Autumn Lake Healthcare At Braddock Heights

Based on interviews and record review, it was determined that the facility failed to 1) effectively manage residents' pain, and 2) ensure pain management was provided to residents according to professional standards of practice. These was evident for 2 (Resident #43, #2) of 3 residents reviewed for pain management during the recertification survey.The findings include:1). A pain scale ranges from 0 to 10, with 0 indicating no pain and 10 representing the worst pain. It is used to assess the level of pain a patient is experiencing and to guide treatment. Non-pharmacological pain management is an intervention that does not involve medications. In an interview on 1/14/26 at 10:16 AM, Resident #43 reported back pain and said s/he received Tylenol for it, but it was not always helpful. In a subsequent interview on 1/15/26 at 11:45 AM, Resident #43's representative reported that the resident had constant back pain and had been taking Tylenol, which was ineffective at times. She added that she had just asked the staff for more medication before this interview. Record review for 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 record review and interview, it was determined that the facility failed to ensure that residents were cared for by licensed Geriatric Nursing Assistants (GNAs). This was evident for 1 GNA (Staff #10) of 5 GNA licenses reviewed during the staffing investigation portion of the recertification survey.The findings include:On 1/20/26 at 9:53 AM a review of the facility's staff list was conducted. From that list, 5 Geriatric Nursing Assistants (GNAs) names were randomly selected to review for evidence of licensure, and the facility was asked to provide copies of their licenses.A review of the licenses revealed that Staff #10's GNA license was issued on 6/05/25, but the staff list indicated that he was hired on 8/07/24.On 1/22/26 at 3:43 PM an interview was conducted with the Director of Human Resources (Staff #17) to review that Staff #10's GNA license was effective 10 months after his hire date at the facility. She was asked to provide evidence of the employee's status changes such as hire date and position status changes, and evidence of hours worked 4 months past his hire…

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, the facility failed to ensure that resident medication storage areas and medical supplies were properly stored, free from expired items, and maintained in a sanitary and organized manner within 2 of 2 medication storage areas observed during the annual recertification survey. The findings include: On [DATE] at 12:30 PM, the surveyor observed the medication storage room on the Skyline unit. During the observation, the surveyor identified expired medical supplies stored in the medication storage area, including:(2) Medline suction/connection tubing, expired [DATE](1)Medline Gastrostomy Tube, 3-port, expired [DATE]On [DATE] at 12:55 PM, the surveyor reviewed the findings with Staff #3 and Staff #4 at the nurses' station on the Skyline unit.On [DATE] at 1:00 PM, the surveyor observed the medication storage room on the Roosevelt unit. Staff #5 provided access to the storage area. Upon entry, the surveyor observed that the counter space was cluttered, and the handwashing sink…

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 record review, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 observations of the facility's kitchen during the recertification survey.The findings include:An initial tour of the facility's kitchen with the dietary manager on 1/14/26 at 8:15 AM revealed the following:- An observation of leftover prepared pear fruit in a container with no label indicating the date it was prepared or the use-by date in the reach-in refrigerator.-An observation of boiled eggs labeled with a use-by date of 1/13/26 in the reach-in refrigerator. Staff indicated they should have been discarded.-An observation of leftover plates of cinnamon brown sugar blondie, labeled with a use-by date of 1/12/26, stored in the walk-in refrigerator. Staff indicated they should have been disposed of.A review of the facility's Food storage policy on 1/16/26 at 5:32 PM, stated that all foods will be stored wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure that staff accurately documented in a resident's medical record. This was evident in one (Resident #69) of three residents reviewed for infection control.The findings include:An initial observation was made on 1/14/26 at approximately 10:10 AM of Resident #69 seated on the resident's bed, speaking with staff #2, a social worker, who was also seated in a chair by the resident's bedside.During a subsequent observation on 1/14/26 at 11:24 AM, signage on Resident #69's door read, Special droplet/contact precautions in addition to standard precautions; only essential personnel should enter this room. The observation also noted a small cart of personal protective equipment (PPE) in front of Resident #69's room.Staff #11, a registered nurse, was interviewed on 1/14/26 at 11:24 AM and reported that Resident #69 had tested positive for COVID-19 on 1/12/26, prior to admission to the facility on 1/13/26. However, 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, record reviews, and interviews, it was determined that the facility failed to ensure all staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions. This was evident for 1 (Resident #62) of 3 residents reviewed for pressure ulcers. The findings include:Enhanced Barrier Precautions (EBP) - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).Resident #62 had been residing in the facility since mid-2025. During an interview with the resident on 1/14/26 at 10:24 AM, s/he reported having a wound in the sacral area and indicated that staff would wear gloves and masks when providing his/her care but would often skip wearing the gowns.While still in the interview with Resident #62, a…

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

Based on observations and interviews, it was determined that the facility failed to ensure full visual privacy was provided to residents residing in semi-private rooms. This was evident for 1 (Resident #12) of 1 resident reviewed for privacy. The findings include:While Resident #12 was being interviewed on 1/15/26 at 9:10 AM, it was observed that the ceiling suspended curtain that moved around the resident's bed was not long enough to provide full visual privacy. Approximately 2 feet of opening was observed when the curtain was fully extended, in combination with the roommate's curtain. On 1/20/26 at 12:34 PM, the Director of Nursing (DON) was invited to inspect Resident #12's room with the surveyor. During the inspection, the DON confirmed that the ceiling suspended curtain left an approximate 2 feet opening when fully extended and stated, That's a privacy issue.On 1/23/26 at 10:46 AM, the concern with the ceiling suspended curtain not providing full visual privacy was discussed with the Nursing Home Administrator (NHA), Regional Director of Nursing (RDON), and the DON. The DON…

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, staff interviews, and facility policy review, the facility failed to ensure four of six residents reviewed for abuse (Residents (R) 22, R11, R106 and R35) out of a total sample 29 were free from resident-to-resident abuse. This failure had the potential to cause physical injury or psychosocial distress for the four residents involved. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation dated 11/13/23 indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Abuse' means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 1. Review of R22's electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interviews, and review of Centers for Disease Control (CDC) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidelines, the facility's water management program was incomplete in that it was not consistent with current ASHRAE guideline, which specifically called for the design to evaluate the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for the 43 facility residents, who were over the age of 65, to be infected by Legionella Findings include: Review of the CDC website titled Legionella. Prevention and Control, dated 03/25/21, indicated, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.Key Elements.Seven key elements of a Legionella water management program are to. Establish a water management…

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 investigate a grievance regarding care concerns for a resident. This was evident for 1 (#14) of 8 residents reviewed for complaints. The findings include: An observation on 8/12/24 at 1:35 PM revealed Resident #14 turned on his/her call light. When the call light came on there was 2 geriatric nursing assistants (GNA) sitting in the nurses' station that had a notification that the call light was on. There was 1 activity assistant (AA) in the common area (across the hallway from Resident #14's room) providing an activity to the residents. The 2 GNAs, later identified as GNA #2 and GNA #3 made no attempt to answer the call light. At 1:38 PM, AA #1 went to answer the resident's call light. She came out of the room and went to the nurses' station and addressed GNA #2 and GNA #3. The surveyor was unable to hear what AA #1 stated to them, but overheard GNA #3 state she had to complete documentation. AA #1 went back to the resident's room and went in, turned off the call light and came back out. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure two of two residents (Resident (R) 23 and R55) reviewed for hospital transfers in the sample of 29 was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for the residents and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled, Bed Hold Notice Upon Transfer, dated 12/27/22, revealed At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .Information will specify the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined facility staff failed to ensure that a resident who relied on staff for care needs had the care provided. This was evident for 2 (#14 and 902) of 8 residents reviewed for complaints. The finding 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. 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. 1) A review of a compliant in 3/2023 for Resident #14 on 8/12/24 at 9:30 AM revealed a concern that the resident was not assigned an aide on night shift for 9/16/23 as care had not been provided. Review of a complaint in 10/23 revealed a concern with the resident receiving showers. On 8/12/24 at 11:47 AM a medical record Resident #14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, document review, and manufacturer's instruction review, the facility failed to provide education for one of one Licensed Practical Nurse (LPN1) to possess the competencies and skill set necessary to ensure proper technique was used to administer insulin for one of two residents (Resident (R)52) that received insulin during medication administration. This failure had the potential to result in the resident receiving the wrong dose of insulin. Findings include: Review of R52's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R52 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (DM) with hyperglycemia. Review of R52's Physician Orders, dated 05/31/24, located in the EMR under the Orders tab, revealed an order for Insulin Lispro (1 [one] unit dial) subcutaneous solution pen-injector [short acting insulin] 100 Unit/Milliliter (ML). During an observation on 08/13/24 at 12:06 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one of six residents (Resident (R) 37) and/or their representatives reviewed for immunizations, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards out of a current facility census of 54. This practice had the potential to increase the risk for the residents to contract pneumonia. Findings include: Review of the facility's policy titled Pneumococcal Vaccines dated 12/18/22 indicated .It is our policy to offer our residents . immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.For adults 65 years' or older who have not previously received any pneumococcal vaccine.Give 1 dose of PCV15 or PCV20.If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with 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, it was determined that the facility staff failed to ensure that a call bell was within reach for every resident. This was evident for 2 (Residents #8, #47) residents observed during the initial tour of the facility. The findings include: A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant on duty. There is a call light for each resident in the room, for each bed. 1) During an observation on 06/24/19 at 8:05 AM, Resident #8 was noted to be seated in his/her bed and the Resident's pressure sensitive call bell was sitting on the table located to the side and behind the bed. 2) During an observation on 06/24/19 at 8:15 AM, Resident #47 was noted lying in his/her bed and the Resident's pressure sensitive call bell was sitting on the table located to the side of the bed and not within reach.

Based upon record review, resident interview, and staff interview, it was determined that facility staff failed to put a system in place to ensure that resident's grievances regarding call bell response time and staff interaction with residents were addressed in a timely manner and outcomes communicated back to the resident. This was true for three out of 48 resident council members but had the potential to affect all residents in the facility. The findings include: On 6/25/19 at 12:17 PM, Record review for the month of March Resident Council meeting minutes revealed resident's concerns regarding call bells not being answered in a timely manner. Review of April's resident council meeting minutes failed to reveal that the concerns of call bells were addressed by the staff. Record review of Resident Council meeting minutes for the month of May revealed concerns of care and treatment of residents. The June resident council meeting minutes revealed that the facility's staff failed to address the previous month's concerns. In an interview on 6/25/19 at 1:08 PM with Activities Director,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility staff failed to discuss changes in the resident's medical status related to end stage condition with the Resident Representative (RR). This was evident in 1 (R#45) of 1 resident reviewed regarding advanced directives in the investigative portion of the survey. The findings include: Review of the medical record for Resident #45, on [DATE] at 10:18 AM, revealed a Maryland order for life sustaining treatment (MOLST) completed on [DATE]. The MOLST developed for Resident #45 was for him/her to have full code status, should the resident require cardiopulmonary resuscitation (CPR). Further review of Resident #45's medical record revealed a physician visit on [DATE] and [DATE] certifying that any life sustaining treatment rendered for Resident #45 would be medically ineffective, including CPR. The facility social work designee was interviewed on [DATE] at 11:22 AM. The paperwork regarding Resident #45's code status and certifications 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 record review, observation, and staff interview, it was determined that the facility staff failed to 1. notify or include a Resident Representative (RR) in changes regarding residents' care and 2. to notify the physician, resident and/or their family and care staff of the unavailability of medications.This was evident for 2 (R#6 and #36) of 20 residents reviewed during the investigative portion of the survey. The findings include: 1. Interview with Representative of Resident #6 on 6/24/19 at 9:25 AM revealed a concern that, during a recent visit with Resident #6, s/he noted that the chair alarm that was ordered for Resident #6 was no longer in place. When the representative inquired with staff where it was, s/he was told that the 'state said they could not have them anymore.' The representative was very upset regarding the change as s/he is here to visit Resident #6 everyday all day and this change was not discussed with him/her prior to it occurring. The Administrator was interviewed on 6/26/19 at 10:31 AM regarding the Representative's concerns. She stated the alarms 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a facility reported incident and staff interview, it was determined that the facility staff failed to protect a cognitively impaired resident's right to privacy. This was evident for 1 (R #98) of 20 residents reviewed during an annual recertification survey. The findings include: Review of facility reported incident MD00129799 on 06/24/19 revealed an allegation that GNA #5 took a cell phone picture of Resident #98 on 08/06/18, and then posted the picture to a social media site. In an interview on 06/24/19 at 2:25 PM, GNA #4 stated that s/he observed a picture, that was posted by GNA #5 to a social media site, of Resident #98 seated in his/her wheelchair while in the facility. GNA #4 stated s/he witnessed the picture within 24 hours of being posted to the social media site. GNA #4 stated s/he brought this information the facility administration. In an interview on 06/25/19 at 8:17 AM, the former administrator stated s/he recalled the incident and that there was no nudity involved in the posted…

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 Reported Incident MD00 1390223, investigation review, and interview with staff, it was determined that the facility failed to follow policy on completing background employee checks of potential new employees. This was evident in 1 of 2 employees records reviewed. The findings include; On 6/27/19, a facility reported incident involving a geriatric nursing assistant (GNA staff # 20) and a resident was reviewed. This review revealed an allegation of abuse. Further review of the investigation revealed that the facility, per abuse policy and procedure, immediately reported to the Director of Nursing (DON) and the administrator, who then reported it to the state agency the allegation of abuse. Review of staff # 20's employee file failed to reveal a prior employment reference check. During an nterview with the facility Administrator, on 6/27/19, the surveyor requested a copy of the prior employee reference. The administrator acknowledged that it was not done. Review of the abuse prevention policy and procedure revealed the following: Pre-Employment Screening-…

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, facility investigations and interviews, it was determined that the facility failed to complete a thorough investigations of abuse allegations related to injury of unknown origins. This was found to be evident for one out of the seven facility reported incidents (FRI) reviewed during the investigative portion of the survey (R#149). The findings include: During the review of the FRI on 6/26/19, it was noted in the facility report that Resident #149 was found with an injury of unknown origin. Further review of the FRI revealed that Resident #149 had increased complaints of pain and an x-ray was completed. The results of the x-ray showed a fracture requiring intervention. Further review of the facility investigation failed to reveal any interviews with any staff or attempts to determine when this injury could have occurred. The FRI included the nursing notes for 72 hours around the time that Resident #149's complaints of pain started, the x-ray, and an updated care plan. The facility DON and Chief Nursing Officer were interviewed on 6/26/19 at 2:10…

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 provide the resident/resident representative with a copy within 48 hours of admission to the facility. This was evident for 1 (Residents #36) of 20 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #36's medical record on 6/25/19 revealed that Resident #36 was admitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a baseline care plan was provided to the resident/resident representative at that time. In an interview on 6/25/19 at 2:14 PM, the facility social service designee stated that s/he was not able to locate any documentation that Resident #36 or Resident #36's representative was provided with a copy of the base line care plan within 48 hours after his/her…

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 develop a person-centered comprehensive care plan to as evidenced by the facility's failure to develop a care plan to address a resident's chronic diagnosis and long-term use of antibiotics. This was found to be evident for 1 out of 20 residents (Resident #23) reviewed during the investigative stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 6/27/19, Resident # 23 medical records and care plans were reviewed. This review revealed that the resident had a diagnosis of chronic urinary tract infection (UTI) and was taking Bactrim DS (double strength) for chronic UTI's. Review of the care plans failed to reveal a care plan for Chronic UTI and the prophylactic use of an antibiotic. During an interview with the Director of Nursing on 6/27/19, the surveyor requested the resident care plans for chronic UTI and antibiotic use. 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 the facility staff failed to revise Resident #27's oxygen care plan regarding weaning Resident #27 from the use of continuous oxygen. This was evident for 1 of 1 resident reviewed for oxygen use. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #27 medical record on 6/27/19 revealed a physician's order, dated 6/18/19, instructing the nursing staff to administer 2 liters of oxygen by nasal cannula to Resident #27 and to wean Resident #27 off of oxygen as tolerated. Review of Resident #27's care plan failed to reveal a revision for oxygen use and the process of how the nursing staff were going to wean Resident #27 off of oxygen. In an interview on 6/27/19 at 9:35 AM, Nurse #18 stated that Resident #27 does need oxygen at present and that the nursing staff were checking Resident #27's oxygen saturations. A review of the care plan failed to reveal the new nursing interventions…

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 with staff, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, as evidenced by failure to ensure a follow up urology consult to determine if the continued use of an antibiotic was necessary. This was evident for 1 of 20 (R#23) residents reviewed during the investigative stage of the long-term care survey process. The findings include: On 6/27/19, Resident # 23's medical records were reviewed. This review revealed that the resident was admitted to the facility in March 2016 with diagnoses and symptoms which included, Overactive Bladder (a sudden, uncontrolled need or urge to urinate) high blood pressure, and diabetes. During a review of the medical records on 6/27/19, a urologist consult was completed for R# 23 in February 2017 which revealed the following: Start Bactrim DS (double strength) every 12 hours dispense 20 (for 10 days) and after that, Bactrim SS (single strength) 1…

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 staff, it was determined that the facility failed to have an effective system in place to ensure that pharmacist recommendations (resulting from identified irregularities during the monthly pharmacy review were addressed and acted upon by the physician. This was found to be evident for 1 out of the 5 residents (Resident #23) sampled for medication regimen review during the investigative stage of the survey. The findings include: On 6/27/19, Resident # 23's medical records were reviewed. This review revealed that, on 3/14/19, a pharmacist completed the required monthly medication review. The review found irregularities with the resident medication and recommendations were made. The March pharmacy recommendation revealed the following documentation, 'The resident is currently receiving Bactrim prophylactically and is normally subjected to a stop date. Please provide a stop date/therapeutic endpoint or taper to D/C (discontinue) if reasonable or document contradiction to D/C based on prior failure and subsequent recurrence'. 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 medication administration observation and staff interview, it was determined that the facility staff failed to ensure a medication administration error rate of less than 5 percent. This was evident for 3 errors involving Residents # 36 and #47 out of 30 opportunities for error observed on the Skyline Unit resulting in a medication administration error rate of 10%. The findings include: On 06/27/19 from 7:20 AM to 9:15 AM, a medication administration observation was conducted on the Skyline unit with Certified Medication Administer (CMA) staff #14). At 8:40 AM, the CMA completed the administration of Resident #36 medications. Upon review of the electronic administration log, surveyor noted that one of the medications, a probiotic was selected not administered by the CMA. Interview with the CMA revealed that she administered the last available dose of the medication to the resident on the morning of 6/26/19. She added that, although she notified the resident's nurse (staff #17) and electronically requested a refill, she did not know that the medication was not available this…

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.

DELETE - KS TO IMPORT Based on observation, record review and staff interview, it was determined that the facility staff failed to put a system in place to; ensure all drugs and biologicals in the facility are labeled according to professional standards, keep consistent temperature logs for medication and biological storage, and keep an accurate inventory log for controlled substances. This was true for 2 of 3 medication carts and 2 of 2 storage rooms reviewed during the survey. Findings include: An observation was conducted on the Skyline unit medication storage room on 06/27/19 at 11:13 AM. Charge Nurse (Staff #16) was present. Review of the January through June 2019 Refrigerator Temperature Logs revealed that for the months of May and June, there were several missing temperature entries. Observation of the refrigerator found one undated and unlabeled multi-use vial of insulin. In addition there was ice noted on the inside walls of the freezer compartment. Interview with the charge nurse revealed that it was her expectation that the night shift nurse would measure and document…

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

Based on observation and staff interview, it was determined that the facility staff failed to apply standard infection control practices while administering medications to residents. This was true for 2 (Residents # 10 and #36) of 3 residents reviewed during a medication administration observation on the Skyline unit. However, this deficient practice has the potential to affect all residents, visitors, and staff in the facility. Findings include: On 06/27/19 from 7:20 AM to 9:15 AM, a medication administration observation was conducted on the Skyline unit with Certified Medication Administer (CMA) staff #14. At 07:35 AM, the CMA entered the room of Resident #10 to administer medications. At the bedside table, she repositioned the resident's personal items to one side, placed the resident's medications which included a cup of 6 pills, a box with a bottle of eye drops and another that held a bottle nasal spray in the emptied space without application of a disinfectant or provision of a protective barrier. The resident refused the receipt of the medications, but agreed to have the CMA…

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 take steps to offer a resident the pneumococcal and flu vaccine after admission. This was evident for 1 (Residents #47) of 5 residents reviewed for immunizations during an annual recertification survey. The findings include: A vaccination is the act of introducing a vaccine into the body to produce immunity to a specific disease. Immunization is a process by which a person becomes protected against a disease through vaccination. Review of Resident #47's medical record on 6/25/19 revealed that Resident #47 was admitted to the facility on [DATE]. Further review of Resident #47's medical record failed to reveal documentation that the facility staff offered the pneumococcal and flu vaccine after admission. In an interview on 6/27/19 at 8:40 AM, the infection control practitioner stated that s/he was also unable to locate any documentation in Resident #47's medical record that indicated the facility staff offered 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.