Autumn Lake Healthcare At Ballenger Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 4 (Resident #35, #311,#110,# 25) of 68 residents reviewed during the survey. The findings include: 1.The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A review of Resident #35's admission MDS assessment dated [DATE], revealed that in Section P, Question P0100 the resident used a limb restraint. On 6/23/25 at 9:58 AM an observation and interview were conducted at the resident's bedside with a family member present. No restraints were…

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

Based on observation, medical record review, and interview, it was determined that the facility staff failed to develop and implement comprehensive person-centered care plans for residents residing in the facility. This was evident for 4 (Resident , # 56, #26, #77, #40) of 68 residents reviewed during the recertification survey. The findings include: Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The findings include: 1. Resident #56 has resided at the facility for more than one year and is legally blind. A review of the Minimum Data Set assessment, with an assessment reference date of 7/5/24 revealed the resident was interviewed in regard to activity preferences. This assessment revealed it was very important for the resident to have books, newspapers and magazines to read; to listen to music the resident likes; be around animals such as pets and to participate in religious services or practices. On 6/25/25 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 interviews, observations, and record review it was determined that the facility failed to provide activities of daily living (ADL) care to dependent residents. This was evident for five (Resident #83, #25, #112, #15 and Resident #62) out of ten residents reviewed for ADL care. The findings include: 1.On 06/23/25 at 8:44 AM Resident # 83, a long-term resident of the facility, and their family members were interviewed. During the interview they reported that the resident goes a long time without receiving incontinent care from the staff. On 6/25/25 at 7:39 AM an observation in Resident #83 room was made. A family member and a resident were in the room. Observation revealed that the resident's top bedsheet was soaked with liquid, which had a slight smell of urine. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected on the MDS drives Resident care planning decisions. MDS assessments…

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 4. Resident #56 has resided at the facility for more than one year and is legally blind. A review of the Minimum Data Set assessment, with an assessment reference date of 7/5/25 revealed the resident was interviewed in regard to activity preferences. This assessment revealed it was very important for the resident to have books, newspapers and magazines to read; to listen to music the resident likes; be around animals such as pets and to participate in religious services or practices. During an interview with the resident on 6/23/25 at 10:58 AM the resident denied that activity staff visit him/her. On 6/25/25 a review of the medical record revealed a care plan for activities, initiated in 2024 and with a revision date of 5/19/25. The interventions included, but were not limited to: Staff to provide 1:1 room visits as desired/available; Staff to assist resident in locomotion to activities as desired; and Staff to encourage resident to attend activities of interest as they occur. On 6/25/25 at 12:40 PM review of…

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

Based on review of the medical record and interviews it was determined that the facility failed to keep a resident safe from significant medication errors. This was found to be evident for one (Resident #56) out of three residents reviewed for behavioral health services. The findings include: Review of Resident #56's medical record revealed the resident received dialysis treatments Mondays Wednesdays and Fridays in the mornings, and the resident also has a diagnosis of Anxiety. Review of the most recent psychiatric nurse practitioner note, dated 3/27/25, revealed the resident: should continue Ativan 1.5 mg Q [every] Mon, Wed, and Fri; and Ativan 0.5 mg QHS [at bedtime]. a.On 6/26/25 review of the medical record revealed an order for Ativan Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth at bedtime for anxiety was in effect from 3/20/25 until it was discontinued on 6/19/25. Further review of the medical record revealed a current, identical order, was put in place on 6/19/25 for the 0.5 mg of Ativan at bedtime. Review of the medication administration record on 6/26/25, revealed…

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

Based on medical record review, observation and interview it was determined the facility failed to ensure staff accurately documented in the medical record. This was found to be evident for one (Resident #56) out of three residents reviewed for behavioral health service; and three (Resident #40, #62, and #268) out of ten residents reviewed for Activities of Daily Living. The findings include: 1. Review of Resident #56's medical record on 6/26/25 revealed an order for Ativan Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth at bedtime for anxiety, was in effect from 3/20/25 until it was discontinued on 6/19/25. Further review of the medical record revealed a current, identical order, was put in place on 6/19/25 for the 0.5 mg of Ativan at bedtime. Review of the medication administration record on 6/26/25, revealed staff documented the administration of the 0.5 mg Ativan to the resident at 9:00 PM every evening from 6/1/25 through 6/25/25. Ativan, also known as Lorazepam, is an antianxiety medication and considered a controlled substance. Therefore, there are controlled drug…

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 facility policies, interviews, and observations, it was determined that the facility failed to implement an effective infection prevention program that ensured staff implemented infection control practices. This was found to be evident for two (Resident #96, #70) of the 68 resident's reviewed and has the potential to affect all residents.The findings include:1. On 6/26/25 at 8:23 AM surveyor observed nurse #24 prepare and administer Resident #96's medications. At 8:38 AM the nurse was observed wearing gloves while washing the resident's feet prior to administration of a medicated cream. The nurse changed gloves after washing the resident's feet and prior to applying the medicated cream, however the nurse failed to perform hand hygiene after removing the gloves worn while cleaning the resident's feet.After applying the medicated cream the nurse remove his/her gloves, did not perform hand hygiene, and then removed two new gloves from the clean supply but did not put them on. The nurse proceeded to put those gloves back in the box of clean gloves.…

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

Based on observation, interview, document review it was determined that the facility failed to have an effective process in place to ensure a resident's personal property was kept safe and available to the residents. This was evident for 1 (Resident# 83) of 7 Residents reviewed for food during a survey. The findings include: On 6/23/25 at 8:48 AM Resident # 83, a long-term resident of the facility, reported that the food served in the facility is hard to chew and his family often brings in food form home for him/her to eat. On 6/24/25 at 7:20 AM an observation was made of Resident #83s family members speaking with the long-term care unit 1 secretary (Staff #10). Resident #83s family member reported to the secretary that s/he brought food in for Resident #83 on 6/23/25. However, s/he just looked in the unit refreshment refrigerator and the food was not there. 06/24/25 08:00 AM the corporate dietician provided the facility's policy titled Food from Home Policy. On 6/24/25, a review of the Food form Home Policy revealed that all food items that are brought in by the family must 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 observations, record review and interviews, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to ensure access to call lights and lighting controls. This was found to be evident for one (Resident #40) out of ten residents reviewed for activities of daily living; and 10 out of 10 rooms observed for location of lighting controls.The findings include: 1. On 6/26/25 at approximately 12:11 PM, the surveyor observed Resident #40 out of bed and seated in their wheelchair on the right side of their bed. The surveyor noted that the resident's call bell was tied to the left side bed rail and was out of the resident's reach. The surveyor then asked a Nursing Assistant (GNA #17) to enter the room and assess the placement of the call bell. GNA #17 confirmed that the call bell was out of reach and repositioned it closer to the resident.On 6/27/25 at 1:55 PM, the surveyor observed Resident #40 out of bed and seated in their wheelchair on the right side of the bed. Once again, the surveyor noted that the call bell…

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

Based on medical record review and interview it was determined that the facility failed to ensure health care advance directives were discussed with a resident. This was found to be evident for 1 (Resident #79) out of three residents reviewed for advance directives. The findings include: Resident #79 has resided at the facility for several years and is certified as having adequate decision making capacity. Review of an Advanced Directive admission assessment form revealed the following: An advanced directive allows you to decide who you want to make health care decisions for you if you are unable to do so yourself. You can also use it to say what kinds of treatments you do or don't want, especially the treatments often used in a medical emergency or near the end of a persons life. Review of the Advance Directive admission form for Resident #79 revealed that staff documented in February 2023 that an Advanced Directive was currently in place. Further review of the medical record revealed a Social Service Assessment, dated 3/26/24, that documented in the section titled: Health 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.

2. An observation on 6/24/25 at 6:58 AM revealed that Resident #48's room had dark debris, dried food particles, and dried sticky fluid on the floor. The Resident's Representative was present and said, The floor has been like this for at least 2 weeks. In an interview on 6/24/25 at 9:21 AM in Resident #48's room, staff #36, a housekeeping technician, confirmed the concerns and stated that Residents' rooms were to be swept, mopped, and wiped down daily. During a subsequent interview with staff #37, the director of environmental services, in Resident #48's room, he confirmed that there were dark stains, debris, and dried sticky fluid on the floor. Staff then added that the Resident's room looked dirty and would be taken care of after the surveyor's intervention. Based on observations, record review and interviews, it was determined that the facility failed to ensure a clean, comfortable, and home-like environment for residents. This was found to be evident for one (Resident #62) of 10 residents reviewed for activities of daily living and one (Resident #48) identified during an…

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

Based on interview and record review it was determined that the facility failed to implement their grievance policy when a resident alleged their property was missing. This was evident for 1 (Resident #102), of 3 residents reviewed for personal property during the recertification survey. The findings include: On 6/24/25 at 8:56 AM an interview was conducted with Resident #102 who reported that when they were admitted to the facility they brought their wheelchair with leg rests. The resident further explained that the leg rests of their personal wheelchair had been missing for approximately one month and that the physical therapist (Staff #11) had tried to find them. In the meantime, the facility provided other leg rests to the resident. 06/24/25 at 2:35 PM an interview was conducted with unit nurse (Staff #16) regarding Resident #102's wheelchair and leg rests. She said that she was aware of the resident's concern that their personal wheelchair leg rests were missing and the Physical Therapist (Staff #11) was looking for them. When asked if there was anything in writing about 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 upon record review and pertinent staff interviews, it was determined that facility failed to ensure that incidents of alleged abuse were thoroughly investigated and reported to the state agency in a timely manner. This was evident for 1 (Resident #125) of 13 residents reviewed for abuse during the survey. The findings include: 1) Resident #125 was admitted into the facility in early 2022. A quick look into the resident's medical record indicated severely impaired mental cognition. A review of the intake information related to MD00192139 was conducted on 6/27/25 at 12:48 PM. The review indicated that Resident #125's family member alleged that another resident may have been inappropriately touching the resident. On 6/27/25 at 1:43 PM, a review of the investigation packet for MD00192139 revealed that the initial report was sent on 5/5/23 at 5:36 PM by the Director of Nursing (DON). The initial report noted the time and date of the incident as 5/5/23 at 4 PM. However, a statement by a nurse (Staff #20) reporting the allegation was signed and dated 5/3/23. The DON was interviewed…

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 interviews, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records. This was evident for 1 (Resident #311) of 6 residents reviewed for accidents The findings include: The MDS is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. The admission MDS assessment is a comprehensive assessment for new Residents and, under some circumstances, returning residents. It must be completed by the end of day 14, considering the date of admission to the facility as day 1. The last day of the observation period is the Assessment Reference Date (ARD). This is the end date of the observation period and provides a common reference point for all team members participating in the…

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

Based on medical record review and interview it was determined that the facility failed to ensure interdisciplinary care plan meetings were held following Minimum Data Set (MDS) assessments. This was found to be evident for one (Resident #11) out of six residents reviewed for unnecessary medications. Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The findings include: Review of Resident #11's medical record on 6/24/25 revealed the resident has resided at the facility for several years. A quarterly Minimum Data Set (MDS) assessment, with an assessment date of 3/6/25, was completed in March. A significant change MDS, with an assessment reference date of 5/11/25 was completed in May. Further review of the medical record failed to reveal documentation to indicate an interdisciplinary care plan meeting was scheduled or occurred following either of these MDS assessments. On 6/25/25 at 2:35 PM surveyor requested from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and relevant interviews it was determined that the facility failed to provide care consistent with professional standards of practice to promote healing of an existing diabetic foot wound. This was evident for one (Resident #116) of two residents reviewed for pressure injuries during the survey process. The findings include: Negative Pressure Therapy is a vacuum assisted closure (VAC) therapy that uses suction and a dressing to remove excess wound drainage and to promote wound healing. Nursing responsibility for proper VAC functioning and care includes assessing and monitoring that the vacuum device is properly calibrated and functioning and to document the findings. On 6/24/25 at 12:39 PM a record review of the admission face sheet revealed Resident #116's diagnosis was Type 2 Diabetes Mellitus with foot ulcer, Encounter for orthopedic aftercare following surgical amputation, Bipolar Disorder, Post-Traumatic Stress Disorder and Cerebral Infarction, also known as a Stroke. On 6/24/25 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, medical record review and interview it was determined that the facility failed to ensure care plan interventions to assist with resident safety were implemented. This was found to be evident for three (Resident #11, #56 and #99) out of six residents reviewed for accidents. The findings include: 1. Review of Resident #11's medical record on 6/24/25 revealed the resident has resided at the facility for several years. The resident has a history of falls, including a fall from bed in 2025. The resident has had a care plan addressing fall risk for several years and on 5/5/25 the following intervention was initiated: low bed with bilateral floor mats. In addition to the care plan intervention, the resident has a physician order, dated 5/5/25 for low bed with bilateral floor mats. Review of the Treatment Administration Record (TAR) revealed an area for nursing staff to document regarding this order every shift. On 6/24/25 at 8:49 AM the resident was observed in bed eating breakfast, no fall mats observed on the floor at this time. On 6/24/25 at 3:20 PM surveyor…

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

Based on record review and interview, it was determined that the facility failed to provide pain management, per physician orders, to residents. This was evident for 2 (Resident #50, and #42) of 5 residents reviewed for pain management during the recertification survey. The findings include: 1. A review of Resident #50's medication orders revealed an order dated 6/17/25 for the short-acting pain medication oxycodone to be given every 4 hours as needed (PRN) for acute pain [rated] 7-10. On 6/23/25 at 10:22 AM an interview was conducted with Resident #50. They said they were in severe pain and that they had been waiting since 6:00 AM to receive the PRN oxycodone but was told by their nurse that the medication was not available. On 6/23/25 at 10:57 AM an interview was conducted with Resident #50's assigned nurse (Staff #16) who said the night shift agency nurse told her she medicated the resident at 6:00 AM but that it was the last one so needed to be re-ordered. On 6/23/25 at 11:10 AM an interview with the Unit Nurse Manager (Staff #15) and nurse (Staff #16) was conducted at 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, medical record review and interviews it was determined that the facility failed to ensure behavioral health care services were provided as needed. This was found to be evident for one (Resident #56) out of three residents reviewed for behavioral health services. The findings include: Resident #56 has resided at the facility for more than one year. Minimum Data Set (MSD)assessments were completed by facility staff in January and April of 2025. Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. Review of Section D Mood of the 4/4/25 MDS revealed that, based on a Resident Mood Interview the resident had a severity score of 10, indicating moderate depression. On 6/23/25 at 11:18 AM during an interview with the surveyor, the resident became agitated and teary eyed. Surveyor informed nurse (Staff #45) that the resident had become upset during the interview when discussing an event in the past, the…

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

Based on medical record review and interview it was determined that the facility failed to ensure pharmacist reviewed sufficient sections of the resident's medical record to identify significant medication errors. This was found to be evident for one (Resident #56) out of three residents reviewed for behavioral health services. The findings include: Review of Resident #56's medical record on 6/26/25 and 6/30/25 revealed significant medication errors in regard to the anti-anxiety medication Ativan during the month of June 2025. These errors included the failure to administer an evening dose of Ativan on 7 out of 25 days reviewed; and the administration of an extra 0.5 mg of Ativan on 5 occasions. These errors were identified by reviewing the drug control sheets for the resident's Ativan as well as the Medication Administration Record in the electronic health record. Cross reference to F 760. Review of the facility's drug control sheets revealed they are kept in a bound book located on each of the medication carts. These sheets were not found in the electronic health record. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and pertinent interviews, it was determined that the facility failed to maintain safe operating condition of patient care equipment. This was evident for 1 resident complaint (Resident #115) of 20 resident complaints reviewed during this survey. The findings include: A Hoyer Lift is a mobility device to support residents who require mobility assistance to safely transfer to/from bed to a wheelchair or chair. On 6/24/25 at 10:33 AM a record review of the grievance log dated April 2023 revealed that a grievance form was filed on 4/18/23. A review of this grievance revealed that Social Service Designee (Staff #23) completed and submitted the form. The investigative process conducted by Registered Nurse (RN #26) confirmed the validity of the grievance and concluded that one of two facility Hoyer lifts was not in safe operating condition due to dead batteries. On 6/24/25 at 9:00 AM in an interview with the Complainant regarding Resident #115's care, it was confirmed that a grievance was filed…

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 develop and implement abuse policies and procedures. This was evident for 1 of 1 abuse policy reviewed and 1 self- reported incident (MD00164226) of 34 self-reports of abuse allegations. The findings include: A review of the facility's Abuse, Neglect, and Exploitation policy, dated 8/1/21, v was conducted. In section III: Prevention of Abuse, Neglect, and Exploitation, reads, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:. Letter A reads, Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may…

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, it was determined that the facility failed to have an effective system in place to ensure that annual performance reviews were completed for the geriatric nursing assistants (GNA). This was found to be evident for all of the GNAs working in the faciltiy. The finding include: On 11/15/22 at 10:10 AM, surveyor requested the annual evaluations for 3 randomly selected GNAs from the Director of Nursing (DON). The DON reported that she had not completed the GNA evaluations. She went on to state she had a pile on her desk to work on.

Based on resident representative and resident interview, observation, medical record review and staff interview, it was determined that the facility 1) failed to develop and implement comprehensive person-centered care plans, 2) failed ensure staff to follow the resident's care plan related to behavior monitoring, and 3) failed to ensure staff followed the resident's care plan to use a mechanical lift for resident transfers. This was evident for 1 (#14) of 7 residents reviewed for unnecessary medications and 1 ( #118) out of 37 residents reviewed for abuse. 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 1) On 10/20/22 at 9:20 AM, a review of Resident #14's medical record revealed Resident #14 was initially admitted to the facility in July 2021, transferred to the hospital in July 2022 and readmitted to the facility in July 2022 with multiple diagnoses including depression. 1a) Review of Resident #14's October 2022 MAR (medication administration record) revealed a 7/11/22…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 (#14) of 7 residents reviewed for Activities of Daily Living. 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 10/20/22 at 9:20 AM, an initial review of Resident #14's medical record revealed Resident #14 was admitted to the facility in July 2021, transferred to the hospital in July 2022 and readmitted to the facility in July 2022 with multiple diagnoses including ESRD (end stage renal disease), diabetes, cardiovascular disease and required assistance of staff for all ADLs. ADLs (activities of daily living) are activities that people perform every day such as, getting dressed, taking showers or baths, cooking, and eating. Review of Resident #14's quarterly assessment with an ARD (assessment reference date) of 7/18/22 documented the resident had a BIMS (Brief…

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

Based on observation and interview, it was determined the facility staff failed to provide thorough grooming and personal hygiene services for a resident who was dependent on staff for bathing. This was evident for 1 (#14) of 7 residents reviewed for Activities of Daily Living. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. ADLs (activities of daily living) are activities that people perform every day such as, getting dressed, taking showers or baths, cooking, and eating. 1) On 10/12/22 at 2:23 PM, an observation was made of Resident #14, in bed, in his/her room. At that time, Resident #14's hair appeared greasy, and uncombed, his/her face was unshaven, the resident's…

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

Based on observations, medical record review, and staff interview, 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 (#36) of 3 residents reviewed for activities. The findings include: Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an…

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

Based on observation, medical record review and staff interview, it was determined the facility staff failed to provide care in accordance with standards of nursing practice as evidenced by 1) failing to ensure that medical devices brought with the resident at the time of admission were assessed, ordered and care planned, and 2) failing to ensure medications ordered for bowel regimen were administered as ordered. This was found evident for 1 (#109) of 5 residents reviewed for personal property (loop recorder), 1 (#419) of 1 residents reviewed for pressure ulcers and 1 (#500) of 4 residents reviewed for neglect. The findings include: 1) Reviewed of medical record on 10/18/22 revealed that Resident #109 was recently admitted to the facility following hospitalization for difficulty walking and neuropathy (nerve damage). Resident's past medical history included but was not limited to, hyperlipidemia hypertension, coronary artery disease and lower extremity weakness. Further review revealed that Resident #109 had a cardiac pacemaker and loop recorder. Review of Minimum data set…

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

Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 1 (#14) of 4 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is incapacitated On 10/13/22 at 4:16 PM, a review of Resident #14's paper and EMR (electronic medical record) failed to reveal evidence that Resident #14 had an advanced directive, and there was no documentation found as to whether the resident/representative was informed of his/her right to formulate an advanced directive or wished to formulate an advanced directive. On 10/13/22 at 4:30 PM, during an interview, Staff #5, SW (social worker) stated that when a resident is admitted to the facility, during an intake assessment, the resident would be asked if he/she had an…

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

Based on record review, Interviews, and observations, it was determined that the facility failed to follow their grievance process for a resident with missing property. This resulted in the resident not having access to a medical recorder/transmitter. This was evident for 1 resident, (#109) out of 5 residents reviewed for personal property. The findings include: Review of medical record on 10/18/22 revealed that Resident #109 was recently admitted to the facility following a hospitalization for difficulty walking and neuropathy (nerve damage). Residents past medical history included but was not limited to the following diagnoses: hyperlipidemia, hypertension, coronary artery disease and lower extremity weakness. Further review revealed Resident #109 had a cardiac pacemaker, and loop recorder. Review of Minimum data set assessment (MDS)revealed resident had a BIMS of 13. The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screenings items employed as part of a standardized, reproducible, 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 facility report investigation documentation and medical records, and interviews, it was determined that the facility failed to ensure that a resident was free from neglect as evidenced by the facility's failure to ensure that a medication for the treatment of constipation was administered as ordered; and the facility staff's failure to demonstrate basic assistance with activities of daily living for a resident dependent on staff for assistance. This was found to be evident for 1 (#500) of 4 resident's reviewed for neglect during the survey. The findings include: 1) On 11/1/22, a review of Resident #500's medical record revealed that the resident was admitted to the facility in October 2018 for rehabilitation after surgical repair of a hip fracture. Review of facility report MD00135705 revealed that the facility received a letter from Resident #500's family, after the resident was discharged , alleging neglect. On 11/1/22 review of the letter, dated 1/4/19, revealed concerns regarding the failure of staff to provide needed assistance with care. These concerns…

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 conduct a thorough investigation of an allegation of abuse. This was evident for 1 (#17) of 32 residents reviewed for abuse. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. A medical record review on 10/14/22 at 12:42 PM, revealed a progress note from the attending physician, dated 8/3/22, which documented that Resident #17 had been at the facility since 2018. The note read that Resident #17 had a stroke which…

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 staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#14, #89) of 7 residents reviewed for unnecessary medications. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident 1) On 10/19/22 at 12:32 PM, a review of Resident #14's medical record was conducted. In a progress note with an effective date of 7/15/22 at 12:00 AM, and a created date of 7/19/22 at 2:27 PM, the Nurse Practitioner wrote that Resident #14 current medications included Eliquis (Apixaban), (anticoagulant) (blood thinner) by mouth 2 times a day for a-fib (irregular heart…

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

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 1 (#87) of 1 residents reviewed for hospitalization. The findings include: A baseline care plan is a set of instructions for facility staff to provide care that is effective and resident-centered until a comprehensive care plan can be developed and implemented. The baseline care plan is to be developed within 48 hours of a resident's admission and the baseline care plan, along with a summary of their medications, is given to the resident/resident representative. This allows residents and their representatives to be more informed about the care that they receive On 11/10/22 at 11:49 AM, a review of Resident #87's medical record revealed that the resident, who resided in the facility for long term care was transferred to the hospital in late July 2022 following a change in his/her health status and readmitted to the facility…

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

Based on observations, record review, and staff interview, it was determined that the facility failed to have a director of the activities department that met the minimum qualifications. This was evident during the annual survey and had the potential to affect all residents. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that physician progress notes were written, signed, and dated at each visit. This was evident for 1 (#14) of 7 residents reviewed for unnecessary medications. The findings include: On 10/24/22 at 9:50 AM, a review of Resident #14's EMR (electronic medical record) revealed physician progress notes that were not written, signed, and dated on the day the resident was seen. There was a NP (Nurse Practitioner) progress note ,with a date of Service of 7/15/22, that was electronically signed by the NP on 7/19/22 at 2:27 PM, and there was a physician's progress note with a Date of Service of 10/14/22, that was electronically signed by the physician on 10/19/22 at 3:08 AM. On 10/27/22 at 12:40 PM, the concerns related to the above concerns were discussed with the Director of Nurses.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to ensure the attending physician document in the medical record when an irregularity had been reviewed and what, if any action was taken. This was evident for 2 (#89, #48) of 7 residents reviewed for unnecessary medications. The findings include: 1a) On 10/24/22 at 11:34 AM, a review of Resident #89's medical record was conducted. Review of the pharmacist's MMR monthly medication reviews for Resident #89 revealed a Consultation Report for July 1, 2022, through July 29, 2022, which was signed by the pharmacist on 7/29/22. The pharmacist wrote, Resident #89 was receiving cyanocobalamin (Vitamin B-12) daily, and asked if the order was still indicated, with the recommendation to evaluate and discontinue cyanocobalamin if appropriate. The pharmacist also wrote, if the prescriber preferred to continue medication, to consider switching the administration time to 9 am or 9 pm. Next to the space for the physician's response, was handwritten please check vit B-12 level first and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to adequately monitor a resident for behavior related to psychotropic medication. This was evident for 2(#73), (#14) of 7 residents reviewed for unnecessary medications. The findings include: 1) On 10/17/ at 09:30 AM, a review of Resident #73's medical record was conducted and revealed documentation that the resident was admitted on [DATE] with the diagnosis of major depression and anxiety. On 06/16/22, in a Psychiatric Evaluation and Consultation note, the NP (Nurse Practitioner) documented that Resident # 73 had a history of depression and anxiety. During that time, the resident was receiving the following psychotropic medications, Trazodone 25mg and Lexapro 20mg for depression and anxiety, as well as Remeron 7.5mg for appetite. The resident was currently on Trazadone, Lexapro, and Remeron. The NP wrote to continue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records as evidenced by 1) failing to ensure a resident's active MOLST (medical order for life-sustaining treatment) form was maintained in the resident's medical record and accessible to staff, 2) failing to ensure primary provider notes in the electronic medical record documented the actual date of service, 3) failing to ensure geriatric nursing assistant documentation accurately reflected service provided to the resident, and 4) failing to ensure newly written MOLST forms were placed in a resident's medical record when received by the facility. This was evident for 82 medical records This was evident for 1 (#419) of 4 residents reviewed for advanced directives, 1 (#270) of 32 residents reviewed for abuse, 2 (#109, #417) of 3 residents reviewed for pain management, and 1 (#112) of 3 residents reviewed for closed records. The findings include: A Maryland MOLST form (medical orders 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 record review and interview, it was determined that the facility failed to develop a Quality Assurance Plan that included the facility specific plan for conducting quality assurance and performance improvement activities. This was evident during the survey. The findings include: On 11/15/22 at 3:00 PM, a review of the Quality Assurance and Performance Improvement (QAPI) plan revealed the facility had developed and updated the plan on 2/23/21. There was a letter attached to the front with no date that had been signed by the Administrator, however, this plan was created and updated prior to the Administrator's hire date. In addition, the place on page 4 for the Administrator to sign had been left blank. There were additional pages regarding experimental research, room variances, etc. that had been signed by the Administrator. On 11/15/22 at 4:01 PM, an interview with the Administrator revealed that she was uncertain as to whether the QAPI plan had been reviewed and updated since 2/23/21. On 11/15/22 at 4:30 PM, the Director of Nursing (DON) provided a QAPI plan that was 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.

Based on medical record review, observations and interview, it was determined the facility 1) failed to ensure that all staff completed COVID screening prior to the start of work as per the facility's current policy; 2) failed to ensure that an employee report of a respiratory illness was conveyed to the Infection Preventionist (IP) nurse to facilitate tracking of possible respiratory outbreak, and failed to ensure that same employee accurately answered the COVID screening questions regarding recently experiencing symptoms upon return to work; 3) failed to ensure separation of clean and dirty portions of the laundry processing areas; and 4) failed to ensure that a resident with an antibiotic resistant infection (MRSA) was placed in an available private room. These deficient practices were found to be evident for 2 (#85, #86) of 8 employees reviewed for screening prior to start of shift; and 1 (#47) of 2 residents reviewed for transmission based precautions. The findings include: 1) Review of the Coronavirus Testing policy, with a reviewed/revised date of 8/26/22 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 review of the medical record and staff interviews, it was determined that the facility administered blood pressure medications when the resident's blood pressure and/or pulse were outside of the physician ordered parameters, or when the parameters were unknown This was evident for 1 (#92) of 5 residents reviewed for unnecessary medications. The findings include. Review of resident #92's medical record on 11/16/18 at 2:15 PM revealed that resident #92 was prescribed two medications (Clonidine and Hydralazine) to treat high blood pressure. The physicians' orders indicated to Hold the medication for SBP (Systolic Blood pressure - top number) less than or equal to 140. Review of the current MAR (medication administration record) revealed resident #92 was administered Clonidine 0.1 mg at 2 PM with a documented blood pressure of 132/60. The systolic blood pressure was below 140. On 11/16/18 at 3 PM, interview of the nurse (Staff #13) who had signed-off as administering Clonidine 0.1 mg (milligrams) at 2 PM revealed the medication was administered to resident #92. Upon surveyor…

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

Based on review of facility documentation and interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assessment and Assurance (QAA) Program with the Nursing Home Administrator (NHA), on 11/19/18 at 5:22 PM, revealed that effective processes were not put in place regarding repeat deficiencies. The accuracy of MDS assessments was a repeat citation from the surveys dated 4/18/18, 9/21/17, 8/20/16 and 5/5/15. Drug storage related to unlocked and unattended treatment carts was cited on the last survey dated 4/18/18. There was a repeat observation of an unlocked and unattended treatment cart on 11/14/18. Cross Reference F761. Development and implementation of comprehensive care plans was cited on 4/18/18 and 9/21/17 and was again identified as a concern. There was a repeat deficiency related to 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 medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#45) of 1 resident reviewed for restraints, 1 (#76) of 5 residents reviewed for unnecessary medications, and 1 (#100) of 2 residents reviewed for Hospitalization. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of the medical record for Resident #45 on 11/16/18 revealed September/October 2018 physician's orders which stated, bed and chair alarm to alert staff of unassisted movement. Review 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 interview with facility staff, it was determined that the facility failed to implement comprehensive, resident-centered care plans to meet the residents medical, nursing, mental and psychosocial needs. This was evident for 2 (#92, #50), ) of 27 residents in the final sample. 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. 1) Resident #92's medical record was reviewed on 11/16/18. Resident #92 was prescribed two medications (Clonidine and Hydralazine) to treat high blood pressure. The physicians' orders indicated to Hold the medication for SBP (Systolic Blood pressure - top number) less than or equal to 140. Review of the MAR's (medication administration record) revealed that resident #92 was administered Clonidine 10 times outside of the physician ordered hold parameters between 10/23/18 and 11/16/18. An order for Hydralazine 25 mg by mouth twice a day was initiated on 11/3/2018. Hydralazine was documented as given 7…

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 medical record review, it was determined the facility failed to revise care plans to meet resident needs. This was evident for 1 (#79) of 4 residents reviewed for activities and 1 (#90) of 2 residents reviewed for position and mobility. 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. 1) An interview was conducted on 11/13/18 11:29 AM, with Resident #79, who told the surveyor, there is no reason why I am in this bed all this time. I have not been offered any activities. The Assistant Activities Director was interviewed on 11/15/18 at 9:26 AM and stated, occasionally we will go in and we know what she will say and no what her preferences. The Activities Director stated on 11/16/18 at 10:19 AM, the resident likes dogs and I will go in but the resident refuses. The activities participation records for September, October and November 2018 were reviewed with the Activities Director (AD) and it was revealed that the AD…

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 staff interview, it was determined the facility failed to follow physician's orders and the care plan for potential for altered skin integrity for a resident who was totally dependent on staff for all mobility needs. This was evident for 1 (#31) of 2 residents reviewed for positioning and mobility. The findings include: Observation was made, on 11/14/18 at 8:39 AM, of Resident #31 lying in bed with his/her hands contracted, held up against chest. Resident #31 was lying on his/her back with knees facing towards the window with a pillow between the knees. There were slipper socks on the feet and the feet were directly on the mattress. A pillow was positioned on the right side of the resident and there was a pillow behind the resident's head. The resident was observed again, on 11/14/18 at 11:13 AM, lying in the same position. On 11/14/18 at 1:00 PM, Resident #31 was still lying on his/her back with knees facing towards the window and a pillow between the knees. The position had not changed, and the resident's head was still tilted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to provide adequate supervision to residents with swallowing issues, as evidenced by Resident #50 not receiving one-to-one supervision during his/her meals. This was evident in 1 out of 3 residents reviewed for activities of daily living (ADL). Findings include: On 11/14/18 at 8:37 AM, the surveyor heard a resident in room [ROOM NUMBER] B moan loudly three times from the hallway and walked into the room to observe Resident #50 lying in bed with head of the bed elevated, and had a thick, cream colored liquid coming from his/her mouth spilling over the chin. Nursing staff were notified that the resident needed assistance. During an interview with Geriatric Nursing Assistant (GNA) (Staff # 9) on 11/19/18 at 10:05 am, the GNA stated that Resident #50 ate breakfast in their room on a daily basis and that staff check on the resident throughout the meal. On 11/19/2018 at 10:36 am, a review of care plan, dated 11/7/18, revealed an…

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

Based on observation and staff interview, it was determined the facility staff failed to keep a treatment cart locked when unattended and failed to date and label a bottle of sterile water when opened. This was evident in 1 of 5 hallways observed. The findings include: Observation was made, on 11/14/18 at 2:10 PM, of the treatment cart for the 200 and 300 halls, unlocked and unattended, sitting in an alcove across from the mechanical/electrical room on the 200 hallway. In the top drawer was a bottle of ammonium lactate lotion, tubes of Triamcinolone Acetonide cream, Nystop powder, 4 pairs of scissors and Santyl ointment. In the second drawer were water vials for respiratory treatments and bandages. In the third drawer was an opened 250 ml. bottle of sterile water, Lot #1803121, which was not dated when opened. There was approximately 75 ml. in the bottle. In the fourth drawer were (3) tubes of Aquaphor creams. The Assistant Director of Nursing was shown the unlocked treatment cart on 11/14/18 at 2:16 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interview and medical record review, it was determined that the facility failed to have complete and accurate medical records. This was evident for 1 (#43) of 4 residents reviewed for vision and hearing, 1 (#31) of 2 residents reviewed for positioning and mobility, 1 (#67) of 9 residents reviewed for unnecessary medications, 1 (#300) of 1 residents reviewed for pain management. and 1 (#8) of 2 residents reviewed for turning and repositioning. The findings include: 1) An interview was conducted with Resident #43's Power of Attorney (POA) on 11/14/18 at 12:07 PM. The POA stated that Resident #43 lost his/her first pair of glasses. The POA replaced the glasses, however, the lens was now missing. The medical record was reviewed on 11/6/18 and there was no documentation found about the glasses. On 11/16/18 at 12:01 PM, the Director of Nursing (DON) was asked about the glasses and the DON stated, he/she threw his/her glasses across the room and the lens came out. On 11/16/18 at 1:25 PM, Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and facility documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to ensure that a resident's urinary catheter bag was properly kept off the floor, failing to label and date a tube feeding spike tube set and failing to keep resident's linens off the floor . This was evident for 3 (#31, #90, #65) of 30 residents investigated during the survey. The findings include: 1) Observation was made, on 11/14/18 at 8:38 AM, of a urinary catheter bag lying on the floor on the right side of the bed. The Director of Nursing (DON) was informed on 11/15/18 at 12:59 PM. 2) Observation was made on 11/13/18 at 2:18 PM of Resident #90's tube feeding, which was hanging on a tube feeding pole. The tube feeding was off and the bottle of Jevity 1.2 was hanging on the pole. The tube feeding, and the spike tubing set was not labeled or dated. There was less than 100 cc of feeding 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.