. Review of the progress notes from Resident #8's Urology appointment on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaint, medical record review, and staff interview it was determined the facility failed to provide timely treatment/services to prevent/heal pressures ulcers. This was evident for 2 (#23, #18) of 28 residents reviewed for complaints during a complaint survey. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). 1) On 2/27/25 at 10:15 AM a review of…

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

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure orders for a topical anesthetic patch included the duration of time the patch should be applied. This was evident for 1 (#1) of 37 residents reviewed for complaints. The findings include: A Lidocaine (local anesthetic) patch, when applied to the skin, helps reduce pain by causing a temporary loss of feeling in the area where the patch was applied. Depending on the Lidocaine patch product, the patch may be left on the skin for up to 8 or 12 hours. According to MedlinePlus a division of the National Institutes of Health (NIH), Lidocaine 4% patches can be applied up to 3 times daily and for no more than 8 hours per application. Applying too many patches or topical systems or leaving them on for too long may cause serious side effects. On 3/3/25 at a review of Resident #1's February 2025 Medication Administration Record (MAR) revealed an 1/11/25 order for Lidocaine Pain Relief 4% Patch, apply to lower back topically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and interview, the facility staff failed to ensure a resident receives dental services as recommended (Resident #16). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey. The findings include: Review of Resident #16's medical record's on 2/25/25 revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #16's medical record revealed the Resident was seen by the Dentist on 7/3/24 for initial examination and the Dentist noted the Resident had severe gingivitis. At that time the Dentist recommended a periodic oral examination on 1/3/25. Further review of Resident #16's medical record on 3/3/25 revealed the Resident had not had a follow up dental visit since 7/3/24. Interview with the Assistant Director of Nursing on 3/3/25 at 12:00 PM confirmed the facility staff failed to ensure Resident #16 had a 6 month dental visit in January 2025.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to assess a resident's need for rehabilitation services (Resident #7). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey. The findings include: Review of Resident #7's medical record on 2/25/25 revealed the Resident was admitted to the facility on [DATE] from the hospital for subacute rehabilitation. Interview with Resident #7 on 2/25/25 at 11:30 AM the Resident stated he/she isn't getting physical therapy and would like to receive to be able to discharge from the facility. Further review of Resident #7's medical record revealed the Resident received physical and occupational therapy from admission until 8/6/24. Interview with the Director of Rehabilitation (DOR) on 2/25/25 at 12:58 PM, the DOR stated after 8/6/24 until 2/25/24 the Resident had not received any physical or occupational therapy. The Surveyor asked the DOR for evidence of quarterly evaluations of the Resident. The DOR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #8). This was evident for 1 of 28 residents reviewed for complaints during a complaint survey. The findings include: Review of Resident #8's medical record on 2/25/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include neuromuscular dysfunction of the bladder and the Resident had a suprapubic catheter. A suprapubic catheter is a tube inserted directly into the bladder through a small incision in the lower abdomen. It is used to drain urine when individuals are unable to urinate themselves. Further review of Resident #8's medical record revealed on 2/17/25 the Resident went to the Emergency Department and had a diagnosis of Urinary Tract Infection and to schedule an appointment with Chesapeake Urology in one week around 2/24/25. Further review of Resident #8's medical record on 2/27/25 the Resident had not seen the urologist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility staff failed to maintain infection control procedures while providing patient care. This was evident on 2 of 5 units observed during a complaint survey. The findings include: 1. Observation was made on 2/27/25 at 11:25 AM of a sign on Resident #23's room door. The sign posted on the door stated, Enhanced Barrier Precautions and that hands were to be sanitized prior to entering the room. The sign further stated if giving direct patient care, then a gown and gloves were to be worn. On 2/27/25 at 11:25 AM observation was made of geriatric nursing assistant (GNA) #21 in Resident #23's room. GNA #21 was providing patient care such as brushing Resident #23's teeth and bathing the resident. GNA #21 was wearing gloves. GNA #21 was wearing pants and a top and a nursing jacket. GNA #21 was not wearing a protective gown. A second observation was made on 2/28/25 at 10:15 AM. GNA #21 was in the resident's room providing patient care and did not have a…

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

Based on medical record review secondary to a complaint, interview with representatives and facility staff, it was determined that the facility failed to notify the correct resident representative when there was a documented change in condition. This was evident during the review of 1 of 4 residents reviewed with pressure ulcers. The findings include: Interview on 8/27/24 at 12:30 PM with the representative for Resident #463 revealed multiple concerns including that s/he was power of attorney (POA) for Resident #463 and was not notified of the changes that occurred with him/her. The concern was that there was a decline and Resident #463 eventually passed away 6/4/24. The POA verbalized that they were not included in the changes and care with Resident #463. Review on 8/28/24 at 10:53 AM of the medical record for Resident # 463 revealed diagnosis including multiple sclerosis (a chronic disease of the central nervous system, resulting nerve damage disrupts communication between the brain and the body) with contractures. This review revealed that there were 17 changes in condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews and observation, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#27, #75) of 6 residents reviewed for unnecessary medications, 1 (#92) of 6 residents reviewed for limited range of motion (ROM), 1 (#563) of 7 residents reviewed for accidents, and 1 (#20) of 1 resident reviewed for dental. The findings include: 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. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) A record review on 8/29/24 at 11:24 AM showed that Resident #27 was admitted to the facility in August 2019. Continued review found an MDS assessment dated [DATE] for Resident #27. The MDS had recorded antiplatelet use in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (#101 and #27) and failed to revise a resident's care plan (Resident #6 and #16). This was evident for 3 of 31 residents reviewed during an annual survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. The facility staff failed to have quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident for 3 of 3 residents (#151, #81 and #169) reviewed during an annual survey. The findings include: 1. On 9/8//24 at 12 PM a review of Resident #151's clinical record revealed that the resident's primary physician on 8/10/2024, ordered Dilaudid (Hydromorphone) Oral Tablet 2 MG, give 1 tablet by mouth every 4 hours as needed for Pain. This medication is used to help relieve moderate to severe pain. Dilaudid (Hydromorphone) belongs to a class of drugs known as opioid analgesics. A review of the August 2024, Control Medication Utilization Record revealed Dilaudid (Hydromorphone) on the following days and times was removed 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 observations, medical record reviews, and interviews, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 9 errors identified out of 26 opportunities for error. The findings include: 1) During observation of medication administration on 8/30/24 at 8:52 AM, the surveyor observed that Staff #30, a licensed practical nurse (LPN), had already prepared medications for Residents #76 and #134. The nurse prepared a total of 2 medications for Resident #76 and 4 medications for Resident #134. Staff #30 went into Resident #76's room to administer his/her medications and took Resident #134's medications along with her. Staff #30 was questioned and stated, I know I'm not supposed to pull medications for 2 residents at a time, but you already caught me. A review of the facility's medication Administration policies and standard procedures on 8/30/24 at 12:41 PM noted a statement to prepare one resident's medication at a time. However, staff #30 prepared medications for 2 residents at a time. 2) On 8/30/24 at…

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

Based on observations and interviews, it was determined that the facility failed to properly store medications, as evidenced by not labeling multi-dose medications when they were opened. This was evident for 2 of 2 medication rooms and 2 of 4 medication carts observed during the survey. The findings include: 1) Observation on 9/3/24 at 9:12 AM of the Dogwood unit medication room with Staff #33, a unit manager, showed an antidiabetic injection pen in the refrigerator for Resident #27. The medication had one dose remaining and was not labeled with the opening date. Staff #33 reported that staff was supposed to date it upon opening it. Continued observation noted a multi-dose vial of purified protein derivative (PPD) injection which had been opened but not labeled with the date it was opened. Staff #33 confirmed that it was not labeled with the opening date. 2) Observation on 9/3/24 at 9:17 AM of the Cedar unit medication room refrigerator with staff #33 showed a multi-use vial of PPD which was opened and not labeled with the date it was opened. Staff #33 confirmed it was not dated and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to ensure a resident went to scheduled out of the facility physician visits in a timely manner. This was evident for 3 (#81, #20 and #159) of 31 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to ensure Resident #81 went to a urology appointment in a timely manner. Review of Resident #81's medical record on 9/3/24 revealed the Resident had a schedule Urology appointment on June 13, 2024, at 10:15 AM. Further review of Resident #81's medical record revealed no documentation of a urology follow up on June 13, 2024. On 9/3/24 at 9:30 AM, the Unit Manager #4 was unaware of the missed Urology appointment for Resident #81 and rescheduled the appointment for 9/25/24 at 1:45 PM. Interview with Director of Nursing on 9/9/24 at 10 AM confirmed the facility staff failed to schedule transportation for Resident #81's urology follow up. 2. During initial interview on 8/29/24 at 8:44 AM…

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

Based on record review, observations, and interviews, it was determined that the facility failed to maintain residents' dignity by staff standing over residents while assisting them to eat. This was evident for 2 (#48, #140) of 2 residents reviewed for dignity. The findings include: 1) A medical record review for Resident #48 on 9/3/24 at 9:50 AM showed that the Resident was admitted to the facility in July 2024 with diagnoses including dementia. Continued review noted that he/she required staff assistance with eating. During a meal observation on 9/4/24 at 8:09 AM, staff #41 was noted feeding Resident #48 while standing. An interview with staff #41 on 9/4/24 at 8:37 AM revealed that she was unaware that feeding a resident while standing was a dignity concern. In an interview on 9/4/24 at 9:41 AM, staff #33, a unit manager, reported that staff was expected to sit at eye level when assisting residents to eat and not to stand because of dignity concerns. 2) A meal observation on the Dogwood unit on 9/4/24 at 8:27 AM showed staff #40, a geriatric nurse aid (GNA), standing over Resident…

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

Based on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby from 8/27/24 through 9/9/24 revealed no evidence of the State inspection results in an open and readily accessible area for residents, staff, and visitors to review. A Sign was not posted telling residents where the state survey results were located. On 9/9/24 at 9:30 AM, an interview with the Nursing Home Administrator confirmed the facility staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed.

Based on record review and interviews, it was determined that the facility failed to ensure that Beneficiary Protection Notifications were issued to 1) a resident who was discharged from Medicare-covered Part A stay with benefit days remaining and was discharged from the facility to his/her home and 2) Residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 3 (#514, #147, #65) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The notices include: Notice of Medicare Non-Coverage (NOMNC): This must be issued at least two calendar days before the last day of…

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

Based on review of a facility reported incident with investigation, medical record review, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 2 (#47, #54) of 8 residents reviewed for abuse during an annual and complaint survey. The findings include: 1) On 9/4/24 at 11:30 AM a review of Resident #47's medical record revealed Resident #47 had resided at the facility for the past 8 years. Resident #47 had diagnoses that included post-traumatic stress disorder, schizoaffective disorder-bipolar type, anxiety disorder, and major depressive disorder that was recurrent and moderate. On 9/4/24 at 11:30 AM a review of facility reported incident MD00196514 was conducted and revealed on 9/3/23 at approximately 8:00 AM Resident #47 alleged that Housekeeping Staff #37 screamed and yelled at the resident. Review of Staff #38's written statement documented that Resident #47 was out of the room receiving morning medication. When Resident #47 went back to his/her room and walked into the bathroom, Staff #37…

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

Based on reviews of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3 (#165, #47, #42) of 8 residents reviewed during the annual and complaint survey. The findings include: 1) On 9/3/24 at 11:45 AM a review of facility reported incident MD00199871 was conducted and revealed a written statement from RN #12 that documented around 4:00 AM on 11/25/23 RN #12 received a call from LPN #1 to come to Resident #165's room to check on the resident. RN #12 documented that she immediately went to the resident's room to find out what happened, and the resident stated, the black big guy raped me with his hand and some equipment. It was around 5:30 PM yesterday. Review of the Facility Reported Incident Initial Report Form documented the initial report was sent to OHCQ on 11/25/23 at 8:30 PM, which was not within 2 hours of an alleged sexual abuse. There were no email confirmations provided to the…

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

Based on interviews and medical record review, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 2 (#126, #39) of 7 residents reviewed for hospitalization. The findings include: 1) An interview with Resident #126's representative on 8/29/24 at 1:59 PM revealed that Resident #126 had been hospitalized recently. The representative stated that the facility staff discussed the bed hold policy with her via the phone and not in writing. A medical record review for Resident #126 on 9/6/24 at 7:53 AM showed that the Resident was admitted to the facility in February 2023. Continued review revealed that Resident #126 was having difficulty breathing on 7/31/24. The attending provider was notified and ordered Resident #126 to be transferred to the hospital for evaluation. However, the review failed to show that a copy of the facility's bed hold policy was mailed to the Resident's representative. In an interview on 9/6/24 at 9:52 AM, the assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #159 and #75). This was evident for 2 of 14 residents reviewed for baseline care plans during an annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1. During interview with Resident #159 on 8/29/24 at 10:27 AM, Resident #159 stated he/she was never given a baseline care plan or had a meeting with the facility staff to discuss. Review of Resident #159's medical record on 9/3/24…

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 medical record review, observation and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #20 and #75). This was evident for 2 of 31 residents reviewed during an annual survey. The findings include: 1. During initial interview on 8/29/24 at 8:44 AM with Resident #20, it was revealed that s/he had some visible missing teeth on the upper and lower jaw. S/he verbalized at that time that s/he has been to a dentist recently and there were recommendations, but s/he does not think that there has been any follow up. Resident #20 then showed this surveyor a loose tooth in the front bottom right of his/her mouth. There was no pain reported but some discomfort. S/he reported that they were just waiting for it to fall out. A review of the medical record on 8/29/24 at 9:04 AM for Resident #20 revealed a dentist visit on 8/14/24 with recommendations for Peridex to improve oral health. The consult noted that nursing staff is to provide Peridex-a…

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

Based on observations, medical record review, and interviews, it was determined that the facility failed to 1) provide a resident with the amount of assistance needed during meals, 2) ensure that a resident who was unable to carry out activities of daily living (ADL) fingernails were trimmed. This was evident for 2 (#48, #92) out of 4 residents who were reviewed for activities of daily living (ADL). The findings include: 1) An Observation on 8/29/24 at 8:10 AM showed Resident #48 lying in bed, and a signage reading RN/GNAs-1:1 feed was noted above the head of the resident's bed. Continued observation noted Resident #48 trying to feed him/herself breakfast. The Resident's gown was soiled with food particles in the chest area. Further observation of the staff assignment board later that day showed a statement Assisted diners which included Resident #48's room number. Staff #33 was questioned about it, and she reported that it meant Resident #48 needed assistance eating all his/her meals. A subsequent observation on 8/30/24 at 1:19 PM noted Resident #48 feeding himself/herself lunch.…

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

Based on observations, medical record reviews, and staff interviews, it was determined that the facility failed to provide activities to meet the residents' needs and preferences. This was evident for 1 (#48) of 4 residents reviewed for Activity. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. Observations on 8/29/24 at approximately 12:14 PM and 8/30/24 at approximately 1:17 PM showed Resident #48 lying in bed and not involved in any activity. A record review for Resident #48 on 9/3/24 at 9:50 AM showed that the resident was admitted to the facility in July 2024 with diagnoses including Dementia. The review also noted an admission Minimum Data Set (MDS) assessment for Resident #48 dated 7/26/24, which had documented that the resident had severely impaired cognition. Further review of the MDS assessment noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health. This was evident for 1 (#166) of 4 residents reviewed for quality of care. The findings include: On 9/4/24 at 9:42 AM a review of complaint MD00205771 alleged that Resident #166 was a quadriplegic and in need of assistance. The complaint alleged that the resident felt the facility was not helping the resident and for that reason, had not had a bowel movement in 6 to 7 days because he/she was afraid they wouldn't be cared for correctly. Resident #166 called 911 and was transported to the hospital on 5/13/24. On 9/4/24 at 9:42 AM a review of Resident #166's medical record was conducted and revealed Resident #166 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included a fracture of the left mandible, traumatic subarachnoid hemorrhage, quadriplegia, pressure ulcers of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #263). This is evident for 1 of 4 residents reviewed for pressure ulcers during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure…

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

Based on interview and observation, it was determined that the facility failed to change the oxygen tubing for a resident dependent on Oxygen per facility policy. This was evident during the observations of 1 of 3 (#20) residents dependent on oxygen. The findings include: During an initial observation and interview on 8/29/24 at 8:49 AM with Resident #20, this surveyor was observing the environment when the Resident was asked if the oxygen equipment could be reviewed. The tubing was labeled with the date 7/18/24. A note was made, and the surveyor asked Resident #20 if the staff change the oxygen equipment. S/he stated they do but, they were not sure when the last time was, and they had concerns about the noise the oxygen regulator was making. Interview with that unit manager, staff #4 on the process of changing oxygen tubing at 8/29/24 at 11:02 AM, revealed that the process is every 7 days. This surveyor reported that the tubing for Resident #20 was dated 7/18/24. He immediately took care of the oxygen tubing. A review of Resident #20's physician orders revealed that there was an…

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

Based on observation and interview with consultants and facility staff, it was determined that the facility consultants failed to appropriately assess a resident and their need for psychiatric services, this was evident during the review of 1 of 5 (#107) residents reviewed for outside consultant services. The findings include: Resident #107 was observed in bed asleep during initial tours and observation on 8/29/24 at 8:54 AM Record review on 08/29/24 12:37 PM revealed diagnosis including encephalopathy (a group of conditions that cause brain dysfunction), aphasia (a disorder that affects how you communicate) post cerebrovascular accident and dysphagia (a language disorder that affects the ability to understand and produce spoken language). Again on 8/30/24 at 10:10 AM this surveyor attempted to interact with Resident #107, and s/he was in the middle of physical therapy. S/he was sitting on the side of the bed with the physical therapist but was not verbally interactive noted from the observation and the physical therapist who also confirmed, though s/he could look around 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 reviews of a facility reported incident and medical record and facility staff interview, it was determined that the facility failed to obtain a urinalysis and urine culture, and sensitivity as ordered by Resident #106's physician. This was evident in 1 of 86 resident complaints reviewed during an annual recertification survey. The findings include: The State Survey Agency (SA) received complainant allegations (Intake #MD00205948) indicating that Resident #106 was physically aggressive towards a staff member on 05/22/24. The facility intake MD00205948 indicated that Resident #106 was going to be assessed by his/her attending physician, was to be evaluated by the facility psychiatric services, and was to have blood and urine samples obtained. Resident #106 was assessed by his/her physician on 05/22/24 at 2 PM who wrote orders instructing the nursing staff to obtain a psychiatric consult for Resident #106 and obtain lab specimens that included a CBC/CMP/urinalysis/urine culture and sensitivity due to abnormal behavior. Further review of Resident #106's medical record on…

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

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 2 (#169, #166) of 93 residents reviewed during an annual and 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 9/5/24 at 10:33 AM a review of complaint MD00186126 revealed an allegation that pain medication was not given since Resident #169 was discharged from the hospital. Review of a physician's history and physical documented that Resident #169 was receiving Morphine 50 mg. three times a day, when documentation indicated the resident received Morphine 15 mg. three times a day. The dosages did not match. Additionally, the nurse documented a pain assessment in the resident's vital section of…

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

Based on observations and interviews, it was determined that the facility failed to supply a staff restroom with soap for staff to wash their hands after use. The lack of soap in a staff restroom is an important step in the implementation of appropriate standard and transmission-based precautions to help prevent the spread of infections. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: On 8/30/24 at approximately 11:00 am, the surveyor observed that the staff restroom by the Magnolia Unit nurses' station did not contain soap for staff use due to a malfunctioning automatic soap dispenser. At 11:10 am, the surveyor interviewed Magnolia Unit Manager #4 at the Magnolia nurses' station regarding the lack of soap in the staff restroom and the malfunctioning automatic soap dispenser. Magnolia Unit Manager #4 stated that he/she was unaware of the lack of soap in the staff restroom and the malfunctioning automatic soap dispenser. While the surveyor was interviewing Magnolia Unit Manager #4, the Maintenance Director…

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

Based on observations, administrative record reviews and interviews with facility staff it was determined the facility failed to ensure that an effective call system was in place so that residents could access staff for assistance when needed. This was found to be evident during the facility's annual Medicare/Medicaid survey. Findings include: Intake MD00178023 was reviewed on 9/7/22 for an ongoing concern, regarding multiple outages of call bell system complaints throughout the facility, specifically on the 2nd floor. While conducting an initial tour of the building on 9/7/22 at 4:30 AM an observation was made of Resident #93. Upon entering the resident's room, the call bell was observed not plugged into the wall unit. The call bell must be attached to the wall unit to function. Three staff, Licensed Practical Nurse #2, Registered Nurse Supervisor #1, and Certified Nurse Assistant (CNA) #3 were made aware of this concern at the time of the observation. They stated that they would report the concern to the Maintenance Director (MD), Staff # 12. On 9/19/22 at 11:15 AM Staff # 12 was…

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

Based on administrative record review and interviews with facility staff it was determined the facility staff failed to: 1) report allegations of abuse to the appropriate agency for (Resident #9, #31, #126), and 2.) notify the state agency no later than 5 days of the results of investigations for (Resident #301, #308, #309). This was found to be evident for 6 of 15 intakes reviewed for abuse during the facility's annual Medicare/ Medicaid survey. Findings include: The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, unusual occurrences and misappropriation of resident property are reported immediately to officials in accordance with state laws. 1. The facility failed staff failed to report an allegation of verbal abuse immediately. This was evident during the review of complaint MD00181998 (Resident #31). Review of Resident #31's medical record on 9/12/22 at 8 AM revealed multiple co-morbidities including bipolar disorder. On 9/12/22 at 8 AM, review of the complaint for MD00181998 revealed that 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 medical record review and interviews with facility staff it was determined the facility failed to follow professional standards of practice by documenting that a healed wound was assessed, and that physician-ordered treatment was being done to the wound. This was found to be evident for 1 (Resident # 96) of 16 residents reviewed for pressure ulcers during the facility's annual Medicare/ Medicaid survey. Findings include: Review of Resident #96's medical record on 9/9/22 at 2:25 PM, and a Minimum Data Set (MDS) assessment (a tool used in nursing homes to gather information regarding a resident's strengths and needs) dated 7/24/22 revealed the resident had an unhealed pressure ulcer. The assessment did not include a pressure ulcer stage. Further review of a physician order dated 7/22/22 revealed the following: Cleanse sacrum wound with normal saline, pat dry, medihoney daily and cover with dry dressing everyday shift. An interview was conducted with the ADON on 10/12/22 at 9:30 AM and she was asked to provide a copy of Resident # 96's wound sheets to the survey team for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with residents and facility staff, it was determined the facility failed to follow a physician order for residents (#81, #201, #66, #361, #13, #355, #363). This was evident for 7 of 19 residents reviewed for physician orders during the annual survey. The findings include: 1.The facility failed to change a bandage as ordered by the physician for Resident (#81). Review of Resident #81's medical record on 9/8/22 at 11 AM revealed a physician order dated 9/3/22 to cleanse the right leg surgical site with normal saline, pat dry and wrap with Kling/kerlix. Review of the (MAR) Treatment Administration Record revealed the dressing was not signed off as being done. During an interview with Resident #81 on 9/8/22 at 10:53 AM, s/he stated, My bandage has not been changed on my right leg since Friday (9/3/22). During an interview on 9/8/22 at 12 Noon with the wound nurse staff (#39) she stated, she does not work on the weekends the nurses are responsible for changing the…

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

Based on record review and staff interview, the facility failed to provide continuity of physician supervised care to a resident. This was evident for 1 of 96 (Resident #13) residents reviewed during a recertification survey. The findings includes: Review of Resident #13's medical record on 9/29/22 at 9:38 AM revealed that nursing documentation on 11/11/21 reported that the resident displayed signs of anxiety about living in the facility. Further review of Resident #13's medical record on 9/29/22 at 10:11 AM revealed that the resident was seen by a psychiatric nurse practitioner on 1/10/22 and, according to the visit notes, the resident was ordered the medication Buspar to assist with anxiety. Additional review of the Resident #13's medical record on 9/29/22 at 10:30 AM revealed that the resident did not receive Buspar until 9/26/22. Resident #13 was seen by other psychiatric providers on 1/20/22, 3/03/22, 5/11/22, 5/18/22, 7/6/22, and 9/14/22 and none of these providers provided follow-up on the resident's Buspar order. Interview with the Assistant Director of Nursing (ADON) 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 administrative record review and interviews with facility staff it was determined the facility failed to: 1.) ensure an accurate review of hospital discharge summary information and the application of a wound vac per the recommendation of the surgeon (Resident #66); 2.) provide review and follow-up on orders issued for Resident #13. This was found to be evident for 2 of 96 residents reviewed during the facility's annual Medicare/ Medicaid survey. Findings include: 1. On 9/19/22 at 10:30 AM Intake MD00183034 was reviewed for multiple concerns regarding Resident # 66. A review of Resident #66's medical record on 9/19/22 revealed the resident was readmitted to the facility status post (s/p) incision and drainage (I&D) hospital procedure. Further review of a discharge summary note for a wound dressing dated 8/16/22 revealed the following: please apply a dry gauze dressing to the incision area- apply xeroform gauze to the thin/small open wound areas adjacent to the incision (where xeroform previously placed), cover with dry gauze and secured with micropore tape until the wound…

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

Based on observations, administrative record reviews, and facility staff interviews, the facility administration failed to: 1) provide an alternative means for communication with providers when the providers cannot reach facility staff by normal means. This was evident for 1 out of 96 (Resident #105) residents review during a recertification survey; and 2.) ensure that an effective facility call system was in place so that residents could access staff for assistance when needed. This deficient practice has the potential to affect all residents. The findings includes: 1. Review of Resident #105's medical records on 10/4/22 at 10:06 AM revealed that a provider was unable to contact facility staff twice on 7/23/22 (10:44 PM and and 11:50 PM) to inquire about the resident's medical history to provide emergency treatment at the hospital. During an interview with the Assistance Director of Nursing (ADON) on 10/4/22 at 10:30 AM, the surveyor inquired about the facility policy regarding facility staff availability to answer questions from providers requiring clarification on a resident's…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that accurate records were maintained for residents. This was found to be evident for 6 (Residents #81, #252, #117, #96, #359 and #363) of the 96 residents reviewed during the facility's annual Medicare/Medicaid survey. Findings include, Resident # 96 was admitted to the facility with the following but not limited diagnosis: Hemiplegia and Hemiparesis (Paralysis and Weakness), and Cerebral Infarction (Stroke) Affecting Right Dominant Side. 1. Resident #252's medical record was reviewed on 9/12/22 at 5:33 AM and it revealed the resident had 2 Physician Certifications Related to Medical Condition, Substitute Decision Making, and Treatment Limitations Forms dated and signed by 2 Physicians on 4/24/21 and 4/27/21. Under the section Certification of Ability to Comprehend Information and Make Decisions, both forms have Resident #252 documented as unable to understand and make decisions. Further review of the resident face sheet had the resident as their own Resident…

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

Based on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that effective Quality Assurance and Performance Improvement (QAPI) interventions were implemented to address identified quality deficiencies. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey. Findings include: The facility's annual survey conducted on 9/7/22 identified non-compliance regarding Quality of Care, Infection Control, Resident Abuse, Resident Call System, Resident Records, Resident Rights, Resident Accommodations, Resident Assessments, and Physician Services. An interview was conducted on 10/14/22 at 4:17 PM with the DON to discuss the facility's QAPI process. The DON brought a book to the survey team that had a small number of documents that included 7 signature sheets and a small amount of printouts of various incidents. The signature sheets had missed disciplines attending and included the month of the meeting but the year was cut off. The DON stated that the QAPI personnel shifted many…

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

Based on staff interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify Quality concerns and have a system in place to correct identified concerns. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey. Findings include: The facility's annual survey conducted on 9/7/22 identified non-compliance regarding Quality of Care, Infection Control, Resident Abuse, Resident Call System, Resident Records, Resident Rights, Resident Accommodations, Resident Assessments, and Physician Services. During an interview with the Director of Nursing (DON) on 10/14/22 at 4:17 PM, she brought a binder with a small amount of printouts of various incidents. The DON stated that the facility meets quarterly due to the facility needing staff to cover the units but recognized that they need to meet more frequently to address the many concerns. The DON confirmed that the facility recently hired a new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 interviews, review of pertinent documentation, and survey findings, it was determined the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) committee was in place to correct identified concerns. This was found to be evident while conducting the facility's annual Medicare/Medicaid survey. Findings include: The facility's annual survey conducted on 9/7/22 identified non-compliance regarding Quality of Care, Infection Control, Resident Abuse, Resident Call System, Resident Records, Resident Rights, Resident Accommodations, Resident Assessments, and Physician Services. During an interview with the Director of Nursing (DON) on 10/14/22 at 4:17 PM, she provided the survey team with (7) signature sheets and a small amount of printouts of various incidents. The signature sheets had missed disciplines attending and the dates on the signature sheets included the month, but the year was cut off. A Geriatric Nurse Aide (GNA) was listed on 2 of the 7 signature sheets. The DON stated that the facility meets quarterly due to the…

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

Based on surveyor observation and staff interviews, facility staff and visitors failed to complete the COVID-19 declaration/surveillance form and the facility. This deficient practice has the potential to affect all staff and visitors to the facility. The findings include: From 9/14/22 to 10/3/22, the surveyor made several observations of staff members and visitors failing to complete the COVID declaration/surveillance form. On 9/14/22 and 9/15/22 between 7:00 am and 7:15 am, the surveyor observed 10 employees fail to sign the COVID declaration/surveillance form. On 9/20/22, 9/22/22, and 9/23/22 between 7:00 am and 7:15 am, the surveyor observed 13 employees fail to sign the COVID-19 declaration/surveillance form. On 9/30/22 and 10/3/22 between 6:30 AM and 7:15 AM, the surveyor observed 7 employees and 2 visitors fail to complete the COVID-19 declaration/surveillance form. Surveyor observation revealed no signage at the entrance to alert staff and visitors of the facility's self-screening procedures. During an interview with the Director of Nursing (DON) on 10/3/22 at 9:30 AM, the…

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

Based on observation and interview it was determined the facility staff failed to: 1.) provide a dignified environment while a Resident (#26) was being assisted with dining, and 2.) failed to honor a resident's private space (Resident #126). This was evident 2 of 3 residents observed during the annual survey. The findings include: 1. The facility staff failed to provide a dignified environment while a Resident #26 was being assisted with dining. On 09/12/22 at 12:48 PM during observations in the first-floor dining area, surveyor observed Geriatric Nursing Assistant (GNA) #15 standing over Resident #26 assisting him/her with a meal. A napkin was over the resident's chest, and his/her lower abdomen was exposed. After feeding Resident #26, GNA #15 proceeded to place a wrapped sandwich on top of the resident's feet. On 09/12/22 at 12:53 PM during an interview with GNA #15, he/she verbalized knowing he/she is supposed to sit while feeding a resident and the unit did not have any clothing protectors. The GNA stated the resident was not going to eat the sandwich, he/she was going to feed…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that a resident phone was working properly. This was found to be evident for 1 (Resident # 93) of 79 complaints and facility reported incidents reviewed during the facility's annual Medicare/Medicaid survey. Findings Include: A review of MD00178081 on 9/7/22 at 4:00 AM revealed multiple concerns regarding Resident #93's phone allegedly being unplugged and that the resident family was unable to reach the resident for several days. An initial tour of the facility was conducted on 9/7/22 at 4:30 AM and an observation was made of resident #93's room. The resident phone was observed on the overbed table, and the phone cord was completely severed. There was one piece of cord attached to the phone with an area severed midway down and the other severed piece of the cord was noted in the wall jack. Three staff, Licensed Practical Nurse #2, Registered Nurse Supervisor #1 , and Geriatric Nurse Assistant (GNA) #3 were called to the resident room on 9/7/22 at 4:40 AM and were…

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

Based on interview with facility staff and residents and record review, the facility staff failed to honor residents' preferences of how daily activities will be scheduled. This is evident for 1 of 96 (Resident #355) residents reviewed during a recertification survey. The findings include: During an interview with Resident #355 on 9/7/22 at 10:59 AM, the resident complained of staff failing to get him/her out of the bed daily. The resident stated he/she clearly made the preference of getting out of the bed daily when he/she was admitted to the facility in 8/2022. On 09/15/22 at 12:03 PM, review of Resident #355's electronic records revealed that the resident reported that his/her preferences were not being met in a provider note dated 9/2/22. On 09/15/22 at 12:30 PM, the surveyor voiced concerns regarding facility staff members failing to honor Resident #355's preferences of how his/her daily activities will be scheduled with the Director of Nursing (DON). The DON confirmed the surveyor's findings without providing additional information regarding the deficient practice.

Based on observations and interviews it was determined the facility staff failed to ensure residents received contact information to reach the state agency and the ombudsman assigned to the facility. This had the potential to affect all the residents within the facility. The findings include: On 09/13/22 at 2:16 PM, Seventeen residents attended a Resident Council meeting conducted by the surveyor. Over half of the residents reported not having information to contact the state agency or the Ombudsman. Also, the residents reported they were unaware of their rights. 09/13/22 at 3:15 PM the surveyor made Director of Nursing #5 aware the residents did not have contact information to reach the state agency or the ombudsman. DON #5 reported he/she believes a resident contacted the Ombudsman in the past. After surveyor intervention, the surveyor observed a note in the elevator with contact information to reach the state agency and the ombudsman. On 09/14/22 at 2:12 PM during a telephone interview, Ombudsman #61 informed the surveyor he/she was in attendance via telephone during the Resident…

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

Based on observation and interviews it was determined the facility failed to ensure the residents, family members, and legal representatives had access to the results of the most recent survey results. This practice had the potential to affect all the residents. The findings include: On 09/13 22 at 2:16 PM, during a Resident Council meeting conducted by the surveyor, the residents reported they were unaware of the whereabouts of the most recent survey results. On 09/13/22 at 3:15 PM, Director of Nursing (DON) #5 was made aware the residents did not have access to the most recent survey results. The surveyor and DON walked to the lobby and the surveyor observed the survey book on a table in the corner near the right side of the sofa. The survey book was not visible in that location. The DON stated they were recently cleaning the lobby and the survey book may have been misplaced.

Based on review of facility records and interview with staff it was determined that the facility staff failed to provide residents/representatives with Advanced Beneficiary Notice of Non-coverage (SNFABN) in a timely manner. This was evident for 1 (#144) of 3 residents reviewed for Beneficiary Protection Notification. The findings include: The SNFABN provides information to residents/representative's beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to an expedited review of a services termination. A written copy of the notice must be received by the resident and or their representative in enough time to appeal the decision to terminate the paid coverage. The facility must indicate that the notice was sent/and or given within the specified time. A review was conducted on 10/14/22 at 9:30 AM of the beneficiary notification for Resident #144. The SNF Beneficiary Protection…

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

Based on administrative record review and interviews with facility staff, resident and family member, it was determined the facility failed to ensure that a resident's personal property was replaced when lost in the laundry. This was found to be evident for 1 (Resident # 111) of 79 intakes that were reviewed during the facility's annual Medicare/Medicaid survey. Findings include, Intake MD00174961 was reviewed on 10/3/22 at 2:23 PM and one of the concerns was that Resident #111's cell phone was lost and was not replaced. A phone interview was conducted with a family member of Resident #111's on 9/16/22 at 1:35 PM and they stated that Resident #111 had a cell phone when admitted . They further stated that the cell phone was checked on the inventory list that was filled out at the time of admission. The family member stated they have tried for two years to get the resident phone replaced without success. They went on to say that they spoke with the DON recently concerning this matter and it has not been resolved. The DON #5 provided a copy of the resident inventory form to the survey…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) provide complete and thorough documentation of an investigation and 2.) properly screen a current employee that had a previous substantiated allegation of abuse by the facility. This was found to be evident for 1 (Resident # 259) of 79 intakes that were investigated during the facility's annual Medicare/Medicaid survey. Findings include: 1. Intake MD00161046 was reviewed on 9/29/22 at 11:00 AM and revealed the facility provided to the Office of Health Care Quality (OHCQ) information of a staff-to-resident allegation of abuse that occurred on 11/28/21. According to (OHCQ) intake documentation, Staff # 63 smacked Resident #259 on the hand as the resident was going behind the nurse station. The intake information indicated the abuse allegation was substantiated and Staff #63 was terminated. An interview was conducted with the Corporate Staff team on 9/29/22 at 11:45 AM and they were asked to provide documentation of the facility's investigation regarding 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 interviews it was determined the facility failed to notify the state agency of allegations of abuse within the mandated 2-hour time frame. This was evident in 2 (Residents #301 and #308) of 8 intakes investigated for abuse. The findings include: 1. On 09/14/22 at 2:12 PM, a review of the Facility Reported Incident (FRI) MD00177417 revealed while hospitalized Resident #301 reported being raped at the facility. The Social Worker reported the alleged incident to Staff #13 on 05/23/22 a little after 3:00 PM. Staff #13 reported the alleged incident to the Director of Nursing #5 and Staff #57 via email on 05/23/22 at 8:22 PM. The Self Report form provided by the facility revealed the alleged incident was reported to the state agency on 05/24/22. On 09/14/22 at 3:37 PM during an interview with Social Services Assistant Director #13 he/she vaguely remembers the incident and never met the resident. He/she got a phone call from the Social Worker from the hospital. After the alleged incident was reported the resident never came back to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with facility staff it was determined the facility failed to have a system in place to ensure that residents and/or resident representatives were notified in writing when a resident is transferred out of the facility to a hospital and the rationale for the transfer. This was found to be evident for 1(Resident # 111) of 3 residents reviewed for Minimum Data Set (MDS) Quarterly Assessments during the facility's revisit survey. Findings include, The MDS is a federally mandated process that is used to clinically assess all residents in nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps staff to identify health problems. On 12/15/22 at 9:30 AM, while reviewing the facility's compliance with the MDS Quarterly Assessment for resident # 111, it was revealed the resident was transferred to the hospital on [DATE]. On 12/15/22 at 3:30 PM the Interim DON, Staff # 64 was asked to provide the survey team with a copy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident responsible party (RP) are given written notification of the facility bed hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 1 (Resident # 111) of 3 residents reviewed for Minimum Data Set (MDS) Quarterly Assessments during the facility's revisit survey. Findings include, The MDS is a federally mandated process that is used to clinically assess all residents in nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps staff to identify health problems. On 12/15/22 at 9:30 AM, while reviewing the facility's compliance with the MDS Quarterly Assessment for resident # 111, it was revealed the resident was transferred to the hospital on [DATE]. Further review of a progress note dated 11/29/22 revealed the resident was sent out to the…

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

Based on record review and interview, it was determined that the facility staff failed to ensure that quarterly Minimum Data Set assessments were completed on time. This was evident for 1 of 96 residents reviewed for the facility's recertification survey. Findings includes: Minimum Data Set (MDS) provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Assessment Reference Date (ARD) is the last date for the observation period for resident assessment On 9/22/22 at 11:59 AM, Regional Clinical Director #9 provided a list of residents that were found to have incorrect information on their face sheets in the medical record. A surveyor review of the list revealed that Resident #95's quarterly assessments were not completed on time. On 9/22/22 at 12:30 PM, the surveyor review the MDS information for Resident #95 and discovered the quarterly assessment with a ARD of 3/10/22 which should have been completed by 3/24/22 was not completed until 3/31/22. On 10/11/22 at 11:45 AM, interview with MDS Coordinator #58…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 staff failed to ensure that resident assessments were transmitted to the Center for Medicare Services (CMS) timely This was evident for 3 of 96 (Resident # 147, #366 and #375) residents reviewed for the facility's recertification survey. Findings includes: Minimum Data Set (MDS) provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Assessment Reference Date (ARD) is the last date for the observation period for resident assessment 1. On 10/13/22 at 7:56 AM, the surveyor reviewed the medical record for Resident #147. The surveyor discovered that MDS assessment showed delays in transmitting the data to CMS. The ARD of 5/18/22 was not transmitted to CMS by 6/2/22. 2. On 10/13/22 at 1:53 PM, the surveyor reviewed the medical record for Resident #366. The surveyor discovered that MDS assessment showed delays in transmitting the data to CMS. The ARD of 3/9/22 was not transmitted to CMS by 3/23/22. 3. On 10/14/22 at 9:33 AM, the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) accurately assess a resident with a sacral wound resident (#96); and 2.) accurately assess a resident (#54) for bowel and bladder on the Minimum Data Set (MDS). This was found to be evident for 2 of 96 residents reviewed during the annual survey. Findings include: The MDS is a federally mandated-assessment tool used by nursing homes to gather information on each resident's strengths and needs. The information collected drives the resident care planning decisions to meet the resident's specific needs. The MDS assessments need to be accurate to ensure each resident receives the care they need. 1. A medical record review was done on 9/9/22 at 2:25 PM for Resident # 96 and revealed the resident had a sacral wound. Further review of Resident #96's MDS assessment on 9/9/22 at 2:25 PM revealed an MDS assessment dated [DATE]. On section M0210 for unhealed pressure ulcer, yes was indicated. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that facility staff failed to develop a Comprehensive Care Plan for residents to identify measurable goals, interventions, and approaches to address the resident's needs. This was evident for 3 out of 19 (#15, #81 #361) selected residents for review for care plans during the annual 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. 1a.) The facility staff failed to develop a care plan for a Resident #81 receiving a blood thinner medication. Review of resident # 81's medical record on [DATE] at 10 AM, revealed a physician order dated [DATE] to administer Xarelto 20 MG (milligrams) by mouth one time a day for (DVT) Deep Vein Thrombosis prophylaxis and Plavix 75mg once a day for DVT. Xarelto is used to treat and prevent blood clots and Plavix is used to prevent stroke, heart attack, and other heart problems.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with facility staff it was determined the facility failed to: 1.) update resident care plans for residents (# 96, #15, #126, #363). This was evident for 4 of 96 residents reviewed during the annual survey; and 2) ensure a resident had an interdisciplinary care plan meeting while residing in the facility. This was evidenced in 1 (Resident #307) of 3 resident records reviewed for care plan timing. Findings include: 1. The facility failed to update Resident #96's care plan for pressure ulcers. Review of Resident #96's medical record on 9/9/22 at 2:25 PM, and a Minimum Data Set (MDS) assessment (a tool used in nursing homes to gather information regarding a resident's strengths and needs) dated 7/24/22 revealed the resident had an unhealed pressure ulcer. The assessment did not include the stage of the pressure ulcer. Further review of a physician order dated 7/22/22 revealed the following: Cleanse sacrum wound with normal saline, pat dry, Medi honey daily and cover 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 interviews with facility staff it was determined the facility failed to ensure that activities were being provided to meet the resident's needs. This was found to be evident for 1 (Resident #252) of 96 residents reviewed during the facility's annual Medicare/Medicaid survey. Findings include: Resident #252 was admitted to the facility with the following but not limited diagnosis: Nontraumatic Subarachnoid Hemorrhage Bleeding around the brain), Hemiplegia and Hemiparesis (paralysis and weakness), and Contracture (tightening of muscles and tendons that causes joints to become very stiff) of the Right Knee. Multiple observations were made of Resident #252 on 9/7/22 at 11:45 AM, 9/8/22 at 11:45 AM and 4:00 PM, and 9/9/22 at 10:40 AM and 2:40 PM and there were no activities provided to the resident. A review of the resident care plan revealed the activity care plan was initiated and revised on 9/8/22 which indicated the resident preferred to stay in the room and engage in self-leisure activities such as visits with family. An interview was conducted…

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

Based on record review and facility staff interview, the facility failed to provide 24 hour emergency physician services for a resident (Resident #68). This was evident for 1 out of 96 residents review during a recertification survey. The findings includes: On 10/12/22 at 11:32 AM, the surveyor reviewed a facility communication form for Resident #68 dated 7/22/22 which revealed that facility nursing staff communicated the resident's change of status and requested orders to transfer the resident for emergency treatment. Further review of Resident #68's medical records on 10/12/22 at 11:40 AM revealed that resident's primary care physician was not available at the time of the resident's change of status and arranged for another physician to attend to the caseload. Additional review of Resident #68's medical record on 10/12/22 at 12:00 PM revealed that facility nursing staff was unable to reach the alternate physician for emergency treatment orders, so the facility nursing staff transferred the resident for emergency treatment without a physician order. During an interview on 10/12/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months as required. This was evident in 2 of 2 requested copies of nursing staffing sheets related to Facility Reported Incidents (FRI) for Resident #306 and #309 reviewed during the annual survey. The findings include: On 09/16/22 at 02:32 PM, a review of FRI MD00173563 revealed Resident #309's family reported an allegation of abuse on 10/21/22. The surveyor reviewed the investigation provided by the facility which included a statement by various staff. On 09/23/22 at 9:52 AM the ADON made the surveyor aware the facility did not have a copy of the assignment sheets for Magnolia unit on 10/20/21 and 10/21/21 for the 11 PM-7 am shift. On 09/23/22 at 10:21 AM during an interview with the Assistant Director of Nursing #7 she revealed that the Unit Manager on Magnolia unit was Staff #36. The staff were supposed to do an assignment sheet for every shift. The assignment sheets are completed daily and kept on file. They should be kept up to 3-5 years then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined the facility staff failed to secure and store medications in locked medication carts. This deficient practice has the potential to affect all the residents within the facility. The findings include: On [DATE] at 1:44 PM, upon exiting the elevator on the second floor, the surveyor observed an unlocked medication cart; when the top drawer was pulled, the surveyor had access to the medications. None of the staff were near the unlocked cart. The Certified Medication Aid (CMA) #23 came from behind a closed door where the staff area was located. CMA #23 stated, I don't work at this facility all the time and I can't tell you nothing about this cart. CMA #23 had keys to the unlocked cart. During an interview with the Director of Nursing #5 on [DATE] at 3:15 PM, she reported the staff were supposed to lock the medication carts when they are not administering medications and it should not have been unlocked and unattended. On [DATE] at 12:17 PM, the surveyor checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide intact and securely anchored handrails on the Magnolia unit. This deficient practice has the potential to affect all the residents on the first floor. The findings include: During observation rounds on 09/13/22 at 11:23 AM, the following was observed on the Magnolia unit: 1. The handrail outside of room [ROOM NUMBER] was missing the end cap. 2. Both ends of the handrail across from room [ROOM NUMBER] were broken. One end of the handrail was missing, and metal was exposed on the other end. 3. The handrail was loose and broken outside room [ROOM NUMBER]. 4. The handrail outside room [ROOM NUMBER] had a missing end cap. 5. The handrail across from room [ROOM NUMBER] was broken, and the end cap was off. On 09/13/22 at 12:18 PM, Maintenance Director #12 walked through the units on the first floor with the surveyor and confirmed the handrails were broken. He reported, the maintenance department was working on fixing the handrails.