Sterling Care Forest Hill

Based on record reviews and staff interviews, it was determined the facility failed to ensure that influenza immunizations were consistently offered or administered during the active flu season. This was evidence one (Resident #124) out of a five-resident sample reviewed during the recertification survey.The Findings include:A review of medical records on 12/19/25 at 9:14 AM revealed that Resident #124, who was admitted in September 2025, lacked documentation of influenza vaccination. The electronic medical record (EMR) listed the resident's status as pending consent.During an interview on 12/19/25 at 10:41 AM, the Infection Preventionist (Staff #9) stated that all residents and staff are offered the vaccine during flu season and that the EMR should be updated to reflect vaccination or refusal.At 1:49 PM on 12/19/25, Staff #9 provided a consent form signed by the resident's family on 9/12/25. She confirmed that although the resident had been scheduled for vaccination on 12/06/25, the dose was not administered. Staff #9 acknowledged the oversight and stated that the vaccine would be…

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

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' COVID-19 vaccine statuses were monitored and maintained in a timely manner. This finding was evident for one (Resident #129) of five residents whose immunization records were reviewed during this recertification survey.The findings include:A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease.On 12/19/25 at 9:14 AM, the surveyor reviewed five randomly selected residents' vaccination records. The review revealed that Resident #129 was admitted in October 2025; however, the resident's immunization status for COVID-19 was documented only as pending consent.During an interview with the Infection Preventionist (Staff #9) on 12/19/25 at 10:41 AM, she stated that facility staff review residents' vaccination status upon admission and offer vaccines to those who are eligible. The surveyor reviewed Resident #129's Immunization Session tab in the electronic…

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

Based on observation and interview with facility staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This was found to be evident during the facility's survey and has the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During the initial tour of the kitchen conducted on 08/06/2024 at 8:35 AM with the dietary aide staff #13 accompanying the surveyors. Inside of the stand-alone refrigerator was a large bowl of croutons with a date-in of 06/13/24 and a date-out of 06/19/24. The dietary aide staff #13 immediately removed it after confirming that it should have been out of the refrigerator. During a continued tour of the kitchen on the same day at 08:40 AM, inside the walk-in freezer, the following items were observed, a small bag of sugar cookies was opened, 5 large bags of pancakes and 3 bags of French toast. There was no date label on any of the items observed. The dietary aide staff #13 stated that the items should have been dated and she removed 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 interviews it was determined that the facility failed to allow the residents on Unit 300 move freely throughout the facility as evidenced by the unit being locked and requiring a code to enter and exit. This deficient practice was discovered during the survey. The findings include: On 08/07/24 at 10:20 am the surveyor entered Unit #300 which required a code to gain entry onto the unit. Unit #300 is primarily used for residents who require rehabilitations services. On 08/07/24 at 10:37 am the surveyor asked Registered Nurse (RN) Unit Manager #35 why the unit was locked. RN Unit Manager #35 verbalized a resident on the unit was an elopement risk but was easily redirected. The resident's family and visitors receive the codes at the front desk. On 08/07/24 at 11:00 am while the surveyor was interviewing Resident #49 in their room, Geriatric Nursing Assistant (GNA) #34 knocked on the resident's door. Upon entry GNA#34 proceeded to give the resident a piece of paper with the code to enter and exit the unit. When asked does the residents have the code to enter and…

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

Based on resident interview, record review, and staff interviews, it was determined that the facility failed to address and/or follow up on an ophthalmologist's recommendation. This was evident for 1 (Resident #31) of 5 resident's reviewed for vision. The findings include: On 08/06/24 at 10:37 AM, an interview was conducted with Resident #31. The resident stated they needed their eyes checked. The resident stated, my last appointment was January, and nothing has been done about my cataracts. They said I was going to need surgery. On observation the resident was not wearing glasses and glasses were not at bedside. On 8/07/24 at 9:23 AM, Resident #31's medical record was reviewed. There was an order for an Optometrist consult placed on 10/19/2023. On 08/08/24 at 10:10 AM, an interview was conducted with the Unit Manager (Staff #24) for Unit 1. When asked about who schedules the specialty appointments for the residents, Staff #24 stated, I do. When asked about how often the residents see the specialists, Staff #24 stated, The specialists come to the facility at least once a month or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined the facility failed to maintain facility equipment in good repair and provide a clean homelike environment. This was evident for 2 resident's rooms out of 8 resident rooms reviewed during the survey. The findings include: During observation rounds on 08/06/24 at 9:22 AM in residents' room [ROOM NUMBER] there was a heating and air-conditioning unit not working, with a wet black substance noted on the inside of the unit's grill, the unit's cover was falling off and there was a musty odor permeating throughout the room. During observation rounds on 08/06/24 at 9:25 AM in residents' room [ROOM NUMBER] bathroom, there was approximately a 1-inch layer of dry gray/white substance located on the inside of the air duct vent opening. The bathroom sink was also noted to be detached from the wall. During observation rounds on 08/06/24 at 9:48 AM in residents' room [ROOM NUMBER] there was a heating and air-conditioning unit leaking water onto the floor, there was…

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

Based on record review and interviews it was determined that the facility staff failed to ensure the assignment sheets were completed daily on Unit 300 and failed to reserve the posted daily nursing staff data for a minimum of 18 months. This deficient practice was discovered during the survey. The findings include: On 08/07/24 at 11:50 am the surveyor asked Geriatric Nursing Assistant #34 for a copy of the assignment sheets dated 08/02/24 - 08/07/24 all shifts. The surveyor reviewed the staffing sheets which revealed the written copy of the schedule for the dates 08/02/24 11pm-7 am, 08/03/24 & 08/04/24 all shifts, 08/05/24 11pm-7am, and 08/06/24 11pm- 7 am were not available. During an interview with RN Unit Manager #35 on 08/07/24 at 11:54 am the surveyor reported some of the assignment sheets were missing. RN Unit Manager #34 verbalized the staff are expected to complete the assignment sheets daily for all shifts. On 08/14/24 at 2:03 pm during an interview with Assistant Director of Nursing #5 they verbalized the assignment should be completed every shift. After one month they…

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

Based on observations, interviews with resident and facility staff, it was determined that the facility failed to ensure that repairs were made, as needed, in the resident's room. This was evident for 1 resident (Resident# 32) out of 66 resident's rooms observed during the facility's survey. The findings include: During an observation of Resident #32's room on 08/06/24 at 11:37 AM, surveyors observed a large area of the baseboard (approximately 25 feet) located at the head of the resident's bed was totally separated from the wall with broken pieces of dry walls noted. In addition, observation of the resident's bathroom sink was noted to have a large area of separation along the width of the sink, between the sink and the corresponding wall, that was in need of caulking. During an interview with the resident at that time, he/she stated that some repairs were done but after a flood in the hallway some time ago, the wall located at the head of the bed shifted. The resident also stated that personal shoes and bags were placed in a plastic bag while on the floor. On 08/07/24 at 12:24 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined the facility staff failed to report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 resident (Resident #1) reviewed for abuse during the complaint survey. The findings include: On 10/23/2023 at 8:45 AM, during a brief entrance conference, surveyor requested from the Nursing Home Administrator (NHA), all documentation of the investigations related to the Facility Reported Incidents (FRIs) that were sent to OHCQ (Office of Health Care Quality) concerning Resident #1. On 10/23/2023 at 9:40 AM, review of the investigation of a Facility Reported Incident (FRI), MD00197629, revealed that on 9/27/2023 Resident #1 alleged that Geriatric Nursing Assistant (GNA #5), was inappropriate during incontinent care. The report indicated that Resident #1 told the Director of Nursing (DON) on 9/27/2023, that when GNA #5 was applying barrier cream to her/his buttocks, the GNA's…

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

Based on observation and staff interview it was determined that the facility staff failed to treat residents in a dignified manner (#52, #54, #48, #87, #115). This was evident for 5 out of 56 residents in the survey sample. The findings are: 1. This surveyor was having a conversation with Resident #52 on 9/23/19 at 9:14 AM when Geriatric Nursing Assistant #2 entered the room. She walked to the other side of the resident's bed and picked up the breakfast tray from the table. The resident asked if GNA #2 knew where the nurse was because he/she would like his/her morning medications. The resident began to explain why he/she was asking for the nurse but GNA #2 turned around and walked out of the room while the resident was still talking. The resident asked me if I knew when the nurse was coming and I said that I saw the nurse pushing the medication cart in this direction. I added that the nurse was two or three doors down the hall. I interviewed the Director of Nursing(DON) on 9/25/19 at 7:40 AM. I informed her of the findings and she said that she would investigate. 3. Observation of…

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

Based on observation and interview, the facility staff failed to ensure that call bells were within reach for Resident (#94). This was evident for 1 out of 56 residents selected for review during the annual survey process. The findings include: A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant on duty. There is a call light for each resident in the room, for each bed. Of note, the facility staff obtained a pancake type of call light for Resident #94 in which any pressure on the call light would activate the light and notify the staff of the resident's need for attention. Surveyor observation of Resident #94 on 9/24/19 at 7:54 AM and 9/27/19 at 8:45 AM revealed the resident in bed. Further observation revealed the facility staff placed the resident's call light in the top draw of the bed side table and not within Resident #94's reach. On 9/5/19 the facility staff assessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were competent for health care decision making capacity prior to the residents signing medical forms (Residents #94 and #87). This was evident for 2 of 9 residents selected for review of advance directives and 2 of 56 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to ensure Resident #94 was cognitively intact prior to the resident completing a MOLST. Medical record review for Resident #94 revealed on [DATE] and [DATE] the resident was assessed by 2 physicians and determined: the resident is unable to understand and sign admission documents and other information, unable to understand the nature, extent or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risks and benefits of the treatment and is unable to effectively communicate a decision. It was also determined at that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This was evident for 2 resident rooms in the facility. The findings include: On 9/23/2019 at 9:35 AM during an interview with Resident #57 in room [ROOM NUMBER] cobwebs and peeling wallpaper were observed above the window/door adjacent to the resident's bed. On 9/25/2019 at 9:57 AM room [ROOM NUMBER] was observed with peeling wallpaper on the wall outside the bathroom door. Inspection of the wall behind the peeling wallpaper revealed a black residue adhered to the drywall towards the bottom of the wall. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 9/27/2019.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview and staff interview it was determined that the facility staff failed to notify the state agency upon being notified of an accusation of theft of resident property. This was evident for 1 out of 56 residents in the survey sample. The findings are: I interviewed Resident #26 on 9/23/19 at 3:05 PM. The resident stated that he/she went to the hospital in either November or December of 2018. The resident said that he/she had a computer that was missing upon return to the nursing home but was later found in a hospital locker. The Administrator was interviewed on 9/25/18 at 11:29 AM. Resident #26 was sent to the hospital on [DATE]. The Administrator received a call from the corporate headquarters inquiring about an online review where a reviewer accused the facility staff of stealing the resident's computer. An investigation was launched. The Administrator called the hospital and they found a backpack with the computer and other items in a Security Department locker. The backpack was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to notify the responsible party and/or resident in writing of Resident's (#120, #74, #15) transfer to the hospital. This was evident for 3 of 5 residents investigated for hospitalization during the annual survey. The findings include: 1. On 9-4-19 Resident #120 who is his/her own responsible party was transferred to the hospital for treatment requiring a higher level of care. On 9-24-19 at 1:00 PM the Director of Nursing confirmed that the facility had not sent a written notification stating the reason for the transfer to the hospital to the resident. 2. Resident #74's medical record was reviewed on 9/25/2019 and revealed that Resident #74 was transferred to the hospital on 8/11/2019. There is no documentation in the medical record to indicate that the ombudsman's office was informed of this transfer. The findings were shared with the Director of Nursing on 9/25/2019 at 12:48 PM who confirmed that the facility had not sent…

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

Based on medical record review and interview, it was determined the facility staff failed to administer pain medication to Resident (#61) in accordance with the standard of nursing practice. This was evident for 1 of 7 residents selected for review of pain management and 1 of 56 residents selected for review during the survey process. The findings include: 1. The facility staff failed to administer pain medication to Resident #61 in accordance with the standard of practice. Medical record review for Resident #61 revealed on 3/27/19 the physician ordered: Oxycodone 10 milligrams by mouth every 4 hours as needed for pain. Oxycodone is an opioid pain medication sometimes called a narcotic. Oxycodone is used to treat moderate to severe pain. On 6/3/19 the physician discontinued the Oxycodone 10 milligrams by mouth every 4 hours as needed and ordered: Oxycodone 5 milligrams by mouth every 4 hours as needed for severe pain. Review of the Controlled Medication Utilization Record revealed on 6/3/19 at 10:22 PM and 6/4/19 at 10:22 PM the facility staff nurse broke the 10 milligram Oxycodone…

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

Based on observation, medical record review and interview it was determined the facility staff failed to aid with meals for Resident (#55). This is evident for 1 of 4 residents selected for review for ADL care and 1 out of 56 residents reviewed during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. Surveyor observation of Resident #55's lunch on 9/25/19 at 12:30 PM revealed the facility staff served the resident lunch; however, the facility staff failed to cut the resident's pork chop. The…

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

Based on review of the medical record and staff interview it was determined that the facility staff failed to revise a resident's plan of care related to a significant weight loss. This was evident for 1 (Resident #19) of 6 residents reviewed for accidents during an annual recertification survey. The findings include: Geri-Sleeves is an arm protector designed for use by individuals with fragile skin, IV sites, or skin irritation. It provides full coverage of the arm, protecting the upper extremities from abrasions, bruises, snags and tears throughout the day. Geri-Sleeves use slight compression to aid in relieving the discomfort associated with swelling. Review of Resident #19 medical record on 09/23/19 revealed Resident #19 was observed with a skin tear to both arms during incontinence care on 09/19/19 at 6:00 AM. Review of Resident #19's medical record revealed a physician order, dated 09/05/19, instructing the nursing staff to apply Geri sleeves to Resident #19's bilateral arms and to keep them on at all times except that the bilateral arm Geri sleeves can be removed during 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 medical record review and resident and staff interview, it was determined the facility staff failed to ensure that a medication was given as ordered (Residents #120). This is evident for 1 of 3 residents reviewed for dialysis during the annual survey. The findings include: Resident #120 was admitted to the facility for wound treatment and also required dialysis due to kidney failure. Resident #120's physician ordered calcium acetate to be given with meals. To work effectively the calcium acetate must be given while eating a meal. This allows the calcium acetate to bind effectively with the food at it is consumed. During an interview on 9-24-19 at 10:20 AM Resident #120 stated he/she refused the calcium acetate that morning because he/she was given breakfast at 7:00 to 7:30 AM and not offered his/her calcium acetate until 9:00 AM and they had already completed breakfast earlier. Interview with Nurse #1 on 9-24-19 at 11:00 AM and he/she stated Resident #120 refused the calcium acetate because he/she had already eaten. When questioned as to why the medication was not given…

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

Based on review of employee files and staff interview, it was determined that the facility failed to provide at least 12 hours of nursing aides' in-services within a year. This was evident for 1 of 6 randomly selected staff members reviewed during an annual recertification survey. The findings include: Review of the facility assessment on 09/25/19 revealed the facility does care for residents that suffer from cognitive, behavior, and substance abuse issues. Review of Employee #21's employee and education records on 09/27/19 revealed Employee #21's only received 1 hour of nursing aides' in-services in the past year. In an interview with the facility staffing coordinator on 09/27/19 at 9:37 AM, the facility staffing coordinator confirmed that Employee #21 only received 1 hour of education for the past year.

Based on medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Residents (#14). This was evident for 1 out of 56 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to act upon the consultant pharmacist recommendation in a timely manner. Medical record review for Resident #14 revealed the Consultant Pharmacist was in the facility on 7/15/19 and made a recommendation for Resident #14 related to the resident receiving Miconazole 2% cream. Miconazole 2% cream is an antifungal medicine. It is used to treat certain kinds of fungal or yeast infections of the skin. The recommendation from the Consultant Pharmacist was to clarify the order for Miconazole 2% cream by adding a stop date. The recommendation from the manufacture supports the Consultant Pharmacist rationale that long-term use of topical antifungal agents may increased the risk for alteration of normal cutaneous flora, resistant microorganism, and secondary infections.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 ensure medications were secured in a locked environment. This was evident for 1 out of 2 medication administrations. The findings include: This surveyor observed on 9/27/19 at 8:19 AM CMA # 14 walk away from a medication cart and into a resident's room to administer medications. I walked over to the cart and observed the cart to be unlocked. CMA #14 was in the room at the bedside of the resident in the A bed behind the curtain. When CMA #14 exited the room, I showed her that the cart was unlocked and explained why it needed to be locked.

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimens as ordered by the physician or NP for Resident (#94). This was evident for 1 of 56 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to obtain a laboratory blood test as ordered by the physician. Medical record review for Resident #94 revealed on 8/1/19 the physician ordered: BMP on 8/2/19 and 8/5/19. The basic metabolic panel (BMP) is a frequently ordered panel of 8 tests that gives a healthcare practitioner important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance. Further record review revealed the facility staff failed to obtain the BMP on 8/2/19 as ordered. 1 B. The facility staff failed to obtain a laboratory blood test as ordered by the physician. Medical record review for Resident #94 revealed on 7/23/19 the physician ordered: Coumadin 5 milligrams by mouth at hour of sleep for…

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

Based on clinical record review, observation, resident interview, and staff interview it was determined that facility staff failed to arrange a dental consult to repair or replace broken dentures. This was evident for 1 out of 5 reviewed for dental issues. The findings are: This surveyor interviewed Resident #123 on 9/23/19 at 10:15 AM. The resident stated that he/she has dentures, but they are broken. The dentures were not broken on admission but sometime afterwards. The resident could not say when the dentures were broken or how they were broken. Resident #123's clinical record was reviewed, and it was revealed that the primary physician wrote an order for oral care to be provided twice a day and as needed. The resident inventory list includes upper dentures on the list. The resident also has a care plan: [Name of resident] has oral/dental health problems r/t Poor oral hygiene and use of upper dentures. The Unit Manager for Unit 2 was interviewed on 9/26/19 at 8:41 AM. He stated he was unaware that the resident has dentures and that they are broken. The Director of Nursing 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 resident interview and surveyor observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents. The findings include: On the morning of 9/26/2019 the Food Service Manager (Staff #11) was asked to provide a test tray of a regular diet lunch to the 1st floor of the facility in response to resident complaints of cold food during individual interviews and during a meeting with representatives from the Resident Council. On 9/26/2019 at 8:02 AM Resident #57 began to eat their breakfast and allowed the temperature of their breakfast sausage to be taken. The sausage registered at 96 F. The resident stated that it was fine but they would prefer if their food was warmer upon arrival. On 9/26/2019 at 11:04 AM a meeting was held with representatives from the facility's Resident Council to discuss any ongoing issues in the facility. Resident #16, Resident #22, Resident #46 and Resident #47 all confirmed that food was lukewarm or cold by the time the trays were delivered to them at…

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

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 9/23/2019 at 9:11 AM a tour of the facility's main kitchen was conducted with the Food Service Manager (Staff #11) and the Assistant Food Service Manager (Staff #12). Observation of the dish drying rack revealed wet stacked pans. This was acknowledged and corrected by the Assistant Food Service Manager. On 9/26/2019 at 12:33 PM surveyors obtained a test tray on the 1st floor hallway. When observing the utensils, dried food debris was observed between the prongs of the fork. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 9/27/2019.

2. Resident #92 who is a diabetic was admitted to the facility after surgery for rehabilitation. On admission the physician ordered blood sugars to be taken once a day by the facility nursing staff to monitor Resident #92's diabetes. The nursing staff completed the task of taking the blood sugars but from 8-5-19 to 8-9-19 failed to record the results in the medical record. On 9-26-19 at 9:44 AM the Director of Nursing confirmed that the nursing staff took the blood sugars from 8-5-19 to 8-9-19 but failed to record the results in the medical record. The results were recorded on the nurses scratch papers and 8-5-19 was obtained from the requested labatory blood draw but not transcribed onto the blood sugar results section of the medical record. Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for a residents (#14and #92) in the most complete and accurate form. This was evident for 1 of 56 residents selected for review during the annual survey process. The findings include: A medical record is the official…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state 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 it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of flies. This was evident in the facility's main kitchen. The findings include: On 9/25/2019 at 11:33 AM during a brief visit to the main kitchen 2 house flies were observed flying in the kitchen. Additionally on 9/26/2019 at 9:44 AM when entering the kitchen to request a test tray, a house fly was observed flying above a prep table. At this time the air curtain mounted over the kitchen's rear exit was observed with excess dust. An air curtain is a device that blows a stream of air downwards through a doorway or opening to prevent entry of pests. The Administrator and Director of Nursing were made aware of these findings on 9/27/2019 during the exit conference.