Autumn Lake Healthcare At Riverview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to provide written notification of transfer to the resident and resident representative or provide written notification of bedhold, and failed to ensure the local ombudsman was notified of transfer to the hospital. This was evident for 1 (Resident #9) out of 3 residents reviewed for hospitalizations. The findings include: On 6/2/2025 at 12:13 PM, during a review of Resident #9 medical record, the Surveyor discovered that Resident #9 was transferred to the hospital on [DATE], 10/17/2024, and 3/30/2025. An additional review failed to reveal documentation to verify that Resident #9 received a copy of the facility's bed hold form upon discharge to the hospital on [DATE], 10/17/2024, and 3/30/2025. Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 6/3/2025 at 2:00 PM, during an interview conducted with Unit Manager #34, the Surveyor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission. This was evident for 1 (Resident #84) of 4 residents reviewed for care planning during 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. During a record review on 05/29/25 at 12:32 PM it was revealed that Resident #84 was admitted to the facility on [DATE]. The baseline care plan for Resident #84 was dated 10/31/23, six days after the resident's admission. An interview was conducted with Staff #4 on 05/30/25 at 11:31 AM. Staff #4 stated that the facility's expectation is for the baseline care plan to be developed within 48 hours of a resident's admission. On 05/30/25 at 12:23 PM, Staff #4 provided documentation indicating that a care plan meeting took place on 10/27/23, which was within the 48-hour requirement;…

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

Based on observations, record review and interviews with staff, it was determined that the facility failed to have a comprehensive person-centered care plan for 2 Residents (#73,# 471) out of 85 residents reviewed during survey. The findings include: 1) Record review on 6/3/2025 revealed Resident #471 had a past medical history of a right-sided stroke with residual of left-sided hemiparalysis, and was discharged from the hospital with a diagnosis of encephalopathy pyelonephritis. Encephalopathy, specifically mild encephalopathy with a reversible splenial lesion (MERS), can occur as a complication of pyelonephritis, an infection of the kidneys. While pyelonephritis is primarily known for its kidney-related symptoms like fever and flank pain, in rare cases, it can lead to neurological symptoms like headache, vision changes, or altered mental status. A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system, which includes the kidneys, bladder, ureters, and urethra. They are typically caused by bacteria entering the urinary tract through the urethra…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, and review of the medical record it was determined that the facility failed to 1) ensure residents were offered the opportunity to participate in their care planning process by holding timely quarterly care plan meetings for 1 (Resident # 21) of 2 residents reviewed for care planning, and 2) develop and revise a comprehensive, person-centered care plans with measurable objectives and timetables to address the resident needs for 1 (Resident #130) of 2 residents reviewed for pressure injuries during the survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the Interdisciplinary Team (IDT) after the completion of a comprehensive Minimum Data Set (MDS) assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care…

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

Based on a review of administrative records and interviews with facility staff it was determined the facility staff failed to properly turn and position a resident while providing care. This was found to be evident for 1 (Resident # 232) of 18 residents reviewed for abuse allegations during the survey. Findings include: MD00204713 was reviewed on 5/30/25 at 1:15 PM for allegations of abuse. According to the facility's investigation, on 4/14/24 GNA #17 was rough while turning and repositioning Resident #232 during ADL care. The resident was interviewed and stated that s/he was fine and was not afraid but does not desire to have the GNA provide further care. An interview was conducted with the DON on 5/30/25 at 1:45 PM and she stated that she worked at the facility for a long period of time and that she can recall this incident. She went on to explain that the GNA did not use proper turning techniques when turning and repositioning the resident. She further explained that the GNA was terminated for not providing good customer service during care. Abuse was unsubstantiated. All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to implement timely, appropriate, and individualized interventions to prevent and treat a pressure injury. This is evident for 1 (Resident #130) of 2 residents reviewed with pressure wounds. The findings include: The Braden Scale is a clinical tool used to assess a person's risk of developing pressure injuries by evaluating factors like mobility, moisture, activity level, nutrition, sensory perception, and friction/shear. A score of 12 or below is considered high risk for developing pressure injuries. During review of Resident #130's electronic medical record on 5/29/25 at 9:59 AM, it was revealed the resident was admitted on [DATE] with a Braden Scale score of 12 (high risk). From that date through 4/23/25, multiple Braden assessments reflected a continued high risk for skin breakdown, with scores ranging from 11 to 13. A nursing note dated 10/14/24 at 11:49 PM indicated a physical therapist reported an open area on the…

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

2. Food temperatures above 41 degrees Fahrenheit (for cold foods) and below 135 degrees Farhenheit (for hot foods) allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. On 06.01.25 at 12:30 PM the surveyor observed the kitchenette/galley serving station in the Seagull activity room/dining room. There was no dietary aide present in the galley preparation area. The surveyor observed a bin of small containers/cups of apricots and applesauce that were not refrigerated on the second shelf next to the hot water/steam serving table. The outside of the containers were warm to touch. The surveyor observed the 40 residents in the Seagull dining room waiting to be served their lunch meal. Six geriatric nursing assistants (GNAs) were present in the dining room. On 06.01.25 at 1:07 PM the surveyor observed the dietary staff # 11 enter the galley area and unloaded the food items to the steam table. The surveyor during the interview informed dietary staff #11 of the presence of the cups of apricots and applesauce that were unrefrigerated. Staff #11 stated that…

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

3. Review of Resident #192's MAR on 6/3/25 at 1:30 PM revealed an order for Rexulti 3 mg(milligrams) one tablet by mouth one time a day; however, there was no indication for the use of this medication for the resident. Rexulti is a medication used to treat several mental conditions. On 6/3/25 at 1:00 PM, the surveyor shared the above concerns with the Director of Nursing (DON). The DON stated all medications should have reason documented as to why the resident is prescribed it. 4. Resident #163's medical record was reviewed on 6/2/25 at 12:05 PM for pressure ulcers. During a review of the residents' Change Of Condition (COC) form dated 11/24/24 it indicated the resident was noted to have a new open area to right heel. Further review of the medical record revealed a care plan for risk for alteration in skin integrity that was initiated 11/11/24. There was no care plan for actual open area. An interview was conducted with the DON on 6/2/15 at 1:00 PM and she was asked to provide a copy of the resident care plan for the identified open area to the resident heel. The DON stated that the…

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

3. On 6/2/25 at 1:25 PM the surveyor observed the Licensed Practical Nurse (LPN) #40 in the dining room on Seagull Unit take a white napkin from her uniform pocket, wipe her nose and then put the napkin back into her uniform pocket. Staff #40 then proceeded to pick up a resident's tray in the dining room and began to cut up the items on the tray without sanitizing and washing her hands. After surveyor intervention the LPN #40 discarded the tray, and another tray was prepared for the resident. LPN #40 stated she knows she should have washed and or sanitized her hands prior to picking up the resident's tray. Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and policies by ensuring that dirty dishes are removed from a resident's room (Resident #59) and a process was in place for cleaning after use and ensuring that staff sanitized their hands in between residents during medication administration. This was found to be evident for 1 out of 85 residents observed and 2 staff observed during the…

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

Based on observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment by ensuring that dirty trash was emptied and removed, clothes bins containing dirty clothes were emptied and the utility room and Dining Room floors were cleaned. This was evident when observations were made on the Seagull Unit during the facility's survey. The findings include: On 5/27/25 at 8 am during observation rounds at Seagull Unit storage room the following was observed: 1. The dirty utility room on seagull located next to the nursing unit was observed with 13 bags of dirty trash noted on the floor. There were 2 large yellow trash cans noted in the room which were full and trash bags hanging them over. 2. Three large clothing bins which were filled to the top with dirty clothing. 3. The room smelled of urine and feces which could be smelled through the closed door to the storage room. The LPN staff #40 accompanied the surveyor to the room and verified the findings. The laundry/housekeeping supervisor staff #41 was contacted and the storage room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AL Riverview F574 Based on observations and interviews, the facility failed to post contact information for the Ombudsman and provide the correct contact information to file a complaint with the Office of Healthcare Quality. The findings include: The Long-Term Care (LTC) Ombudsman advocates for residents of nursing homes by protecting their rights and promoting the well-being of residents of Long-Term Care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state, and national levels that will improve residents' care and quality of life. The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland ' s health care facilities and community-based programs. On 10/21/21 at 11:33 am during the Resident Council meeting the residents denied knowing how to file a complaint with the state and how to reach the LTC Ombudsman ' s office about concerns. 10/21/21 at 11:52 am Next 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.

AL Riverview F577 Based on observation and interviews, the facility staff failed to have the survey results book readily accessible for review by residents, family members, and legal representatives of residents in areas of the facility that are prominent and accessible to the public. This was found to be evident during observations made during the facility's annual Medicare/Medicaid survey. The findings include: On 10/21/21 at 11:33 am during the resident council meeting the residents verbalized they were not aware the facility had a copy of the survey results nor where to find the survey book. On 10/21/21 at 12:00 pm, two surveyors went to the front lobby to assess whether the survey book was readily accessible. Observation of the area confirmed the facility ' s survey book was not was not visible. The surveyors asked the receptionist for the facility ' s survey book. On 10/25/21 at 8:48 am during an interview with the Director of Nursing (DON) (Staff #3). The DON stated the facility ' s lobby has changed since COVID, and the survey book was on a table in the front lobby between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AL Riverview F584 Based on observations and interviews the facility failed to ensure the environment was maintained in a manner that was safe, comfortable, and homelike. This was evidenced for 4 of 46 resident rooms and in 1of 2 communal dining areas observed during the survey. The findings include: On 10/13/21 at 7:47 am during the initial tour, the communal dining room located on the 2nd floor had two chairs that were broken. There was a white substance in an electrical outlet on the wall near the emergency cart, and a metal hook on the wall about 12 inches from the electrical outlet. On 10/14/21 at 11:20 am the air conditioner near the window in room [ROOM NUMBER] had a black substance on the exterior grate. On 10/15/21 at 12:02 pm the hand sanitizer dispenser in room [ROOM NUMBER] did not work and it was not tightly secured to the wall. On 10/26/21 at 10:08 am during a walk-through of [NAME] with Maintenance Director #30 the commode in room [ROOM NUMBER] was stopped up. On 10/26/21 at 10:26 am during a…

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

Based on observation of medication administration, interview with facility staff, and review of facility policy, it was determined that the facility failed to ensure that nursing staff followed professional standards of medication administration when Certified Medical Assistant (CMA) #6 failed to document all medications that were administered to Resident #24 at the time that they were administered. This was evident for 5 of 26 medications observed during the medication administration observation. The findings include: The surveyor observed CMA #6 administer medication to Resident #24 on 10/20/21 at 7:45 AM. During the observation, CMA #6 administered nine different medications to Resident #24: lisinopril, colace, a multivitamin, metoprolol, glipizide, low-dose aspirin, vitamin D3, Januvia, and gabapentin. The resident took and ingested all medication. The surveyor reviewed Resident #24's Medication Administration Record (MAR) on 10/20/21 at 8:50 AM, 9:20 AM, and 9:55 AM. On all three checks, the MAR showed that only four medications had been administered by CMA #6: lisinopril,…

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

Based on observation, interview with facility staff, and review of facility policies, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 4 of 26 medications administered during the observation. The findings include: During a medication administration observation that took place on 10/20/21 at 7:36 AM, the surveyor observed Certified Medical Assistant (CMA) #6 administer medications to Resident #80. The medications included a tablet of Lexapro 10mg (miligrams). Later at 7:45 AM, the surveyor observed CMA #6 administer medications to Resident #24 including Januvia and Gabapentin. During a second medication administration observation that took place on 10/20/21 at 8:01 AM, the surveyor observed Registered Nurse (RN) #7 administer medications to Resident #3. During the administration, RN #7 gave Resident #3 a dose of Wixela inhaler. The RN administered the medication by placing the mouthpiece of the inhaler in Resident #3's mouth and depressing the plunger. RN #7 failed 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 observation and interview with facility staff, it was determined that the facility failed to ensure that medications requiring refrigeration were stored at the correct temperature, that medication was not kept in storage beyond its expiration date, and that narcotic lock boxes in medication refrigerators were secured to the inside of the refrigerator and could not be removed. This was evident for 1 of 3 medication refrigerators and 3 of 3 medication rooms reviewed during the survey. The findings include: During a tour of the 600 unit medication room that took place on 10/25/21 at 9:16 AM, the surveyor found that the lock box in the refrigerator was not permanently affixed to the inside of the refrigerator. It contained three unopened 30 mL vials of Lorazepam, 2mg per mL. A pack of 19 Humanlog Kwikpen insulin pens were reviewed and 1 of the 19 had expired, with an expiration date of January, 2021. Review of the temperature logs showed that temperatures were not recorded 10/9/21, 10/19/21, 10/21/21, 10/23/21, and 10/25/21. The surveyor spoke with Licensed Practical Nurse…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. The findings include: The surveyor conducted an initial brief tour of the kitchen on 10/13/2021 at 7:44 AM with the Kitchen Supervisor/ [NAME] (staff #13). During the tour, the surveyor observed 1) a tray with one pork tenderloin thawing in the refrigerator on bottom shelf without a date the thawing began, 2) paper trash in the ice cream freezer which was contained a small cardboard box on top of frozen goods, 3) wet nesting of clean white dessert bowls, wet-nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow, 4) alfredo sauce in a metal container laid on top of several loaves of bread in the freezer 5) ice on the ceiling of the walk in freezer with evidence of droplets of condensation with multiple small ice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 observations and interview with facility staff and residents, the facility staff failed to protect and value resident's private space (residents #22, #45, #72 & #110). This was evident for 4 out of 75 residents reviewed during a recertification survey. The findings include: On 10/13/21 at 11:30 AM, during the initial tour of the Swan and Egret units, the Surveyor observed several incidents of facility nursing staff failing to protect and value residents' private space by not knocking on resident doors and requesting permission before entering residents' rooms. The Surveyor observed facility staff failing to knock on resident doors and request permission before entering resident's rooms for residents #22, #45, #72 & #110. Interview with resident #110 on 10/14/21 at 10:45 AM revealed that it was normal for facility staff to enter resident #110's room without knocking on the door or asking permission. The surveyor observed facility staff failing to knock on resident #110's room door and request permission before entering on 10/15/21 at 9:15 AM, 10/19/21 at 10:15 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 review of the facility's investigative report, record review, observation, and staff interview it was determined that the facility staff failed to thoroughly investigate an allegation of resident abuse nor notify law enforcement when a resident reported sexual and physical abuse. This was evident for 2 of 13 residents (Resident #133, #125) reviewed for abuse during this recertification/complaint survey. The findings include: On 10/20/2021, Surveyor review of the facility reported incident #MD00138808 revealed that on 4/1/2019 Resident #133 complained to the nurse manager that on Saturday 11-7 shift, resident's Geriatric Nursing Assistant (GNA # 81) threw a small piece of a diaper tab in their face while receiving incontinence care. Further review of the facility investigation revealed the facility was not able to substantiate the abuse, however the facility failed to do a thorough investigation. The facility failed to interview other staff members or residents during the investigation. Surveyor found written interviews from the resident, the nurse, and GNA #81. GNA #81'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of narcotic change of shift counts, it was determined that the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at change of shift. This was evident for 1 (Egret, 400's unit) of 3 nursing units reviewed for accuracy and completeness of controlled medication storage and documentation. The findings include: Narcotic (controlled) medication, due to its potential for abuse and addiction, is required to be thoroughly tracked and accounted for by the facility. This includes but is not limited to an accounting of all narcotics in storage whenever a change of shift among nursing staff occurs. This medication count must be performed by two nursing staff at the same time to verify the counts being conducted. Any discrepancy in the count from what is expected to be found must be addressed immediately. In the course of performing the medication storage facility task, the surveyor reviewed the narcotic count logs for October, 2021, for the Egret unit at [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during the annual survey the facility failed to provide maintenance and housekeeping services to maintain the environment and resident equipment (#46) in a sanitary, safe, orderly, and, comfortable manner. The findings included: 1. On 9-27-18 at 11:30 AM Resident #46's standing walker with a seat was covered with spills on the arms and legs and the padding on both arms was torn. 2. On 9-24-18 at 10:00 AM and on 9-27-18 at 11:35 AM room [ROOM NUMBER] had a strong odor of urine and the main door was chipped and cover peeling. 3. On 9-24-18 at 9:00 AM and on 9-27-18 at 11:40 AM room [ROOM NUMBER] had a main door with chipped and peeling cover, the bottom of the heating/air conditioning unit had paint chipped and gouges in the frame, the cable outlet was torn off the wall, and the bathroom had a strong odor of urine and cleaning fluid. 4. On 9-24-18 at 10:05 AM and 9-27-18 at 11:40 AM room [ROOM NUMBER] had the main door with chips, scrapes and stains and the bathroom had a…

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

Based on observation, it was determined that the facility staff failed to provide a dignified dining experience for a resident. This was evident during the initial tour and observation of Geriatric Nursing assistants aiding during breakfast. The findings include: Observation of the breakfast meal service on the first floor on 09/24/18 at 9:15 AM revealed Resident #35 was left sitting in his/her recliner chair with food particles all over the front of Resident #35's shirt. No staff were around Resident #35 at the time of this observation.

Based on record review, observation and interview, it was determined the facility staff failed to provide Resident #19 with food choices. This was evident for 1 of 41 residents selected for review during the survey process. The findings include: 1 A. The facility staff failed to provide Resident #19 with finger foods as ordered by the physician. Medical record review for Resident #19 revealed the resident was admitted to the facility with diagnosis which included, but not limited to dementia. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Further record review revealed on 1/30/18 the physician ordered: finger foods. People with dementia can face several challenges when sitting down to a meal. A common difficulty faced in middle to late stage dementia is coordinating eating and drinking. People with dementia might also struggle to use a knife and fork. Using finger foods in place of traditional meals may prolong a resident's independence and stimulate them to eat more frequently. Finger foods can be eaten easily, without 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 a resident complaint, reviews of administrative documents and staff interview, it was determined that the facility failed to 1) notify the State Survey Agency of 2 allegations of misappropriation of resident property on 03/07/18 and 07/12/18, and 2) notify local law enforcement of an allegation of misappropriation of resident property on 07/12/18. This was evident for 1 (Resident #84) of 6 residents reviewed for abuse during an annual recertification survey. The findings include: During an interview with Resident #84 on 09/25/18 at 9:54 AM, Resident #84 stated that s/he had missing money 6 months ago. Resident #84 stated s/he reported to the facility staff. In an interview with the facility Director of Nurses (DON) on 09/26/18 at 10:45 AM, the facility DON produced 2 facility grievance forms, one dated 03/07/18 in which Resident #84 alleged $105 dollars went missing from Resident #84's locked drawer, and the other, dated 07/12/18 in which Resident #84 reported someone had broken into his/her locked drawer and stole $50 dollars. The 03/07/18 grievance form documented that…

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

Based on reviews of administrative documents and staff interview, it was determined that a facility staff member failed to report an allegation of physical abuse immediately to the facility administrator. This was evident for 1 (Resident #527) of 6 residents reviewed for abuse during an annual recertification survey. The findings include: Review of facility reported incident MD00128495 on 09/25/18 revealed an allegation Resident #527 was allegedly abused by a staff member on 07/01/18. In an interview with the facility administrator on 09/25/18 at 3:25 PM, the facility administrator stated that s/he became aware of the incident on 07/03/18 when another resident's family member came into the facility and reported that s/he had witnessed GNA #1 being rough with Resident #527 while positioning Resident #527 in bed and feeding Resident #527 to fast with a spoon during lunch on 07/01/18. In an interview with LPN #1 on 09/26/18 at 10:45 AM, LPN #1 stated that on 07/01/18 another resident's family member came to the nursing station and reported that s/he witnessed GNA #1 feeding Resident…

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

Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 1 out of 1 (# 1) residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: A medical record review for Resident # 1 was conducted on 9/26/18. Review of the physician order written on 2/16/2018, 2/25/2018, 3/3/2018 and 5/28/18 revealed that Resident # 1 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, and or resident representative. On 09/28/18 1:34 PM, an interview with the Director of Nursing revealed that a written notice for emergency transfers to the resident and/or the resident representative was not initiated until July, 2018.

Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for Resident (# 171 and # 527). This was evident for 2 of 55 residents selected for investigation during annual survey process. Findings include: Once the facility staff completes an in-depth assessment 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. 1. Medical record review for Resident # 171 revealed the facility staff failed to initiate a care plan on 9/10/18, which stated: Resident is…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to maintain a fluid restriction for Resident #6 as ordered by the physician. This was evident for 1 of 41 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #6 revealed the resident has a diagnosis but not limited to heart failure. Heart failure, sometimes known as congestive heart failure, occurs when the heart muscle doesn't pump blood as well as it should. In heart failure, the main pumping chambers of the heart (the ventricles) may become stiff and not fill properly between beats. In some cases of heart failure, the heart muscle may become damaged and weakened, and the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout the body. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of the body. Fluid restriction has long been considered one of the cornerstones in self-care management of residents with heart…

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

Based on review of a medical record and staff interview, it was determined that the facility staff failed to take steps to ensure that a resident received dental services as ordered by the resident's physician. This was evident for 1 (Resident #35) of 4 residents reviewed during an annual recertification survey. The findings include: Review of Resident #35's medical record on 09/27/18 revealed a physician's order, dated 08/27/17 instructing the nursing staff to obtain a dental consult for Resident #35. In an interview with Employee #8 on 09/27/18 at 3:30 PM, Employee #8 stated Resident #35 has a history of grinding his/her teeth. Employee #8 stated there is no documentation in Resident #35's medical record that Resident #35 was seen by a dentist in 2017. Employee #8 also stated that Resident #35's dental consult order was discontinued on 01/31/18. Employee #8 stated there is no documentation in Resident #35's medical record as to why Resident #35 did not receive a dental consult nor why the 08/27/17 physician order was discontinued on 01/31/18. The nursing staff must take steps 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 observation and interview, it was determined facility staff failed to fully cover all their hair with a required hairnet while in the kitchen preparing resident meal trays. The findings included: On 9-27-18 at 12:10 AM while preparing resident lunch trays Staff #1 and Staff #2 failed to cover all their hair with the required hairnet. Staff #1 had hair hanging down to their shoulder and Staff #2 failed to cover the front of their hair. This finding was confirmed with the Director of Dining Services on 9-27-18 at 12:10 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a medical record and staff interview, it was determined that the facility staff failed to maintain an accurate medical record by not documenting a resident's annual nutritional assessment correctly in the medical record. This was evident for 1 (Resident #35) of 4 residents reviewed for dental services during an annual recertification survey. The findings include: Review of Resident #35's medical record revealed an Annual MDS, dated [DATE], that indicated Resident #35 currently has his/her own teeth and there were no dentures or broken teeth. Further review of Resident #35's medical record revealed an annual nutritional assessment, dated 09/10/18, which indicated Resident #35 had a partial upper denture and lower dentures. In an interview with GNA #2 on 09/27/18 at 10:20 AM, GNA #2 stated Resident #35 had his/her own teeth. GNA #2 showed the surveyor Resident #35's resident care sheet which indicated Resident #35 had his/her own teeth. GNA #2 also stated the nursing staff could check a…

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

Based on observation, it was determined the facility failed to maintain enough outside ventilation to keep all parts of the facility odor free. This was evident during the initial tour of the facility on 09/24/18 at 9:00 AM. The findings include: During the initial observational tour of the facility on 09/24/18 at 9:00 AM the surveyor noticed lingering odors at the end of the Crane unit. There were no trash cans observed in the hallway at this time and there were no odors coming from resident rooms. Observations of the small area outside the Crane unit exit door revealed 4 large trash dumpster's. The surveyor also observed a floor technicians transporting one of the large trash dumpster's thru the unit. The facility staff must take steps to maintain proper outside ventilation to keep all parts of the facility odor free.