Frederick Crossing Of Journey

Based on record reviews and interviews, it was determined that the facility failed to conduct care plan meetings after the completion of the comprehensive assessments. This was evident for 2 (Resident #5, #41) of 2 residents reviewed for care planning. The findings include:1) Resident #5 had been residing in the facility since early 2024. The medical record indicated that the resident was cognitively intact. In an interview with the resident on 2/18/26 at 9:18 AM, s/he was asked about care plan meetings and stated, it's been a while, (social services director) Staff #20 had left and I don't know who took his place.A review of Resident #5's medical record was conducted on 2/18/26 at 2:30 PM. The review revealed the 2 most recent assessments were comprehensive assessments. A significant change assessment with an assessment reference date (ARD) of 1/8/26 and an annual assessment with an ARD of 10/30/25. A review of the resident's progress notes was also conducted and did not reveal any documentation regarding care plan meetings.The social services designee (Staff #19) 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 interviews and record review, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident in one (Resident #110) of three Residents reviewed for ADL. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each resident's strengths and needs. This information informs resident care planning decisions.During an interview on 2/18/26 at 8:54 AM, Resident #110 reported having received only one shower in the past 3 weeks. A review of Resident #110's admission MDS assessment dated [DATE] noted that the resident was totally dependent on staff for assistance with showers. A continued review of the shower schedule for the Unit where Resident #110 resided showed that s/he was to receive 2 showers per week, totaling 8 showers per month.Further review of the GNA (Geriatric Nurse Assistant) shower documentation for Resident #110…

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, staff interviews, and record reviews, it was determined that the facility failed to provide activities programs to meet residents' needs and preferences. This was evident for one (Resident#75) of one Resident reviewed for Activities.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information about each Resident's strengths and needs. The information collected informs Resident care planning decisions.During a tour of the memory care unit on 2/17/26 at 9:11 AM, Resident #75 was observed sitting alone at a table in the dining area, with his/her head bent over and no activity going on. In a later observation on 2/17/26 at 10:33 AM, Resident #75 remained seated in the same spot. A Chronicle paper was noted on the table in front of the Resident, and s/he was observed sleeping in his/her wheelchair. In a subsequent observation on 2/17/26 at 1:52 PM, Resident #75 had finished eating lunch, remained seated in 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 observation, record review, and interview, it was determined that the facility failed to ensure appropriate pressure relieving device settings. This was evident for 3 (Resident #57,#93, and #118) of 3 residents observed with pressure injuries during the annual recertification survey. On 2/17/26 at 9:09 AM, the surveyor observed that Resident #93 had a pressure-relieving mattress on their bed. Resident#93 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #93's last documented weight on 02/03/2026 was 154 pounds. The pressure relieving mattress setting was inflated to 260 pounds. On 2/17/26 at 9:22 AM, the surveyor observed that Resident #57 had a pressure-relieving mattress on their bed. Resident #57 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #57's last documented weight on…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure residents with oxygen therapy received oxygen as prescribed. This was evident for 1 (Resident #41) of 3 resident reviewed for respiratory care. The findings include:Resident #41 was admitted into the facility in early 2024 with diagnosis that includes acute respiratory failure with hypoxia.Hypoxia is a critical condition where tissues are deprived of adequate oxygen, causing symptoms like confusion, rapid heart rate, shortness of breath, and cyanosis (bluish skin). It is caused by lung issues, low blood oxygen (hypoxemia), anemia, or poor circulation. Treatment involves immediate oxygen therapy, medication, or ventilation.During an interview with Resident #41 on 2/18/26 at 8:55 AM, it was observed that the resident was receiving oxygen via nasal cannula set at 3.5 liters/min.A review of Resident #41's medical records on 2/20/26 at 9:33 AM revealed oxygen order to be administered at a rate of 2 L/min. There was no other documentation found to indicate that the rate of oxygen…

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

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #9, #41) of 4 residents reviewed for pain management. The findings include:1) Resident #9 had been residing in the facility since 2024. Diagnosis included but was not limited to chronic pain. A review of Resident #9's medical orders was conducted on 2/19/26 at 2:22 PM. The review revealed an order for narcotic pain medication to be taken on an as needed (PRN) basis and non-pharmacological interventions (NPI) to alleviate pain with numbers 1 through 8 that corresponded to the different interventions. Special instruction indicated to document all NPI's as needed.On 2/20/26 at 11:12 AM, a review of Resident #9's administration record for January 2026 revealed the PRN narcotic pain medication was administered 8 times. 3 of the 8 times the medication was administered failed to show documentation of the pain location, and there was no documentation to indicate NPI's 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, record reviews, and interviews, it was determined that the facility failed to implement appropriate interventions for a resident with an altered mental status and identified behaviors. This was evident in 1(Resident #42) of 2 residents reviewed for behaviors.The findings include:During a lunch observation on the memory care unit on 2/17/26 at 1:12 PM, Resident #42 was seated at the same table as two other residents, Resident #76 and Resident #72. Resident #42 was observed taking bread from Resident #72's lunch tray and eating it. After eating it, Resident #42 also took Resident #76's cake from Resident #76's tray. Resident #76 yelled and snatched the cake back from Resident #42's hand. After the surveyor's intervention, the staff moved Resident #42 to the TV room. Record review for Resident #42 included a psychiatry progress note dated 7/22/25, which stated that Resident #42 had a diagnosis of dementia with behavior.Continued record review included a social services progress note indicating that Resident #42 was sometimes agitated, screamed at staff and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to ensure safe and secure drug storage of resident medications. This was observed for 1 (North Hall) of 3 resident medication carts observed during the annual recertification survey. The findings include: On 2/19/26 at 7:25 AM, the medication administration observation was conducted on the 2 North unit with Staff #6, a Licensed Practical Nurse. When the surveyor approached the cart, Staff #6 was inside room [ROOM NUMBER] with the resident's room door shut. The resident medication cart was unlocked and unattended in front of room [ROOM NUMBER] and the surveyor was able to open and access the medication drawers. Staff #6 exited room [ROOM NUMBER] upon hearing the surveyor accessing the medication cart and acknowledged that it was unlocked and unattended. 2/19/26 at approximately at 1:30 PM, the findings were reviewed with the Nursing Home Administrator. He acknowledged the concern.

Based on observations, record reviews, and interviews, it was determined that the facility failed to conduct a comprehensive assessment of a resident's dietary dislikes and food preferences. This was evident in 1 (Resident #110) of 3 residents reviewed for food.The findings include:During an initial tour of the facility on 2/17/26 at 8:53 AM, Resident #110 was observed in bed eating breakfast. The Resident told the surveyor, Can you write on my ticket again that I don't like eggs? The Resident indicated that s/he had told the staff multiple times that s/he disliked eggs; however, s/he continued to receive eggs for breakfast. Resident #110's diet slip indicated a regular diet but did not list the Resident's preferences or dislikes.On another observation on 2/18/26 at 8:28 AM, Resident #110 was seated in a wheelchair at the bedside, eating breakfast. The Resident reported to the surveyor that s/he had again received scrambled eggs and added, I've told them several times that I don't like eggs, especially when they're not real eggs, and they keep bringing me eggs. I don't know why.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 record review and interview, it was determined that an incompetent resident was documented as having consented to the arbitration process. This was evident for one resident (Resident #10) of 3 residents reviewed for arbitration agreements.The findings include:Resident #10 was admitted to the facility on [DATE]. A review of the resident's clinical record revealed that the resident lacked capacity to make decisions for themselves, which was documented by two providers on 11/16/25. Further review failed to reveal any evidence that the resident had a designated power of attorney (POA), guardian, or surrogate.On 2/19/26 at 9:30 AM the Nursing Home Administrator (NHA) was asked to provide a list of all residents who had arbitration agreements with the facility.On 2/19/26 at 11:07 AM a review of Resident #10's arbitration agreement was conducted and revealed that the document had an electronic signature that indicated the resident signed it on 12/03/25. On 2/19/26 at 11:08 AM an interview was conducted with…

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

Based on observations, 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 #111) of 5 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 #111 was admitted into the facility in late-2025. Medical records indicated that the resident was receiving hospice care.On 2/17/26 at 10:18 AM, the surveyor observed that Resident #111's door was closed. An EBP sign was posted with PPE supplies secured with a hanging storage on the door. After knocking and opening the door, a staff member…

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 with staff it was determined the facility staff failed to ensure resident medical records were complete and accurately documented. This was evident for 1 (Resident #1) of 2 residents reviewed during the complaint survey.The findings include: The facility's report and investigation for Facility Reported Incident #2665129 was reviewed on 1/29/26 at 2:32 PM. The documentation revealed Resident #1 alleged that a staff member answered his/her call bell and hit him/her on the head on 11/7/25 at 10:21 PM. The facility reported the allegation to the State Agency and the local police, conducted an investigation, and submitted a Follow-Up Investigation Report to the State Agency. They were unable to verify the resident was struck on the head by staff as alleged. During the investigation witness statements obtained from staff revealed that Resident #1 was found sitting on the floor of his/her room on 11/7/25 at approximately 11:40 PM. Resident #1's medical record was reviewed on 1/29/26 at 4:16 PM. No documentation was found in the medical record regarding…

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 treat residents with dignity and respect by failing to respond to call lights in a timely manner. This was evident for 3 (#2, #4, and #5) of 3 residents reviewed for call light response times. The findings include:On 10/15/25 at 1:19 PM an interview with Resident #2 revealed s/he waited a long time for call lights to be answered and would yell for the staff to come to his/her room. The resident reported it had been an hour or longer which was why s/he would call the nurses' station and/or the front desk to get help.On 10/16/25 at 8:00 AM during an interview with Resident #4, s/he reported that 60% of the time staff do not answer the call lights. The resident reported that s/he has waited up to an hour at times. Resident #4 reported that the other day his/her colostomy bag busted at 6:45 AM and was not changed until 8:00 AM. An interview with Resident #5 on 10/16/25 at 8:05 AM revealed s/he had waited up to an hour at times for the call lights to be answered. The resident stated that s/he had not been…

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 an allegation of abuse was reported within the required timeframe. This was evident for 1 (#1) of 1 allegation of abuse.The findings include:A review of the facility's investigation file for the facility reported incident #2618838 on 10/16/25 6:29 AM revealed in the initial report that the facility became aware of Resident #1's allegation of abuse involving geriatric nursing assistant (GNA) #5 on 9/16/25 at 7:00 AM when the police came to the facility. However, the initial report noted that it was completed on 9/16/25 at 9:10 AM. There was no confirmation email included to verify the time the initial report was submitted to the State Agency (SA).On 10/16/2025 8:49 AM an interview with the Regional [NAME] President of Clinical Services revealed she had reviewed the previous Director of Nursing (DON) #6 email account and was unable to find the confirmation for the submission of the initial report. However, she found an email addressed to her and the Nursing Home Administrator (NHA) 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 record review and interview, it was determined that facility staff failed to protect their residents from an employee accused of abuse and to conduct a thorough investigation of an allegation of abuse. This was evident for 1 (#1) of 1 resident reviewed for abuse.The finding include:A review of the facility's investigation file for the facility reported incident #2618838 on 10/16/25 6:29 AM revealed in the initial report for 9/16/25 that Resident #1's alleged that geriatric nursing assistant (GNA) #5 slapped him/her on the face. The initial report noted that the facility became aware of the alleged abuse on 9/16/25 at 7:00 AM when the police came to the facility. However, a review of the witness statements revealed staff failed to document the date and time of when they were made aware of the allegation of abuse and when the police arrived at the facility.During an interview with GNA #5 on 10/16/25 at 5:06 AM, she reported that she had become aware of Resident #1's allegation of abuse on 9/16/25 during the night shift by RN #7. She reported that while she was on a break when…

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

Based on record reviews and interviews, it was determined that the facility failed to ensure controlled drug counts were maintained and signed by 2 staff members at change of shift. This was found to be evident for 2 out of 4 drug control books reviewed. The findings include: Drug control books are typically kept in medication carts and are used to determine that drug records are in order and that an account of all controlled drugs are maintained with sufficient detail. All controlled substances kept in the medication cart should match their record in the drug control book. A review of 4 drug control books was conducted on 2/25/25 and has identified several concerns. The concerns were: A) On 2/25/25 at 9:14 AM, a review of the shift count documentation for the south unit drug control book was conducted. The review revealed the documentation had columns in which the nursing staff would document the date, time of day, if the count was correct (Yes or No), coming on duty and going off duty nurse's signatures. The review also revealed that the 3 PM shift count for 2/25/25 had already…

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 that the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections by failing to ensure residents drinkware was clean. This was evident for 4 coffee mugs out of 6 coffee mugs observed during a survey. On 2/25/25 at 9:51 AM an observation of the coffee serving cart revealed a tray of 6 brown coffee mugs face down on a tray. Further observation revealed 4 out of the 6 mugs contained a chalky- grayish brown material inside the cups. This material was easily removed with gentle rubbing On 2/25/25 at 9:45 AM during a brief interview with the kitchen cook Staff # 3, she reported that the cups on the tray were clean and available for use. On 2/25/25 at 9:46 AM staff # 3 confirmed that 4 out of the 6 mugs contained a chalky grayish brown material that was easily removed when wiped. On 2/25/25 at 9:54 the administrator confirmed the observation 4 out of the 6 mugs contained a chalky grayish brown material that was easily removed when wiped. On 2/25/25 at 11:40 AM…

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

Based on surveyor observation and staff interview, it was determined that the facility staff failed to properly store food items in the kitchen's walk-in refrigerator, and failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen and had the potential to affect all residents. The findings include: On 10/25/24 at 8:40 AM, accompanied Staff #10, Dietary Manager, an observation was made of the Kitchen. An observation of the kitchen's walk-in refrigerator revealed: - An opened 46-ounce container of thickened Ready Care lemon Water that was not labeled with date opened. - An opened 8-quart plastic facility container with approximately 2 quarts of Applesauce not labeled with date food was placed in the container. - An opened 8-quart plastic container with approximately 2 quarts of fruit cocktail not labeled with date food was placed in the container. - An opened container of gravy labeled with date 9/19/24. At that time, Staff #10 indicated the gravy container was labeled with the wrong date. - An opened container of…

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

Based on observation and staff interview, it was determined the facility failed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections by failing to ensure residents drinkware was clean. This was evident on 2 of 2 observations of drinkware designated for resident use. The findings include: On 10/25/24 at 8:40 AM, during an observation of the kitchen by 2 surveyors, 11 plastic mugs were observed upside down on a tray on a food cart located next to the door that exited into the dining room. At that time, Staff #12, Dietary Aide, indicated the coffee mugs were clean and were to be used for resident beverages. An observation of the inside of the coffee mugs revealed that 2 of the mugs had a chalky white/gray film, which was easily removed with gentle finger rubbing. Staff #12 confirmed the observation and removed the soiled mugs at that time. On 10/25/24 at 12:30 PM, an observation of the South Wing hallway revealed a food cart near resident rooms that had 2 trays of upside-down plastic mugs. 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 record review and interviews, it was determined that the facility failed to obtain a resident's representative's signature or document refusal to sign the Notice of Medicare Non-Coverage (NOMNC) for a resident who was discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 1 (#88) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The notices include Notice of Medicare Non-Coverage (NOMNC). This must be issued at least two calendar days before the last day of Medicare coverage. The NOMNC informs the beneficiary of his/her right to an expedited review of services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to ensure staff reported areas in resident's rooms in need of repair to maintenance. This was found to be evident on one of the three units. The findings include: 1) On 10/22/24 at 12:50 PM the surveyor observed the bathroom of room [ROOM NUMBER] and found a white pillow on the floor and a fall mat leaning against the wall. The mat was frayed. On 10/28/24 at 2:02 PM the surveyor conducted an observation of room [ROOM NUMBER]'s bathroom with the unit nurse manager (Staff #9) and saw the pillow on the floor and the fall mat leaning against the wall. The surveyor noted the fall mat in the bathroom had multiple cracks. The unit nurse manager reported she would have the fall mat thrown out. 2) On 10/23/24 at 11:19 AM the surveyor observed the wall behind the B bed in room [ROOM NUMBER] with a large area of scrapes and that it was unpainted. On 10/28/24 at 1:31 PM the surveyor observed the area on the wall in room [ROOM NUMBER] had scrapes…

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 with staff, it was determined that the facility failed to provide written notification of transfer to Residents and/or Resident representatives upon transfer to the hospital. This was evident for 1) one Resident (#59) of two residents reviewed for hospitalization and 2) one complaint (#MD001973041) of nine complaints reviewed during the recertification survey. The findings include: 1) A medical record review for Resident #59 on 10/23/24 at 9:52 AM showed that the Resident had difficulty breathing on 8/16/24. The attending provider was notified and ordered to send the Resident to the emergency room for evaluation. Further medical record review showed that Resident #59's representative was notified via phone. However, the review failed to show that the Resident and/or the Resident representative was notified in writing of the transfer and the reason for the transfer. In an interview on 10/25/24 at 12:13 PM, staff #11, a unit manager, stated that the staff notified Residents' representatives of hospital transfers via phone calls and not in writing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1) one Resident (#59) of 2 Residents reviewed for hospitalizations and 2) one complaint (#MD001973041) of 9 complaints reviewed during the recertification survey. The findings include: 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 drives resident care planning decisions. 1) A record review for Resident #59 on 10/24/24 at 5:38 PM showed that the Resident had been living in the facility since November 2022 and had moderate cognitive impairment per an MDS assessment dated [DATE]. The continued review contained a nurse's note that Resident #59 was transferred to the hospital on 8/16/24 due to difficulty breathing. However, the review failed to show that…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psychotropic medications. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications: 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) On 10/23/2024 1:47 PM, a review of Resident #58's medical record revealed the resident was admitted to the facility in early October 2024 following an acute hospital stay. Review of Resident #58's admission assessment with an assessment reference date of 10/13/24 revealed the resident's BIMS (brief interview for mental status) summary score was 3, indicating the resident had severe cognitive impairment, and had diagnoses which included dementia, depression and adjustment disorder with mixed anxiety and depressed mood. Review of the resident's October 2024 Medication Administration Record revealed 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 interviews and medical record review, it was determined that the facility failed to ensure participation in the care plan process by a resident's representative. This was evident for 1 (#89) of 2 residents reviewed for care planning. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. Care plans are developed to guide residents' care in the facility. They must be created within 7 days of completion of a resident's admission comprehensive MDS assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team, including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable). Participation in care planning by a resident and Resident representative can…

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

Based on observation, review of facility policy, and interview, it was determined that the facility staff failed to follow standards of professional practice when administering medications to residents. This was evident for 1 opportunity out of 26 opportunities observed for medication administration. The findings include: During observation of medication administration on 10/25/24 at 8:31 AM, the surveyor observed that Staff #4 prepared medications for Resident #70. Staff stated that the resident was out of Miralax powder, so she borrowed from Resident #73's medicine supply. A review of the facility's Medication administration-general guidelines policy showed that medications supplied for one resident are never administered to another resident. In an interview later that day, staff #4 reported that the medication she borrowed was a house-stock medication. However, she was out of supply and waiting for the facility's supply person to restock. In an interview on 10/25/24 at 3:22 PM, the director of nursing reported that the staff person in charge of restocking house medications was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure discharge plans were appropriate for the resident's needs. This was found to be evident for one (Resident #72) out of three residents reviewed for discharge. The findings include: Review of Resident #72's medical record revealed the resident was admitted to the facility in September 2024 after a hospitalization for an infection. The resident received intravenous (IV) antibiotics, wound care, physical therapy (PT) and occupational therapy (OT) while at the facility. On 9/23/24 a care plan to discharge home was initiated. Review of the 10/15/24 attending medical provider's progress note revealed that the resident was being treated with two different IV antibiotics with an end date of 10/26/24 for the antibiotics. This note also documented that the resident would be going home on [DATE] with home PT, OT and wound care. Further review of the medical record revealed an interdisciplinary care plan conference was conducted…

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, observations and interviews, it was determined the facility failed to implement physician ordered pressure injury prevention therapies. This was evident for 1 (Resident #77), out of 2 residents reviewed for pressure injuries during a survey. The findings include: On 10/22/24, the medical records of Resident # 77, a long-term resident of the facility, were reviewed. The review revealed that the resident had a recently healed pressure injury on his/her heel. On 10/24/24 at 9:07 AM a review of Resident #77's physicians orders revealed the following: 1) Order dated 8/06/24, for the resident to wear protector boots while in bed for skin integrity to heels. Can be removed for ADL (activities of daily living) care, observing skin and administering treatment. Re-apply heel protector boots afterwards, when in bed. Every shift for skin integrity. 2) Order dated 7/21/24, to Float heels when in bed qs (every shift) for skin breakdown. On 10/25/24 at 2:02PM a review of Resident #77's care plan revealed a skin integrity care plan. Further review revealed a therapeutic…

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

Based on surveyor observation, review of clinical records and interview of facility staff, it was determined that the facility staff failed to provide treatment to maintain an individual's range of motion. This was evident for 1 (Resident #80) out of 2 residents selected for position and mobility, during a survey. The findings include: On 10/23/24 at 10:00 AM, review of Resident #80's medical record revealed that the resident was a long-term resident of the facility and due to physical and cognitive limitations s/he was totally dependent on the assistance of staff for her/his activities of daily living. On 10/23/24 at 10:40 AM a review of the resident's physician orders revealed an order dated 2/10/24, Pt will wear bilateral wrist/hand brace/splint for up to 6 hours or as tolerated to reduce risk of further contracture. Skin integrity checks pre/post wear, every day and evening shift. A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to…

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

Based on observation, medical record review and interviews, it was determined that the facility failed to 1) ensure that as needed pain medication orders included pain scale parameters for administration and 2) document pain assessment to include the location of the pain and type of pain for a Resident reporting pain. This was evident for 2 (#25, #89) of 2 residents reviewed for pain management. The findings include: A pain scale is a numerical scale, usually 1-10, used to rate a person's severity of pain. 1) On 10/23/24 at 10:57 AM Resident #25 was observed lying in bed fully dressed with a grimace on his/her face. Resident #25 stated he/she just had his/ her dressing changed, and the nurse went to get some pain medication. On 10/24/24 at 8:39 AM Resident #25's medication orders were reviewed. It revealed a physician order dated 6/18/24 for Acetaminophen (Tylenol - a non-narcotic) 325 mg tablets 2 tablets by mouth every 6 hours as needed for mild pain: moderate pain. Further review of the Medication Administration Record (MAR) revealed another as needed pain medication order 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 review of pertinent documentation and interview it was determined that the facility failed to ensure two staff members completed the controlled drug count at the change of each shift. This was found to be evident for one out of three drug control books reviewed during the survey. The findings include: A review of the facility's Controlled Substance Storage policy, with a revision date of March 2017, revealed the following statement: At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. A review of the Shift Count documentation revealed columns in which nursing staff would document the date, time of day, if the count was correct (Yes or No), signature of Coming On Duty Nurse and the signature of Going Off Duty Nurse. On 10/28/24 at 1:39 PM nurse (Staff #16) confirmed that they sign the Shift Count form when the count is completed. A review of the Shift Count documentation for the Section 1 North medication cart on 10/28/24 at 1:35 PM 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 and staff interview, it was determined that the facility failed to document the specific reason for administering a psychotropic medication prescribed as needed (PRN) and failed to implement non-pharmacological intervention before administering the medicine. This was evident for 1 complaint (#MD00192471) of 9 complaints reviewed during the recertification survey. The findings include: Non-pharmacological interventions (NPI) are interventions without medications. A review of complaint #MD00192471 revealed an allegation that Resident #299 was chemically restrained with the use of an antianxiety medication. A record review for Resident #299 showed an attending provider's orders dated 9/30/22 to 10/4/22 and 10/4/22 to 10/11/22 for antianxiety medication to be administered to Resident #299 every 12 hours PRN for agitation/anxiety. A review of Resident #299's medication administration record (MAR)for September and October 2022 was completed. The MAR had recorded that the nurses administered the antianxiety medication to Resident #299 on 9/30/22 with a…

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

Based on observation and interview, it was determined that the facility failed to ensure medications and needles were secured as evidenced by observations of unlocked emergency carts in residents' hallways. This was evident for 2 emergency carts out of 2 emergency carts observed during a survey. The findings include: On 28/24/24 at 10:42 AM, an observation was made of the emergency cart located in the South Unit, near the nurse's station. Observation revealed the lower drawer of emergency cart was slightly opened. Further observation of the emergency care revealed the emergency cart was not locked. Continued observation revealed the top drawer opened. An observation of the top drawer revealed 1 amp of 1.10.00 epinephrine (a medication that is injected into the veins during a cardiac arrest) and a glucagon syringe, (a medication used to increase circulating blood sugar when a residents blood sugar is too low.) On 2/28/24 at 10:44 AM, an observation of the second emergency cart on the North Unit was made, with the Director of Nursing. The observation revealed the emergency cart was…

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

Based on observation and medical record review it was determined that the facility failed to ensure that the staff only documented interventions that were completed. This was evident for 1 (Resident # 80) out of 35 Resident reviewed during a survey. The findings include: On 10/23/24 at 10: AM, review of Resident #80's, a long-term resident of the facility, medical record revealed that due to physical and cognitive limitations s/he was totally dependent on the assistance of staff for her/his activities of daily living. On 10/23/24 at 10:40 AM, review of orders revealed an order with a start date of 2/10/24, Pt will wear bilateral wrist/hand brace/splint for up to 6 hours or as tolerated to reduce risk of further contracture. Skin integrity checks pre/post wear every day and evening shift. The following observations were made during the survey: On 10/22/24 at 9:24 AM, an observation was made of Resident #80's room. Observation revealed Resident #80 lying in bed. The observation failed to reveal that Resident #80 was wearing a bilateral wrist/hand splint. Further observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed: to ensure proper decision making and accuracy of MOLST(Maryland Orders for Life Sustaining Treatment); to review Advanced Directives with residents and/or the appropriate decision maker; and manage discontinued MOLST's in the proper way. This was evident for 4 (Residents #68, 97, 76, and 84) out of 10 residents reviewed for advanced directives. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The MOLST form contains the following section: Certification for the basis of these orders: [NAME] any and all that apply. I hereby certify that these orders are entered as a result of a discussion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was observed on 2 of 4 nursing units and in 3 of 26 rooms observed during the initial pool process. The findings include: On 4/24/23 at 11:07 AM, observation was made of Resident #56 sitting in a wheelchair. The left wheelchair armrest was missing on the wheelchair and the resident had his/her arm directly on the frame of the wheelchair. On 4/27/23 at 1:13 PM, observation was made of Resident #87 sitting at a table in the dining room in the ACU unit. The left wheelchair armrest was missing on the wheelchair and the resident had his/her arm directly on the frame of the wheelchair. On 5/1/23 at 8:20 AM, while watching medication administration, observation was made of the dining room in the ACU unit (dementia). Observation was made of the floor in the middle of the room that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the record reviews and interviews, the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer, nd failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 1 resident, #82, of 4 residents reviewed during closed record review of residents with hospitalizations and for for 3 (#109, #110, #111) of 13 residents reviewed for abuse. Te findings include: 1) Resident #82 was admitted to the facility with the diagnosis of vascular dementia with behavioral disturbances, persistent mood affective disorder, and diabetes. The resident's (BIMS) brief interview for mental status) examination was 5. )n 04/27/23 at 09:52 AM, the surveyor reviewed the electronic medical record of the resident for the date of service of 10/13/22. Resident #82 was transferred to the emergency room department at [NAME] hospital on [DATE] after being…

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 notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility and failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 3 (#109, #110, #111) of 13 residents reviewed for abuse and 1 (#82) of 4 residents reviewed during closed record review of residents with hospitalizations. 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 those individualized needs, and that the care is provided as planned to meet the needs of each resident. BIMS stands for 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 record review and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to make certain that residents' individual needs were identified. This was evident for 1 (Resident # 73) out of 3 residents reviewed for MDS Assessments. The findings include: A Minimum Data Set (MDS) is a part of a federally mandated set of assessment screening tools that ensures each resident's individual needs are identified, a plan of care is developed and meets the needs of each resident. A Preadmission Screening and Resident Review (PASARR) is a federal mandatory evaluation to identify residents with serious mental disorders and or intellectual disabilities to ensure the resident is in the most appropriate care setting for their needs. Assessment Reference Date (ARD) is defined as the specific end point of look-back periods in the MDS assessment process. It allows for those who complete the MDS to refer to the same period when reporting the condition of the resident. On 4/19/23 at 8:24 AM, a review of Resident #73's hard…

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 the facility failed to complete a thorough comprehensive care plan to address all pertinent care and treatment of residents. This was evident in 1 (Resident #68) out of 3 Resident's reviewed for position and mobility. The findings include: On 04/20/23 at 8:06 AM, Resident #68's medical record was reviewed. Resident #68 was admitted to the facility in April 2021. Resident #68 had a BIMS of 14 and his/her medical history included stroke with hemiplegia. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points. Hemiplegia is total or partial paralysis of one side of the body that results from disease or injury to the motor centers 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 interview and record review, it was determined that the facility failed to assure that the care plan was revised to address a newly identified condition. This was evident for 1 (Resident #84) out of 4 residents reviewed for skin conditions that were non pressure related. The findings include: On 04/18/23 at 12:07 PM, an interview was conducted with Resident #84's family. The resident's family reported that the resident had a skin related issue to his/her backside and that there was a dressing that was to be changed 2 times per day and when soiled. Review of Resident #84's medical record on 4/21/23 revealed that the Resident was admitted to the facility in March 2022. A review was conducted of Resident #84's medical record to include skin assessments and wound care provider documentation. On 11/25/22, Wound Care Provider (WCP) #24 documented that Resident #84 had Moisture Associated Skin Damage (MASD) on his/her sacrum. WCP #24 re-examined Resident #84 on 12/02/22 and considered this wound to be resolved. Moisture-associated skin damage (MASD) is caused by prolonged exposure…

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 interview it was determined that the facility failed to provide activities based on resident preferences and the resident's care plan. This was evident for1 (Resident #5) out of 7 residents reviewed for activities. The findings include: The surveyor obtained multiple observations of Resident #5 throughout the survey. During the observations, Resident #5 was found to be in his/her bed with no television, radio, or other stimulation or activity present. This was found throughout the survey but specifically on the following days and times: 04/17/23 at 10:07 AM 04/17/23 at 12:28 PM 04/18/23 at 8:51 AM 04/18/23 at 11:03 AM 04/18/23 at 2:46 PM 04/19/23 at 9:44 AM 04/20/23 at 12:22 PM 04/21/23 at 9:15 AM 04/21/23 at 2:41 PM On 4/24/23 at 11:36 AM, a review of Resident #5 ' s medical record occurred. Resident #5 was admitted to the facility in August 2022. Resident #5 has a Brief Interview for Mental Status (BIMS) score of 12. He/she had diagnoses that included: anxiety, depression, and schizophrenia. BIMS stands for Brief Interview for Mental…

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 address significant weight loss at the time it was first documented. This was evident for 1 (Residents #84) out of 11 residents reviewed for nutrition. The findings include: On 4/17/23 at 10:54 AM, Resident #84's medical record was reviewed. The review revealed that the resident was admitted in March, 2022, and experienced a weight loss in December, 2022. Review of the resident's weight log from November, 2022, to January, 2023, revealed the following weights: - 11/6/22: 178.8 lbs - 11/26/22: 174.8 lbs - 12/6/22: 165.4 lbs - 12/13/22: 165.2 lbs - 12/20/22: 164.7 lbs - 1/17/23: 161.6 lbs - 1/24/23: 162.6 lbs On 4/26/23 at 11:04 AM, Resident #84's medical record review continued. The review revealed a Plan of Care note written on 12/13/22 by the Registered Dietician (RD, Staff #27). The note stated that the resident had a weight loss of 13.4 lbs (7.4%) between 11/6/22 and 12/6/22. The Dietician recommended the resident be prescribed an 8 oz Glucerna shake at night and to have weights repeated weekly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to ensure that a physician supervised the care of a resident as evidenced by the physician failure to evaluate that a resident had a Stage 3 pressure ulcer upon admission to the facility and give orders for treatment. This was evident for 1 (#117) of 7 residents reviewed for pressure ulcers. The findings include: A pressure ulcer, also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III ( full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full-thickness tissue loss in which the base of the ulcer is…

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

Based on observation, and interview and record review, it was determined that the facility failed to provide reasonable accommodation for a resident to have access to the sink in the resident's bathroom. This was evident for 1 resident (resident #1) out of 1 Resident reviewed for reasonable accommodations during an annual survey. The finding included: On 4/17/23 at 9:08 AM, an observation of Resident # 1's bathroom, revealed 1 sink, 1 toilet, 1 large mechanical lift, 7 medium boxes of medical supplies, and several small boxes. The sink contained a plastic bowl full of water, a fork, food particles, and a tooth bush laying down on the surface of the sink. On 4/17/23 at 9:12 AM, an interview with Resident #1 was conducted. During the interview, Resident #1 reported that he/she would like to have access to the sink, however, s/he was unable to get the wheelchair into the bathroom due to all the items stored in the bathroom. On 4/18/23 at 10:00 AM, a review of Resident #1's medical record revealed that Resident #1 was a long-term care resident that was dependent on a motorized power…

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 2) On 4/17/23 at 10:54 AM, Resident #84's medical record was reviewed. The review revealed that the resident experienced a 9.4 lbs weight loss, going from 174.8 lbs on 11/26/22 to 165.4 lbs on 12/6/22 (a 5.3% weight loss within 1 month). No change in condition assessment was found following the 12/6/22 weight loss, nor was there any nursing note indicating that the resident's attending physician or responsible party were notified of the weight loss. On 4/27/23 at 10:47 AM, an interview was conducted with Unit Manager (UM) #23. During the interview, UM #23 stated that significant weight loss was considered a significant change and should be reported to the resident's attending physician and responsible party. When asked what constituted significant weight change, she stated it was 5-7 lbs. On 4/27/23 at 2:42 PM, Licensed Practical Nurse (LPN) #25 was interviewed. During the interview, LPN #25 indicated that significant weight change was considered a significant change and should be reported to 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.

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 notify the resident / resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer and failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 3 (#109, #110, #111) of 13 residents reviewed for abuse and 1 (#82) of 4 residents reviewed during closed record review of residents with hospitalizations. The findings include: 1) On 4/24/23 at 9:00 AM, a review of Resident #109's medical record was conducted and revealed a 1/8/23 at 4:39 PM nurse's note that documented Resident #109 was found with right flank discoloration and swelling. The physician ordered the resident to be sent to the emergency room for further evaluation. Further review of Resident #109's paper and electronic medical record failed to produce documentation that a written notice of transfer was provided to 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 prepare residents for transfer to the hospital. This was evident for 1 (Resident #5) out of 9 residents reviewed for hospitalization. The findings include: On 04/21/23 at 4:10 PM, a review of Resident # 5's medical record revealed that the resident had a guardian. On 04/24/23 at 11:36 AM, a review of Resident #5's medical record occurred. Based on the MDS assessment (Minimum Data Set) from December 2022, documentation revealed that the resident was able to understand and comprehend others. 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 and that care is planned based on those individualized needs. Continued review of Resident #5's medical record found that the resident was transferred on 02/15/23 to the hospital. No documented evidence could be found to indicate that the resident had been informed of the transfer, where he/she was being transferred…

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 include the recommendations from PASARR into a resident's assessment and care planning. This was evident for 1 (# 73) out of 3 residents reviewed for PASSAR. Findings include: A Preadmission Screening and Resident Review (PASARR) is a federal mandatory evaluation to identify residents with serious mental disorders and or intellectual disabilities to ensure the resident is in the most appropriate care setting for their needs. Assessment Reference Date (ARD) is defined as the specific end point of look-back periods in the MDS assessment process. It allows for those who complete the MDS to refer to the same period when reporting the condition of the resident. On 4/19/23 at 8:24 AM, a review of Resident #73's hard chart revealed a Preadmission Screening and Resident Review I (PASRR I) dated 9/15/21, in section B it was documented that the resident had an identified intellectual disability. A PASSR II had been completed on 9/27/21, that read Resident #73 had an intelligence quotient (IQ) of 47.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications and failed to initiate a baseline care plan within 48 hours of a newly admitted resident's admission. This was evident for 1 (#113) of 13 residents reviewed for abuse . The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 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,…

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

Based on review of resident medical records and interview with facility staff, it was determined that facility staff failed to follow professional standards of practice by striking-out resident weights without a valid rationale. This was evident for 2 (Residents #84 and #76) of 11 residents reviewed for nutrition. The findings include: Resident #84's weights were reviewed on 4/27/23 at 10:00 AM. The review revealed that the resident had the following weights documented for December, 2022, through February, 2023: - 12/6/22, 2:13 PM: 165.4 lbs. - 12/13/22, 4:43 PM: 165.2 lbs. - 12/20/22, 3:00 PM: 164.7 lbs. - 1/5/23, 10:02 PM: 150.6 lbs. This weight was struck out by the unit manager on 1/17/23 at 5:28 PM with the comment, Incorrect Documentation. The original weight was documented by a different staff member. - 1/17/23, 5:28 PM: 161.6 lbs. - 1/24/23, 2:34 PM: 162.6 lbs. - 2/1/23, 3:26 PM: 163.8 lbs. - 2/21/23, 2:54 PM: 156.0 lbs. No note could be found in Resident #84's medical record between 1/5/23 and 1/17/23 that explained why the weight on 1/5/23 had been stricken 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 interview, it was determined that the facility failed to provide quality of care related to weight loss of residents and failed to manage a resident's pressure wound showing signs of infection. This was evident for 1 (#81) of 11 residents reviewed for nutrition concerns and 1 (Resident #5) of 6 residents reviewed for pressure ulcers. 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. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the 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. Significant Weight loss - greater than a 5% weight loss in 1 month, greater than 7.5% in 3 months, and greater that 10% in 6 months. 1) On 4/27/23 at 12:31 PM, a medical record review for Resident #81 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, it was determined that the facility failed to ensure that a residents missing prescription glasses were reported missing and failed to timely follow-up to make sure the glasses were replaced. This was evident for 1 resident (Resident #98 ) out of 2 residents reviewed for communication and sensory during the annual survey. The findings include: On 4/18/23 at 10:19 AM, an observation was made of Resident #98 squinting when viewing the American sign language (ASL) interpreter on a tablet. An interview was conducted with Resident # 98 at that time. Resident #98 reported that they have not had his/her glasses since admission to the facility in January 2023. On 04/18/23 at 10:25 AM, an interview was conducted with Speech Therapist (ST) # 20. ST #20 reported that the resident did have difficult time using the ALS interpretive language line solutions without glasses. ST #20 stated she had not seen the resident with glasses since being admitted to the facility. 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 medical record review and staff interviews, it was determined the facility staff failed to have consistent nursing documentation of when a resident actually developed a pressure ulcer, failed to have appropriate treatment in place to prevent and treat a stage 3 pressure ulcer and failed to deliver the necessary treatment and services to residents with identified pressure ulcers. This was evident for 2 (#117, #73) of 6 residents reviewed for pressure ulcers. The findings include: A pressure ulcer, also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III ( full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon)…

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 that the facility failed to provide ordered treatment to a Resident for contracture management. This is evident for 1 (Resident #68) out of 3 Residents reviewed for limited range of motion. The findings include: On 04/18/23, Resident #68's medical record was reviewed. The resident was admitted in April 2021 with a history of a stroke and hemiplegia. Hemiplegia is total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain. On 04/18/23 at 2:47 PM, surveyor observed a blue wrist/hand splint on the table next to Resident #68's bed. Resident #68 reported that the blue wrist/hand splint was used for his/her left hand. Resident #68 reported that there was not currently any splint on his/her left hand/wrist. Resident #68 reported that therapy would put the splint on him/her if they were available and if they were not, his/her family would place the device when they would come to visit. On 04/20/23 at 8:06 AM, a review of Resident #68's Treatment…

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, review of resident medical records, and interview with facility staff, it was determined that the facility failed to assess residents for the safe use of bedrails prior to placing them on resident beds. This was evident for 3 (Residents #5, #43, and #84) of 49 residents reviewed during the annual survey. The findings include: Bed Rails are adjustable bars that attach to resident beds. While bedrails can assist residents with mobility and safety, they can also prevent the resident from getting out of the bed (a form of restraint) and pose a safety hazard of entrapment if not installed correctly. Proper evaluation of resident needs and abilities prior to installing side rails on a bed is essential to maximize resident benefit and avoid risk. A Side Rail is a specific bed rail that is mounted on the sides of the bed. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bedrail. Entrapment can cause injury, impairment, or death. Enabler bars…

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

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that nurse practitioner notes were written and entered into a resident's medical record at the time of the nurse practitioner's visit. This was evident for 1 (Resident #84) of 49 residents reviewed during the survey. The findings include: Resident #84's medical record was reviewed on 4/21/23 at 10:17 AM. During the review, medical practitioner notes were found that had been consistently entered into the medical record days after the practitioner's visit occurred. The following notes were found: - A nurse practitioner visit on 11/10/22, entered into the medical record on 11/26/22. - A nurse practitioner visit on 11/29/22, entered on 12/9/22. - A nurse practitioner visit on 12/1/22, entered on 12/11/22. - A nurse practitioner visit on 12/5/22, entered on 12/12/22. - A nurse practitioner visit on 12/14/22, entered on 12/19/22. - A nurse practitioner visit on 12/15/22, entered on 12/21/22. The Director of Nursing (DON) was interviewed on 5/9/23 at 12:05 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.

Based on review of employee files and interview with facility staff, it was determined that the facility failed to ensure that all staff working as geriatric nursing aides (GNAs) were certified and competent to work in that position. This was evident for 1 (Staff #26) of 3 staff reviewed for working as GNAs. The findings include: Staff #26's employee file was reviewed on 5/3/23 at 11:45 AM. The review revealed that Staff #26 was hired on 11/2/22 as a geriatric nursing assistant (GNA). However, when the surveyor reviewed the Maryland Board of Nursing license verification service, it was determined that Staff #26 had not had an active GNA license since 2018. Further review of Staff #26's employee record failed to reveal evidence that Staff #26 was in a GNA training program at any point from her start date on 11/2/22 to the date of this review. The DON was interviewed on 5/4/23 at 2:56 PM. During the interview, the DON stated that human resources was responsible for verifying staff credentials prior to beginning any position requiring a license. The DON also stated that any 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 review of employee files and interview with facility staff, it was determined that the facility failed to verify that employees hired as geriatric nursing assistants (GNAs) were registered with Maryland or a compact state as having met competency evaluation requirements. This was evident for 1 (Staff #26) of 3 staff reviewed for working as GNAs. The findings include: A Certified Nursing Aide (CNA) is a licensed nursing assistant position that requires completion of a qualified training program and an exam. A Geriatric Nursing Assistant (GNA) is a specialized CNA who has received additional training. Only a GNA (and not a CNA) can function as a nursing assistant in a long term care facility in Maryland. There are additional training and exam requirements for GNAs. GNAs who have had a continuous period of 24 months without working as a nursing assistant (including providing assistance with activities of daily living for patients) must complete a new training and competency evaluation program prior to…

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

Based on record review and interview, it was determined that the facility failed to complete a thorough annual performance review and provide regular in-service training based off of the annual performance review for geriatric nursing assistants (GNAs). This was evident for 1 (staff # 51) out of 1 geriatric nursing assistant reviewed for annual performance and training reviews. The findings include: On 05/03/23 at 11:45 AM, a review of GNA #51's human resource files was conducted. The review failed to reveal an annual review for GNA #51. On 05/03/23 at 3:07 PM, the Director of Human Resources provided the survey team with an annual review for GNA #51. The review showed an annual review period of April 2022 through April 2023. Although the evaluation was dated and signed by the DON on 02/28/23, it was noted that GNA #51's signature on the document was dated 05/03/23, the same day that the survey team requested the document. The evaluation lacked any specific job related skills pertinent to GNA #51's position. Further review of GNA #51's human resource files failed to reveal that…

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

Based on record reviews, observations, and interviews, the facility failed to provide medically related social services due to the absence of licensed, masters prepared social workers. This was evident for 1 (#88) out of 2 residents reviewed for behavioral/emotional issues and dialysis treatment Findings include: On 04/19/23 at 1:30 PM, the surveyor interviewed the two employees identified as a social worker and a social services designee in the electronic computer system. The social services designee, staff #13, had an associate degree and had worked in the social services area for over ten years, but had only been at this facility for less than one year. The second employee, staff #12, had worked in the social services department for six months and was identified in the electronic medical record as the social worker. However, staff #12 had a master's degree in social work without a social worker license. Staff #12 had not been supervised by a licensed, masters prepared social worker since her date of hire. Additionally, the employee was not able to provide mental health related…

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 assess a resident for food preferences. This was evident in 1 (Resident #84) out of 11 residents reviewed for nutrition. The findings include: On 04/21/23, a review of Resident #84's medical record occurred. The resident was admitted to the facility in March 2022. A nutrition note from 03/25/22 revealed that the writer had met with the resident and family to review food/meal preferences, however, no documented evidence of the resident's food preferences was found in the medical record. On 05/01/23 at 08:34 AM, an interview was conducted with the Licenced Clinical Dietician (LCD) #27. The interview revealed that she was familiar with Resident #84. She reported not being familiar by memory of resident's food preferences, but that the facility was able to accommodate preferences with a meal tracking system. She also reported that they could substitute out foods the resident did not like. On 05/01/23 at 10:14 AM, LCD #27 reported that no food preference sheet could be found in 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 observation and interview, it was determined that the facility failed to a) properly store prepared food stored in the refrigerator and in dry storage, b) have a process to maintain nourishment refrigerators at proper temperatures and, c) maintain the cleanliness of kitchen equipment. This was evident during a tour of the kitchen and nourishment rooms on 1 of 3 nursing units. The findings include: 1. On 4/17/23 at 7:35 AM, an observation was made in the kitchen of the reach in refrigerator. There was a bowl of pudding, a bowl of pears, a bin of apple muffins and 15 small bowls of apple sauce that were sitting on a shelf. The items were covered, however, there were no dates or labels on the food items. The Kitchen Manager (KM) #5 was present with the surveyor at that time and stated she did not know when the items were put into the refrigerator. On 4/17/23 at 7: 43 AM, an observation was made of the dry good storage room. There were several sacks that were open, and the contents were exposed. These sacks of food products included sacks of brown sugar, breadcrumbs, and…

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

Based on record review and interview it was determined that the facility's administration had failed to use their resources to ensure that their residents had optimal supervision of care and services. This was evident during the survey and had the potential to affect all residents. The findings include: On 5/10/23 at 11:00 AM a review of the facility's staffing list revealed they had 13 Registered Nurses (RN) working in the facility. However, they hired a Licensed Practical Nurse (LPN) as the acting Assistant Director of Nursing (ADON) who was performing duties that were outside her scope of practice. One of these duties was to cover for the Director of Nursing (DON) in her absence. The ADON also supervised RNs and LPNs and evaluated the care they provided which was prohibited for an LPN to do. The state laws require that the DON appoint an experienced RN in his/her absence. In addition, they had hired 2 Unit Managers (UM) that were LPNs and their job duties were outside their scope of practice. The LPNs supervised staff and resident care on a specific unit. This required them to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility employed staff in positions that were outside their scope of practice in accordance with state laws and failed to have an effective process in place to ensure that individuals hired to licensed positions had the appropriate license at time of hire and maintained that license as active while employed. This was evident for 5 of 5 staff reviewed for job duties and 2 (Staff #26 and #25) of 5 staff reviewed for working in a licensed position.The findings include: The Annotated Code of Maryland Health Occupations Article, Title 8 is the Nurse Practice Act and contains the laws and regulations in which licensed nurses must follow and defines their scope of practice. Licensed nurses are governed by the Maryland Board of Nursing. During an interview with Unit Manager (UM) #15 on [DATE] at 1:23 PM, she reported that she provided supervision over the care and services provided to the residents on the unit, to include writing their initial…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#110) of 13 residents reviewed for abuse and for 2 (Residents #84 and #76) of 49 residents reviewed during the annual survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 4/24/23 at 11:13 AM a review of facility reported incident MD00182918 revealed Resident #110 had an unwitnessed fall on 8/24/22 and a change in condition on 8/25/22. Resident #110 was evaluated by the Nurse Practitioner (NP) and ordered to be sent to the emergency room (ER) for further evaluation. Further review of Resident #110's medical record revealed on 8/26/22, 8/27/22, and 8/29/22 a COVID-19 evaluation was done even though 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 record review and interview, it was determined that the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan to monitor the quality and safety of the care provided to their residents. This was evident for 1 of 1 plan reviewed and has the potential to affect all the residents residing in the facility. The findings include: A review of the facility Quality Assurance and Performance Improvement (QAPI) Plan on 5/10/23 at 11:29 AM revealed the plan had no date of implementation and a revision date at the bottom of the page of 4/14. Further review revealed it was a policy regarding the development and oversight of the QAPI plan, but had no QAPI plan included. An interview with the director of nursing (DON) on 5/10/23 at 11:36 AM revealed that she developed the nursing QAPI plan by using quality indicators to improve her numbers. An interview with the Administrator on 5/10/23 at 11:46 AM revealed he was not aware of a QAPI plan. The risk management meetings drove what was covered in the QAPI committee meetings. Surveyor's concerns were discussed…

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 staff failed to develop and implement polices and procedures for a QAPI (Quality Assurance and Performance Improvement) program to ensure that residents received quality care that was safe and effective. This was evident throughout the survey and has the potential to affect all residents residing in the facility. The findings include: On 5/10/23 at 11:29 AM, a review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership was conducted. The policy failed to include a date that it was implemented and had a revision date at the bottom of 3/20. The policy failed to include the following and other components described in the regulation: The procedures for the system they use to identify, collect, and use feedback and input from direct care staff, the residents, and resident representatives to identify opportunities of improvement. The procedure for the system they use to identify, collect, and use feedback from all departments and how it will be used…

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

Based on observation and staff interview, it was determined that the facility failed to develop and implement polices and procedures to ensure infection control prevention measures were used by staff while 1) emptying a urinary catheter bag and 2) while folding and storing clean linens in the laundry area and storage of boxes and totes. This evident for 1 of 1 observation of staff emptying a urinary catheter collection bag and 1 of 1 laundry rooms observed. The findings include: 1) On 4/26/23 at 2:31 PM, an observation was made of Geriatric Nursing Assistant (GNA) #16 emptying Resident #91's urinary catheter bag. She put on a paper gown and gloves and went into the bathroom to get a urinal that had no name or room number on it. She placed 3 paper towels on the floor and set the urinal on top of them. She placed the spout of the urinary collection bag into the urinal and then opened the clamp. During this time, her fingers were touching the end of the spout and the spout was touching the inside of the urinal. Once emptying the urinary catheter bag, she placed the spout on the floor…

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, policy review, and staff interview, it was determined that the facility failed to develop and implement policies and procedures to 1) maintain a record that residents were evaluated for contraindications in regards to the COVID-19 vaccination 2) failed to ensure that resident representatives were educated and that the education was documented in the resident's medical record 2) failed to ensure that staff were offered the vaccination and educated regarding the vaccine and failed to maintain records that education was provided. This was evident for 2 (#1 and #91) of 5 residents and 10 (#34, #35, #45, #22, #48, #47, #36, #46, #39, and #49) of 10 staff reviewed for COVID 19 vaccinations. The findings include: On 5/9/23 at 2:37 PM, a review of the facilities, Coronavirus Disease (COVID-19) - Vaccination of Residents policy revealed that #2 read, The resident or resident representative has the opportunity to accept or refuse a COVID0-19 vaccine, and to change their mind. #3 read that the Infection Preventionist oversaw the program and designated a coordinator 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 staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that 100% of staff were fully vaccinated, had an approved exemption, or had a temporary delay to receive the vaccination and/or was not eligible for the required second dose of COVID 19. This was evidenced by a 97.6% vaccination rate with 3 (#34, #35, and #22) of 85 direct hire staff and 1 (#36) of 4 contracted staff. The findings include: On 5/9/23 at 4:30 PM, a review of the facility's Policy, [Corporation Name] Mandatory Vaccination Policy revealed the facility failed to provide a date it was created. In addition, in the section marked, Scope it read that all employees covered by this policy were required to be up-to-date (policy defines as a person received all recommended COVID 19 vaccines, including any booster dose (s) when eligible). It also read that submission of exemptions will be reviewed and a written response of the outcome will be sent to the employee. However, it failed to provide the procedure on how newly hired staff 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 review of employee training files and interview with facility staff, it was determined that the facility failed to ensure that Nurse Aides received 12 hours of training annually that addressed their areas of weakness as determined by nurse aide performance reviews. This was evident for 1 of 1 Geriatric Nursing Aide (GNA#51) reviewed for annual training. The findings include: On 5/3/23 at 11:45 AM, a review of Geriatric Nursing Assistant (GNA) #51's employee file was conducted. The review failed to reveal an annual review for GNA #51. The file also included print outs from online training that GNA #51 had received in the previous year through an online training suite called Relias. The training amounted to a total of 12.45 hours between 2/1/22 and 2/28/23. None of the training indicated that it was related to GNA #51's performance in February, 2022. On 5/3/23 at 3:07 PM, the Director of Human Resources provided the survey team with an annual review for GNA #51, dated 2/28/23. The review was general and lacked any specific job-related skills pertinent to GNA #51's position.…

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.