Forestville Rehabilitation and Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 4 (LPN #45, GNA #46, GNA #47, GNA #48) out of 6 direct care staff employees reviewed during the Extended Survey portion of the facility's recertification survey.A facility must include effective communications as mandatory training for direct care staff. Direct care staff are defined as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Effective communication helps staff understand what a resident is trying to communicate so staff can appropriately respond. It also helps staff to effectively provide information to residents. This helps to ensure that residents are provided with information in a language and manner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive and ensure that a current copy of residents' advanced directives was in the residents' medical record. This was evident for 1 (Resident #1) out of 5 residents reviewed during the facility's recertification/complaint survey. The findings include:An advance directive is a set of written instructions that allows you to make decisions about your future medical care, and/or to designate somebody to make those decisions for you if you are no longer able to do so because of illness, injury, or incapacity. It includes the appointment of a health care agent or advocate, your healthcare instructions, and a signature page where you and two witnesses sign the form to make the document official. Essentially, it is a way to ensure everyone knows what you want and that your healthcare preferences are followed, even when you cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident's medication regimen was free from unnecessary medication/chemical restraints. This was evidenced by the facility utilizing psychotropic medication without appropriate assessment and documentation. This deficient practice was identified in one (Resident #17) of five residents reviewed for unnecessary medication regimens during the recertification/complaint survey.The findings include:Psychosis is a symptom involving a loss of contact with reality (e.g., hallucinations or delusions) that can occur in various conditions.Schizophrenia is a chronic mental health disorder characterized by psychosis and additional symptoms such as disorganized thinking and impaired daily functioning lasting over six months.Risperidone (Risperdal) is an atypical antipsychotic medication primarily indicated for schizophrenia, bipolar disorder, and irritability associated with autism. It functions by balancing dopamine and serotonin levels to stabilize mood and behavior.On 1/07/26 at 7:32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents and interview with facility staff, it was determined that the facility failed to timely report to the State Survey Agency, the Office of Health Care Quality (OHCQ), an allegation of suspected resident abuse, and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the recertification/complaint survey.The findings include:The 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. Allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported to the OHCQ in a timely manner.1) On 01/07/26 at approximately 1:35 PM, a review of the facility concern forms for the month of October 2025 revealed a concern form dated 10/30/2025 filed by Resident #164 of a concern that an assigned geriatric nursing assistant was roughly handling Resident #164. The facility's resolution was…

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

Based on review of facility records and interview with staff it was determined the facility failed to thoroughly investigate an allegation of suspected resident abuse and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the survey. The findings include:1) On 01/07/2026 at approximately 1:35 PM, a review of the facility concern forms for the month of October 2025 revealed a concern form dated 10/30/2025 filed by Resident #164 about a concern that an assigned geriatric nursing assistant was roughly handling Resident #164 and was not assisting with dinner. The facility's resolution was that the assigned geriatric nursing assistant was removed from the assignment, and the Director of nursing was made aware. However, the only accompanying documentation was a statement from the alleged geriatric nursing assistant perpetrator, which solely addressed not receiving assistance with the dinner meal.2) On 01/07/2026, at approximately 1:45 PM, a review of October 2025 facility concern forms revealed an allegation dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide documented evidence to support that the facility notified a representative of the Office of the State Long-Term Care Ombudsman that the resident was discharged . This was evident for 1 (Resident #162) of 2 Residents reviewed for discharge during the recertification/complaint survey process.Findings Included:On 01/09/2026 at 8:39 AM, a review of Resident #162 medical records revealed that the resident was discharged to home on [DATE]; however, there was no documented evidence to support that the facility notified the State Ombudsman's Office in writing.On 01/09/2026 at 9:35AM, in an interview with the Director of Nursing (DON), she was asked who was responsible for transfer and discharge notification to the Ombudsman and she explained that the social worker was responsible for ombudsman notification and it was done via email.On 1/9/2026 at 11:05 AM, in an interview with the social work designee (Staff #1), she explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's status. This was evident for 2 (Resident #8 and #17) out of 32 residents reviewed during the facility's recertification survey.The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial, and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. MDS assessments must be accurate to ensure each resident receives the personalized and resident specific care they need.Psychosis: A symptom involving a loss of contact with reality (e.g., hallucinations 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 review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #1 and #8) out of 52 residents reviewed during the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to the resident and/or RP and there must be evidence in the medical record that it was provided. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaints, medical records, and staff interviews, the facility failed to ensure a resident received necessary treatment and services to promote their highest practicable well-being: evidence by failing to 1) follow Physician orders for Gastrointestinal interventions related to appointments, and 2) arrange a critical diagnostic test and a specialty consultation as ordered by the provider. This was evident for 2 (Resident #19 and #145) of 8 residents that were reviewed during this recertification/complaint survey.The findings included:According to [NAME] Medicine, a gastrostomy tube (G-tube) is a medical procedure in which a tube is inserted through the abdominal wall and into the stomach to provide an alternative route for delivering nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus. A modified barium swallow study (MBSS) is a real-time X-ray (fluoroscopic) procedure that evaluates how a patient swallows different liquids and foods to determine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and staff interviews, it was determined that facility staff failed to provide and document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one resident (Resident #66) of three reviewed for urinary catheter care during this annual survey.The findings include:A Foley catheter is a thin, flexible tube inserted through the urethra into the bladder to drain urine, used for urinary retention, incontinence, or during/after surgery, kept in place by an inflated balloon at the tip. Foley catheter sizes are measured in French (Fr) units, indicating the tube's outer diameter, with larger numbers meaning a thicker catheter.During an interview on 1/05/26 at 11:37 AM, Resident #66 reported that their indwelling catheter had come out several times within one month. The resident stated, I felt like someone was pulling out the catheter.A review of medical records on 1/08/26 at 7:55 AM revealed that Resident #66 has a chronic indwelling catheter due to a diagnosis of paraplegia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and interview with facility staff, it was determined that the facility failed to timely address and notify the provider for a resident with a significant weight change. This was evident for 3 (Resident #8, #17, and #43) of 5 residents reviewed for nutrition during the facility's recertification/complaint survey.The findings include: 1) On 1/5/26 at 9:56 AM review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Further review revealed the following weights: 12/9/24 214.0 lbs (pounds)3/7/25 173.2 lbs6/8/25 181.6 lbs The above weights reflected that Resident #8 experienced a 40.8 lb or 19% weight loss between in 3 months and a 32.4lb or 15.14% weight loss in 6 months. On 1/7/26 at 11:56 AM in an interview with the Registered Dietician (RD #20) when asked how weight loss for a resident was identified, she stated, I know a resident has weight loss because the system flags it. When asked what she does after a resident was identified 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 a review of medical records and staff interviews, it was determined that the facility failed to monitor, including assessment and documentation, for a resident who was on a tube-feeding program. This was evident for one (Resident #78) of three residents reviewed tube feeding during the recertification/complaint survey.The findings include:On 1/12/26 at 9:00 AM, the surveyor reviewed Resident #78's medical records. The review revealed that the resident had been receiving tube feeding since May 2025 for adequate nutrition. Further review of Resident #78's diet orders showed:5/23/25 to 8/29/25: Puree texture, nectar-thickened liquids.8/29/25 to 12/10/25: NPO (nothing by mouth).12/10/25 to Present: Regular diet, puree texture, nectar-thickened liquids (current active order).A review of Resident #78's care plan on 1/12/26 at 9:10 AM revealed two care plans regarding tube feeding: one initiated on 5/24/25 with NPO diet, and another initiated on 5/29/25 including pleasure meals (regular diet, puree texture, nectar-thickened liquids).A review of medical records at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and staff interviews, it was determined that the facility failed to ensure that attending physicians visited residents at the required frequency of at least once every 60 days following the initial 90-day admission period. This deficiency was identified for two residents (Resident #38 and #94) out of three reviewed during the extended survey of the recertification/complaint survey.The findings include:On 1/12/26 at 12:30 PM, the surveyor performed a random audit of physician service records for three residents. The review revealed the following:Resident #38: admitted on [DATE]. The physician conducted an initial assessment on 5/22/25 and a follow-up visit on 6/16/25. However, there was no documentation of any subsequent physician visits for the remainder of the year, exceeding the 60-day regulatory limit.Resident #94: admitted on [DATE]. The physician completed the initial assessment on 3/31/25. No further follow-up documentation was found in the medical record to indicate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 3 (Resident #4, #17, and #43) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the residents' medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. 1) In an interview with the Director of Nursing (DON) on 1/6/26 at 10:33 AM when asked what happens during the monthly pharmacy MRR she stated the Unit Managers (UM's), Director of Nursing (DON), and Assistant Director of Nursing (ADON) receive it. It is printed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (Resident #129 and Resident #99) of 11 residents observed with 30 medication administration opportunities which resulted in an error rate of 6.67% by 2 of 5 nurses observed during the recertification survey.Findings Included:The national library of medicine indicates that Faster Insulin Aspart (Fiasp) is a novel formulation of insulin aspart with an accelerated time-action profile. This results in twice the insulin exposure and 74% greater insulin action within the first 30 minutes post-injection compared to conventional insulin aspart. This highlights a critical difference in the absorption rate and clinical effect between Fiasp and standard insulin aspart.On 01/06/2026 at 09:35 AM, surveyor's observation of medication pass for Resident #129 revealed that Licensed Practical Nurse (LPN) Staff #24 administered scheduled morning medications to the resident. Further observation revealed 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, medical record review, and interviews, it was determined that the facility failed to provide Dental services timely. This was evident for 1 (Resident #19) of 2 residents in review of dental during the recertification/complaint survey. The findings include:On 01/05/2026 at 11:57 AM, during an observation, Resident #19 pointed to his/her mouth and said, hurt. On 01/06/2026 at 9:59 AM, a review of Resident #19's physician orders revealed two separate orders for a dental consultation. The first order was a dental consult dated 10/3/2025 for teeth complications, and the second order, dated 12/9/2025, was for a dental consult due to the resident complaining of difficulty chewing.On 01/07/2026 at 12:22 PM, during an interview, Staff #21 (Unit Manager, Licensed Practical Nurse LPN) detailed the process for dental consultations. The unit manager initiates the process by completing a Health Drive form and submitting it to Health Drive. A provider from Health Drive then visits the facility to examine the residents. The health drive compiles a list of residents to be seen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and interviews with facility staff, it was determined that the facility failed to maintain medical records that were complete and accurately documented for residents. This was evident for 2 (Resident #8 and #55) out of 52 residents reviewed during the facility's recertification/complaint survey.The findings include:The Health Care Decisions Act, which became effective 10/1/1993, applies in all healthcare settings. In Maryland a patient is presumed to have capacity until 2 physicians, one of whom shall have examined the patient within 2 hours before making the certification, shall certify in writing that the patient is incapable of making an informed decision. The certification shall be based on a personal examination of the patient after which the physician attests that a patient lacks the mental ability to understand or make informed decisions about their healthcare or personal affairs, often triggering legal processes like guardianship or activating advance directives 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 surveyor observation, interview with facility staff, and review of medical records, it was determined that the facility failed to ensure that they maintained an effective infection control program evidence by: 1) failing to ensure appropriate personal protective equipment (PPE) was worn when entering a resident's room who was on Contact Precautions, and 2) failing to implement appropriate infection prevention and control practices during the medication administration task. This was evident for 1 (Staff #6) out of 1 employees observed entering the Contact Precautions room, and 1 License Practical Nurse (LPN#29) of 5 Staff observed during the medication administration task during the recertification/complaint survey.The findings include: Contact Precautions are infection control measures, used in addition to Standard Precautions, to prevent the spread of germs spread by touching an infected person or contaminated surfaces. Contact precautions require anyone entering the room to wear a gown and gloves, use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory Quality Assessment and Performance Improvement training. This was evident for 2 (GNA #47 and HH/FT #50) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. The findings include: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 helps long-term care facilities improve the quality of life and care for residents by using a systematic, interdisciplinary, comprehensive, and data-driven approach to identify issues, address the root causes of problems, and implement solutions. It involves ongoing monitoring and teamwork at all staff levels, and continuous review and revision of plans to ensure a safe, resident-focused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received compliance and ethics training. This was evident for 2 (GNA #47 and HH/FT #50) out of 7 employees reviewed during the Extended Survey portion of the facility's recertification survey. The findings include:On 1/8/26 at 11:32 AM in an interview with Human Resources Director (HRD #32) and the Infection Preventionist/Staff Educator (IP/SE #10), when asked if HRD #32 handles any of the staff training, HRD #32 stated, I get staff set up with a background check and orientation paperwork. I do not personally complete any trainings. IP/SE #10 acknowledged and confirmed this. On 1/8/26 at 11:34 AM in an interview with IP/SE #10 when asked the different ways trainings were provided to staff, she stated staff completed Relias training that was scheduled from corporate and that from me personally, I do handwashing, PPE (personal protective equipment), fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to investigate and take appropriate action to further prevent abuse. This was evident during the surveyor's review of facility reported incident #2635881 for Resident #2. The findings include: Resident #2's medical record review on 10/30/2025 at 9:24 AM revealed a care plan focus that Resident #2 had history of attempting to touch female staff and resident, attempting to go to female residents room and touching female residents inappropriately with interventions dated 11/03/2022 that staff were to monitor resident while in the room, redirect resident at all times and educate resident to keep his/her hands to themselves. During review of the facility reported incident #2635881 on 10/30/2025 at 9:50 AM revealed that on 09/29/2025 Resident #2 was witnessed inappropriately touching Resident #1. The facility placed a caregiver (1:1) 24 hours a day, 7 days a week to ensure Resident #2 did not enter other residents' rooms as well as moved Resident #2 to another room.During an interview on 10/30/2025 at 10:00 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 interview and record review it was determined the facility failed to ensure timely administration of medications, follow medical care orders, and follow professional standards. This was evident for 1 out of 1 Resident (Resident #24) reviewed for medication administration during the facility's complaint survey. The findings include: On 10/30/25 at 9:32AM the surveyor reviewed complaint 292569 which included concerns surrounding the timeliness of administration of important medications which included high risk medications.On 10/30/25 at 12:59PM the surveyor requested the medication administration audit report for Resident #24 from the facility's Director of Nursing.On 10/31/25 at 9:01AM the surveyor conducted a review of the facility's policy for liberalized medication administration. Review of that policy revealed: 1.) The medical Director will provide oversight and direction for the liberalized medication administration program, 2.) Medication parameters may be adjusted with approval of the medical director, 3.) Any medication ordered by the physician for a specific time…

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

Based on observation and interview it was determined the facility failed to follow professional standards for food service safety. This was evident during 1 out of 1 random observations made by the surveyor during review of complaint 292569.The findings include: On 10/30/25 at 9:32AM the surveyor reviewed complaint 292569 which included an allegation/concern for the way ice storage used for resident ice water was handled by facility staff.On 10/30/25 at 11:12AM the surveyor observed the facility's second floor nutrition room with an ice scoop holder on the wall which contained an ice scoop, however, the ice scoop was situated on top of and partially within a plastic bag which was observed stuffed within the ice scoop holder. On 10/30/25 at 11:19AM the surveyor observed an open metal cart which contained an ice cooler on the top rack. On the bottom rack of the open style metal cart, the ice scoop for the cooler was observed stored/located approximately three inches from the hallway floor in an open plastic container with the handled ice scoop completely enclosed in a partially open…

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

Based on observation and interview it was determined the facility failed to ensure staff performed hand hygiene. This was evident during 2 out of 2 random observations made by the surveyor during review of complaint #292569.The findings include:1.) On 10/30/25 at 9:32AM the surveyor reviewed complaint #292569 which included an allegation that a facility staff member did not perform hand hygiene prior to medication administration and they had to direct the staff member to perform hand hygiene.On 10/30/25 at 10:00AM the surveyor conducted an interview with an anonymous source who reported to the surveyor that they observed a facility staff member administer medication with their bare hands and interact with other residents before entering their family member's room at which time they directed them to perform hand hygiene prior to working with their central line (intravenous catheter). On 10/30/25 at 10:42AM the surveyor performed a random observation of medication administration. The surveyor observed Licensed Practical Nurse (LPN) #11 proceeding down a hallway holding medication in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure that residents resided in a safe, comfortable and homelike environment related to an adequate response and maintenance for water damage which was present in the room and bathroom of two residents (# 3 and # 66) and 7 rooms. This was found to be evident during multiple observations and tours conducted during the survey. The findings include: 1. During the surveyor's initial tour of the facility on 5/20/24 at 7:44 AM the surveyor observed a bath blanket laying on the floor in the entrance way to room [ROOM NUMBER]. Upon entering the room, the surveyor observed 8 brown stains on the ceiling tiles located above the beds of Resident #3 and Resident #66. One of the stains found covered approximately seventy percent of a ceiling tile. At this time, the surveyor entered the resident bathroom and observed a standing pool of water accumulated on the floor to the left of the commode, with black debris present within it, and 4 ceiling tiles…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, record review, review of other pertinent documentation and staff interviews, it was determined that the facility failed to: 1) treat in a timely manner Resident (#91) complained of pain and a possible fracture and 2) ensure a resident's helmet was in place as ordered by the physician. This was evident for 2 (Resident #91 and #82) of 37 residents reviewed during the survey. The findings include: 1.) During observation rounds on 5/20/24 at 10 am, Resident #91 stated while s/he was being transferred from his/her bed to the chair by the Physical Therapist (PT) #49, s/he heard a popping sound and stated, I told her you broke my leg. S/he stated prior to the transfer s/he told staff #49; You cannot pick me up by yourself, it takes 2 people. The resident stated there were 2 Geriatric Nursing Assistants (GNA) in the room at the time; but Staff #49 told them Not to touch me. It is her job. After the resident was transferred into the chair, The resident told the nurse and the Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to properly store food, maintain sanitary conditions, and consistently monitor freezer temperatures. This deficient practice was discovered during the survey. The findings include: During the surveyor's initial inspection of the kitchen with Food Service Manager #12 on 05/20/24 at 7:49 am, revealed a white powdery substance on a resident communal coffee dispenser, brown spots on the bottom of the food tray rack, and the kitchen floor had a sticky substance. After surveyor intervention the communal coffee dispenser was cleaned. On 05/20/24 at 7:52 am the surveyor opened the refrigerator door and observed an unlabeled black plastic bag of fruit, an undated clear bag of bagels, an open plastic container of Aquafina water, and unlabeled clear bag with beets, and a clear plastic container with a sandwich inside. Manager #12 confirmed the surveyor's findings. On 05/20/24 at 7:58 am the surveyor observed in the larger refrigerator a clear plastic bin containing limes with multiple brown spots, and a clear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to treat a resident (#111) with dignity by exposing the resident in a public area. This was evident in 1 of 8 residents reviewed for dignity during the survey. The findings include: During observation rounds on the 1st floor on 5/20/24 at 8:00 am, the surveyor observed housekeeping (Staff #59) open the shower room door wide open for Resident #79 to use the shower room. Staff #59 opened the door without knocking or checking to see if the shower room was occupied. This exposed Resident #111 who was showering to the residents, staff, and surveyors in the hallway. On further observation, there were no signs or notice outside of the door showing there was a shower in progress, the room was occupied, or to knock before entering. The door had an entry key on the outside. During an interview with the Licensed Practical Nurse (LPN) Staff #55 on 5/20/24 at 8:03 am, Staff #55 stated that only staff had codes to the entry key for the shower rooms. When asked how staff would know that a resident was showering in…

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

Based on record review, interviews, and observations the facility failed to ensure that a resident's choice to receive a shower twice per week as requested was provided. The determination was found to be true for 1 (#55) out of 5 residents reviewed for choices during the survey. The findings include: On 05.20.24 at 1:00 PM the surveyor toured the second-floor clinical unit and observed resident # 55 resting in bed in a hospital gown with his/her head tilted to the left and leaning towards chest. The resident stated that he/she had received a bed bath but that he/she preferred to be showered. The surveyor observed that the resident had a malodorous mouth odor and his/her teeth appeared yellow and thick sputum was present when the resident spoke. The surveyor on 05.22.24 at 08:39 AM observed resident #55 in bed with a yellow stained pillowcase and other bed linen appeared dingy in color. Resident #55 stated that he/she had not received AM care (morning) related to bathing. Also, the surveyor on 05.22.24 at 10:30 AM returned to resident #55's room and observed that 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 resident interview, record review, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for a resident (#91). This was evident for 1 out 8 residents reviewed for accidents during the survey. The findings include: During observation rounds on 5/20/24 at 10 am, Resident #91 stated while s/he was being transferred from his/her bed to the chair by the Physical Therapist (PT) #49, s/he heard a popping sound. I told her you broke my leg. Resident #91 stated prior to the transfer s/he told PT #49; You cannot pick me up by yourself it takes 2 people. The resident stated there were 2 GNA's in the room at the time; but PT#49 told them Not to touch me. It is her job. After I was transferred into the chair, I told the nurse and the Physical Therapist (Staff #49), I was feeling pain in my right leg; however, neither one responded. When asked by the surveyor when this incident occurred the resident stated around November 22nd the 23rd. The resident stated, I remember this because it was prior to Thanksgiving. The resident went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview and review of Facility Reported Incident MD00202293, it was determined that the facility failed to ensure resident #18 was free from misappropriation of property. This was evident for 1 of 60 residents reviewed during the survey. Findings include: Review of the Facility reported incident MD00202293 on 5/24/24 at 9:30 am revealed that on 2/6/24 the Administrator received a call from the 911 dispatcher reporting that resident #18 attempted to call 911 for another resident before the staff was verbally aggressive telling him/her not to call 911 and then the phone hung up. On 5/24/24 at 10:30 am a review of the facility's investigation revealed the facility confirmed that a GNA (Geriatric Nursing Assistant) # 61 had taken resident's #18's cell phone while s/he was attempting to call 911 for resident #166. The GNA # 61 removed the cell phone from the room and turned it over to the Nursing Supervisor RN # 63. According to the investigation GNA #61 was instructed to return the phone to resident #18. During an interview at 11 am on 5/24/24 with 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 interviews with the resident and facility staff it was determined the facility failed to ensure that care plan meetings were provided to the resident quarterly and as needed. This was found to be evident for 1 (Resident # 13) of 4 residents reviewed for care plans during the survey. Findings Include: An interview was conducted with resident #13 on 5/21/24 at 10:16 AM and the resident was asked if s/he is invited to participate in the care plan meetings that the facility conducts with the residents and the resident stated, no. The resident went on to say that s/he has not had a care plan this year and didn't recall having one the previous year. On 5/23/24 at 1:30 PM, the survey team requested a copy of the last six (6) care plan meeting notes, a copy of the attendance sheets of staff that attended the meetings and a copy of the invitation that was sent to the resident to attend the meeting. On 5/24/24 at 10:30 AM the Administrator, and the DON provided the survey team with a copy of three resident invitations as follows: Invitation dated 5/23/24 for…

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

Based on medical record reviews and interviews it was determined that facility staff failed to ensure resident's plan of care was followed and/or updated according to professional nursing standards as evidenced of residents not receiving showers twice a week. This deficient practice was evident for 2 (#126 & #134) out of 2 resident records reviewed for Activities of Daily Living care during the survey. The findings include: The Maryland Nurse Practice Act guide and govern nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 C Nursing Plan of Care (2) Implementation. The LPN participates in the implementation of the nursing plan of care by (b) Assisting in the coordination of client care with other health care team members as directed by the RN; (d) (ii) Continue to collect and report data regarding the implemented plan including the client's response to interventions and problem identification. 1. 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 observations, staff interviews, and review of the medical record, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (#82) of 2 residents reviewed for activities. 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. On 5/20/24 at 11:21 AM, Surveyor observed Resident #82 lying in bed with no activities. On 5/28/24 at 9:59 AM, in an interview with Licensed Practical Nurse (LPN) #43, they reported Resident #82 does not participate in activities. On 5/28/24 at 10:01 AM Resident #82 was observed lying on their right side in bed. No TV or music was on, and there were no forms of activity or engagement in the resident's room. On 5/28/24 at 1:19 PM, in an interview with Activities Lead (AL) #45, they reported Resident #82 does not regularly participate in activities except when…

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

Based on observation and interview it was determined the facility failed to ensure safety of a resident who was being transferred via a Hoyer lift. This was evident for 1 out of 1 resident (#91) observed to be transferred via a Hoyer lift. The findings include: On 5/24/24 at 11:30 AM, the surveyor observed Staff #20, Geriatric Nursing Assistant, and Staff #41, Geriatric Nursing Assistant, bring Resident #91, who was suspended in the sling of a Hoyer lift, (machine which helps lift/transfer a resident) into the resident hallway and prepare to transfer them onto the reclining shower chair. The surveyor observed GNA #20 use the Hoyer lift remote to lift the resident above the level of the reclining shower chair, however, the Hoyer lift equipment failed to work properly, and would not continue to raise the resident to the level needed to safely place them on the chair. The resident was observed to be suspended in the sling several inches below the level of the chair they were being transferred to. The surveyor observed GNA #41 reach and lean over the shower chair placing their hands 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 observation, review of the medical record, and interview with staff it was determined the facility staff failed to provide appropriate and sufficient care for a resident with an indwelling urinary catheter. This was evident for 1 (#41) of 2 residents reviewed for urinary catheter or urinary tract infection (UTI). The findings include: An indwelling urinary catheter, often referred to as a Foley catheter, is inserted into a patient's urethra (the tube that carries urine from the bladder to the outside of the body) and remains in place to collect the urine into a drainage bag. The bag has a valve that can be opened to allow urine to flow out and be emptied. Urinary catheters can be ordered for several reasons such as urinary incontinence (leaking urine or being unable to control when you urinate), urinary retention (being unable to empty your bladder when you need to), during and/or after a surgery, or related to other medical conditions such as a spinal cord injury. However, urinary catheters are associated with an increased risk of urinary tract infections (UTI) as well as…

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

Based on observations, staff interview, and resident medical record review it was determined the facility failed to administer oxygen to resident #74 as prescribed by physician orders. This was evident for 1 (resident #74) of 1 residents that was reviewed for respiratory care services during survey. The findings include the following: On observation rounds on 05/20/24 at 08:04 AM it was observed that resident #74 was on 1 liter of oxygen with humidification via aerosol collar. During an interview on 05/20/24 at 08:10 AM with staff #7, she stated and confirmed that resident was on 1 liter of oxygen and should be on 3 liters of oxygen. After surveyor intervention, staff #7 placed resident #74 on 3 liters of oxygen with humidification via aerosol collar. Review of resident #74 medical record on 05/20/24 at 11:05 AM revealed a physician order dated 11/13/23 for resident #74 to be administered oxygen with humidification via aerosol collar at 3 liters every shift for shortness of breath.

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure a medication error rate of 5% or less. This was evident for 2 of 27 opportunities for error observed during the medication administration, resulting in an error rate of 7.41%. The findings include: 1) On 5/24/24 at 8:06 AM, the surveyor observed Registered Nurse (RN) #6 dispense the medications Calcium/D 600mg (milligrams), Finasteride 5mg, Gabapentin 300mg, and Oxcarbazepine 300 mg into a medication cup for Resident #17. On 5/24/24 at 8:15 AM, RN #6 administered 4 medications with water to Resident #17. Review of the medical record on 5/24/24 at 9:07 AM revealed a physician's order that stated, Xanax Oral Tablet 0.5 MG (Alprazolam) *Controlled Drug*, Give 1 tablet by mouth two times a day for Anxiety MGT (0700-1000 and 1700-1800). RN #6 did not give the Xanax. Further review of the Medication Audit Administration Record (MAAR) in the medical record at 9:39 AM revealed the Xanax was not signed off that it was given. On 5/24/24 at 11:36 AM in 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 observations and interviews with facility staff it was determined the facility failed to ensure that medications were date labeled upon opening them and that medications/biologicals were stored and secured in a locked medication/treatment cart. This was found to be evident for 3 of 3 medication carts and 1 treatment cart reviewed during the survey. Findings include: A medication storage observation was done on 6/3/24 at 10:15 AM on the Second floor. 1. An observation was made of Registered Nurse (RN), Staff # 6 medication cart: Bottle x 1 of Lantus (100 units) for Resident # 164 that had an open seal. The bottle did not have a date label on it. Bottle x 1 of Lispro (100 units) and Bottle x 1 of Glargine (100 units) for Resident # 165 that had an open seal. The two bottles did not have a date label on it. An interview was conducted with the nurse (# 6) at the time of the observation. The nurse was asked to explain the facility's policy for labeling medications, and she stated that medications are to be dated at the time that they are opened. She went on to explain that the…

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

Based on observations and interviews, it was determined that facility staff failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident in 1 of 1 food test tray samples reviewed during the survey. The findings include: On 05/30/24 at 8:48 am during an interview with Dietary [NAME] #19 they verbalized, the kitchen staff began preparing breakfast trays at 7:05 am. The surveyor started observing the dietary staff prepare breakfast trays on 05/30/24 at 7:58 am. At 8:43 am after the last resident tray was prepared, the surveyor requested a test tray. At 8:53 am, the food cart, surveyor, and Regional Healthcare Service #11 departed the kitchen and followed the food trays to Unit 2. On 05/30/24 at 8:55 am the last food cart arrived on the unit, but at 9:08 am, the last breakfast tray was delivered to Resident #141 who was dependent on the staff for feeding. GNA #60 warmed the resident's food and at 9:11 am the resident was fed breakfast, which was 28 minutes after the tray was prepared. On 05/30/24 at 9:11 am Regional Healthcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews review of MD00201072 and interviews it was determined that the facility to ensure a new hire nursing staff had an active, valid registered nurse license. This was evident for 1 (#56) of 5 licensed healthcare professional employee files reviewed during the survey. The findings include: On 05.28.24 at 11:30 AM the surveyor reviewed the intake information related to MD00201072, a facility reported incident which indicated Staff #56 applied for a nursing position on the facility website for a registered nurse position at the facility. During an in-person interview by staff # 57 on 11.15.23 staff #56 was hired. At the time of the interview staff #56 presented a copy of a RN license, it was later determined on 12.29.23 by the director of nursing (DON), staff #1 that the document was fraudulent and Staff # 56 was terminated. Based on review of the administrative documents provided by the facility the police were notified on 12.30.23, and OHCQ and the Ombudsman, and the Maryland Board of Nursing (MBON) were notified on 01.03.24 of the nurse impersonator allegation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to accurately document the dates on a resident's Preadmission's Screening and Resident Review (PASARR) form. This was evident for 1 (Resident #152) of 2 residents reviewed for PASARR. The findings include: On 5/21/2024 at 9:50 am, the surveyor reviewed Resident #152's record. There was no record of PASARR in the resident's paper or electronic chart. On 5/21/2024 at 10:10 am, the surveyor interviewed the social worker (Staff #17). Staff #17 stated that all PASARR's are kept in social services. Staff #17 stated they would provide the survey team with Resident #152's PASARR as soon as possible. On 5/21/2024 at 12:30 pm, Staff #17 provided the survey team with Resident #152's PASARR. At this time the PASARR was reviewed. The PASARR form was dated by social services designee (Staff #47) on 4/8/1964. The date of admission documented on the PASARR as 4/8/1964. It should be noted that Resident #152's date of admission is 4/8/2024 as documented in the residents medical record.

Based on record reviews, observations and interviews it was determined that the facility staff failed to maintain infection control precautions and ensure that the policies and procedures related to infection control were updated. This deficient practice was discovered during survey. The findings include: 1. On 05/30/24 at 7:56 am while observing the kitchen staff prepare breakfast trays the surveyor observed Dietary Aide #54 in the kitchen on the tray line with his/her undergarments were exposed. On 05/30/24 at 8:18 am during an interview with Food Services Manager #12 they verbalized Dietary Aide #54 received verbal counseling multiple times about their undergarments being exposed. On 05/30/24 at 8:20 am while observing the cook prepare breakfast rays the surveyor observed [NAME] #19 placed slices of cheese on the cutting board that had food particles. On 05/30/24 at 8:35 am during an interview with Healthcare Services Regional Manager #11 they verbalized the surface on the cutting board should have been wiped before the cheese was placed. 2. On 05/30/24 at 8:56 am while on Unit 2…

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

Based on observation and interview it was determined the facility failed to ensure residents had access to call bells. This was evident for 3 residents (#3, #66, #49) observed during the surveyor's initial tour of the facility during the recertification survey. The findings include: Upon surveyor's initial tour on 5/20/24 at 7:44 AM, the call bell for Resident #3 was observed to be pulled out from the wall, leaving it unable to be utilized until plugged back in. On 5/20/24 at 8:00 AM the surveyor observed Staff #26, Licensed Practical Nurse, fixing Resident #66's breakfast at their bedside. The surveyor observed Staff #26 leave the room. The surveyor observed that Resident #66 had no call bell present in the room. The surveyor requested a dual observation of the resident with Staff #26, at which time Staff #26 observed with the surveyor and stated: the resident does not have a call bell. At this time, the surveyor shared their concern. During an interview with Resident #66 on 5/20/24 at 8:06 AM they responded yes when asked if they would use the call bell if one was provided 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 observations and interviews, it was determined that facility staff failed to provide a safe, sanitary, and comfortable environment for staff. This deficient practice was discovered during the survey in multiple areas within the facility. The findings include: 1. On 05/20/2024 at 8:32 AM the surveyor observed multiple areas of standing water and a leaking pipe under the sink next to the dishwasher. There was a hole around a pipe beneath the sink and corrosion on several pipes under the stainless-steel tables in the dishwashing area. Food Service Manager #12 reported that plumbers serviced the pipes last summer, but used the wrong size pipes, causing the pipes to leak. 2. On 05/29/24 at 9:26 am the surveyor observed two holes in the wall above the door near a vent in the clean laundry room. Administrator #3 was made aware and confirmed the surveyor's findings. At 9:29 am the surveyor observed a buildup of green & white washing chemicals on the wall near the washing machines, along with a taped hose that was leaking. The dryer room had plaster falling from the ceiling 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 record review and interview, it was determined that the facility failed to place a discharge summary on a resident's (#579) medical record after discharge. This was evident for 1 of 21 residents reviewed during the survey. The findings include: Review of resident #579's medical record on 5/31/24 at 12:50pm revealed no evidence of a physician discharge summary after the resident discharged from the facility on 4/7/22. Interview with the Director of Nursing (DON) on 6/3/24 at 8:36am revealed the resident had a planned discharged from the facility after successful rehabilitation. The surveyor pointed out the lack of a physician discharge summary on the resident's medical record. The DON reviewed resident #579's medical record and confirmed that he/she was unable to find a physician's discharge summary in the medical record.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility staff failed to ensure all resident rooms and hallways were maintained in a homelike manner. This was evident for 11 of 19 rooms reviewed during the survey. The findings include: 4. During an initial tour of the facility on 6/19/19 at 10:00 AM, observations revealed the blinds in the windows of rooms [ROOM NUMBER] were damaged. In all three rooms, the edges of the blinds were bent on both sides of the windows. This damage prevented the window blinds from blocking light coming into the room. One of the two residents in room [ROOM NUMBER] expressed in interview with the surveyor that the blinds were horrid and agreed that they detracted from the homelike environment of the room. The Director of Maintenance was made aware. Further observations of the facility revealed the following: 1. A hole near the base of the wall behind the door in room [ROOM NUMBER]. The hole was over one (1) foot in width. The bathroom door and the walls adjoining the door…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it was determined facility staff failed to maintain an environment free of unnecessary accident hazards as evidenced by: 1) Residents #1, #35 and #84 using their own lighters during a smoke break while Resident #46 was being observed; and 2) a medication cart that was found unlocked and unattended. Observations of the residents smoking were evident during 2 smoking breaks. The findings regarding the medication cart were noted on 1 of 4 days of observation during the survey. The findings include: 1. On 6/20/19 during the 9:15 AM smoke break Resident #46 was being observed for smoking safety. The writer noted that as the residents went outside to smoke, before staff could light all the cigarettes, Residents #1, 35, and 84 pulled out their own lighters, lit their cigarettes and proceeded to light other residents' cigarettes. Writer informed staff outside with the Residents. On 6/21/19 prior to the 9:15 AM smoke break the writer observed the 1st floor unit manager asking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to correctly code the Minimum Data Set (MDS) for Residents #153 and #68. This was evident for 2 of 46 residents investigated during the survey. The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions (also referred to as MDS Items). Each triggered care area must then be assessed in order to determine if care planning is needed. The MDS triggers are used to provide direction for the development of an effective plan that will ensure the assessed needs of each resident are met when care is delivered. The MDS is a key tool in the process of assessing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives to meet the medical, nursing, mental and psychosocial needs for 1 out of 39 residents (Resident #68) reviewed during investigative portion of the annual survey. A plan of care is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of resident care. The finding includes: On 6/24/19 at 1:30 p.m. Resident #68's medical record was reviewed. The review revealed an assessment dated in September 2012. According to the assessment, Resident#68 scored a three (3) out of 15 on his/her Brief Interview for Mental Status (BIMS), which signifies mental impairment and inability to make decisions. Further review of the record revealed that on 2/2/19 Resident #68 experienced a change in condition and was given a new medical diagnosis. The resident was also admitted to hospices services and given new physician orders for care and…

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

Based on review of resident records and interview with facility staff, it was determined that the facility failed to ensure that residents' plans of care were reviewed and revised by the interdisciplinary team at least quarterly. This was evident for 1 of 2 residents reviewed for care plans (Resident #103). The findings include: Resident #103 was interviewed on 6/20/19 at 9:40 AM. During the interview, the resident states that s/he does not receive quarterly care plan meetings. Resident #103's electronic medical record was reviewed on 6/24/19 at 1:15 PM. During the review, notes were found from meetings that took place on 5/14/19, 8/14/18, and 1/30/18. No meeting note could be found in the electronic record that established that a meeting had taken place between 8/14/18 and 5/14/19. Resident #103's paper medical record was reviewed on 6/24/19 at 2:30 PM. During the review, sign in sheets were found for meetings that took place on 5/14/19, 8/14/18, and 4/25/18. Again, no meeting sign in sheet could be found that established that a meeting had taken place between 8/14/18 and 5/14/19.…

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

Based on medical record review and staff interview it was determined staff failed to: 1) clarify an order for pain medication; and 2) consistently document thorough pain assessments for Resident #402. This was evident for 1 of 46 residents investigated during the survey. The findings include: On 6/24/19 beginning at approximately 11:00 AM, the medical record of Resident #402 was reviewed. During the review, it was noted that Resident #402 had an order for Oxycodone Hydrocloride (HCL) 5 milligrams, with instructions to give to the resident 1 tablet by mouth every 6 hours as needed for pain. The order was not clarified to state whether the nurse is to give the medication for mild, moderate or severe pain. According to drugs.com (website https://www.drugs.com/oxycodone.htm), Oxycodone is an opioid pain medication sometimes called a narcotic. Oxycodone is used to treat moderate to severe pain. It is a minimum standard of nursing practice that nursing staff are to clarify orders that are unclear. During the same medical record review, the June 2019 Medication Administration Record (MAR)…

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

Based on review of resident medical records, it was determined that the facility failed to ensure that pharmacy record reviews were acted on in a timely manner. This was evident for 1 of 6 residents (Resident #123) reviewed for unnecessary medications. The findings include: Resident #123's medical record was reviewed on 6/21/19 at 10:57 AM. During the review, it was found that consultant pharmacist recommendations were made on 5/13/19 around the time of the resident's admission to the facility. One of the recommendations made on 5/13/19 was related to an anticoagulant medication that had been prescribed for illness prevention ('prophylaxis'). The recommendation stated, Please clarify as this appears to be a full therapeutic dose as opposed to a prophylactic dose. The physician response stated, [prophylactic] dose, and was signed on 5/15/19. A follow up note was written that stated Discontinued on 5/28/19, continued on another anticoagulant. This represented a delay from the from the physician's response on 5/15/19 to the discontinuation of the medication on 5/28/19. A second 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 medical record review and staff interview it was determined there was an error in the diagnostic list in the admission Record for 1 of 46 residents investigated during the survey (Resident #35). The findings include: On 6/21/19 at 10:08 AM A review of Resident #35's medical record revealed a diagnosis of diabetes insipidus listed under the section titled Diagnosis Information. According to information on Mayo Clinic website https://www.mayoclinic.org/diseases-conditions/diabetes-insipidus/symptoms-causes/syc-20351269: Diabetes insipidus (die-uh-BEE-teze in-SIP-uh-dus) is an uncommon disorder that causes an imbalance of fluids in the body. This imbalance makes you very thirsty even if you've had something to drink. It also leads you to produce large amounts of urine. While the terms diabetes insipidus and diabetes mellitus sound similar, they're not related. Diabetes mellitus - which can occur as type 1 or type 2 - is the more common form of diabetes. Further review of the medical record revealed no ordered lab tests or medications that would be associated with a diagnosis…

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