Northampton Manor Nursing And Rehabilitation Cente

Based on medical record review and interview it was determined that the facility failed to ensure residents were free from significant medication errors. This was found to be evident for one (Resident #4) out of six residents reviewed for unnecessary medications.The findings include: 1)On 1/23/26 review of Resident #4 medical record revealed a diagnosis of diabetes and orders for both long acting and fast acting insulin. The order for the fast-acting insulin, with a start date of 10/31/25, revealed a Humalog KwikPen Insulin (insulin lispro) with a strength of 100 units per ml and the amount to be given was per carb intake. The order also included the following Special Instructions: method for calculating insulin coverage. Blood glucose -100=X Round X to the nearest 10th. Give 1 unit of insulin for each 10mg/dL. Resident will continue to calculate with each dose. (example BS is 294. 294-100= 194. Resident to get 19 units of insulin). This insulin was to be administered before meals and at bedtime.According to these special instructions, any blood glucose level above 110 would require…

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, record review, and interview, it was determined that the facility failed to ensure that medications were secured and stored at the required temperature and that the narcotics were stored in permanently affixed compartments. This deficiency was evident for 1 out of 3 narcotic boxes observed, 1 out of 3 medication refrigerators observed, and 1 medication cart observed during a random observation.1.On 1/27/26 at 2:27 PM, an observation was made of the medication room on the [NAME] Creek unit with Staff #4. Review of the medication refrigerator revealed a narcotic box with a lock on the front side. Further observation showed that the box was not affixed to the refrigerator.On 1/27/26 at 2:29 PM, during a brief interview, Staff #4 reported that the narcotic box could be removed from the refrigerator.On 1/27/26 at 3:54 PM, the Director of Nursing (DON), was interviewed and stated that the expectation was for all narcotic boxes in the medication refrigerators have to be locked and be permanently…

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 ensure concerns identified through the Quality Assurance and Performance Improvement (QAPI) process were addressed through the development of a Performance Improvement Project (PIP). This was evident for 1 of 1 QAPI plans reviewed during the QAA/QAPI task.The findings include:In long-term care, the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) programs are systems designed to monitor care, identify concerns, and implement corrective actions to protect resident health and safety. QAA focuses on identifying and correcting areas of noncompliance, while QAPI uses ongoing data analysis and proactive improvement efforts to prevent problems and improve outcomes. Performance Improvement Projects (PIPs) are structured, team-based initiatives within QAPI used to investigate identified concerns, determine root causes, and implement measurable system improvements.On 1/27/26 at 1:23 PM, the surveyor interviewed the Director of Nursing (DON) and asked her 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 observation and interview it was determined that the facility failed to ensure staff appropriately wore source control (face masks) during a period of increased influenza in the community. This was found to be evident during 6 random observations made on day one of the survey.The findings include: On 1/22/26 at 8:25 AM the survey team entered the facility. Night nurse supervisor #37 reported that due to the high flu rate in the county face masks were currently required. On 12/31/25, the Maryland Department of Health (MDH) issued recommendations in response to increased rates of respiratory virus-associated hospitalizations. MDH advised that healthcare facilities implement facility-wide source control measures in patient care areas and other patient-facing settings. These measures include requiring all individuals-including clinical staff, non-clinical staff, and visitors-to wear masks in patient-facing areas.On 1/22/26 at 10:17 AM the surveyor observed Geriatric Nursing Assistant (GNA #39) coming out 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 record review and interviews, it was determined that the facility failed to ensure employees completed required annual training. This was evident for 4 (Staff #10, #11, #16, and #29) of 5 staff reviewed for the sufficient and competent staffing task.The findings include:On 1/27/26, the surveyor requested that the Nursing Home Administrator (NHA) provide education records for Staff #10, #11, #16, #29, and #30, as well as annual performance evaluations for three Geriatric Nursing Assistants (GNAs #25, #26, and #27).On 1/28/26 at approximately 10:00 AM, the surveyor reviewed the annual performance evaluations for GNAs #25, #26, and #27. The evaluations revealed that both GNA #25 and GNA #26 received a score of 1, defined as Performance Below Standard. Comments included Relias 0% and Needs to do Relias (Relias is the program used by the facility to provide staff education).Further review of training records for Staff #10, #11, #16, #29, and #30 revealed the following:-Compliance and Ethics Training (F946) was not completed by Staff #10, #11, or #16-Dementia Training (F949) 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 records review and interviews, it was determined that the facility failed to implement their abuse policies and procedures by 1) failing to report all allegations of abuse to the state agency and the facility's abuse coordinator and 2) failing to conduct a thorough investigation of all allegations of abuse. This was evident for 1 of 1 policies and procedures reviewed for abuse, neglect, exploitation, or mistreatment and has the potential to affect all residents of the facility. The findings include: A review of the facility's abuse, neglect, exploitation or mistreatment policies and procedures was conducted on 8/26/24 at 2:19 PM. The policies and procedure indicated in the bottom of the document that it had a complete revision on 11/1/2017. In the section under Policy, item number 2. indicated that if the events that cause the allegation involve abuse, the facility shall report immediately, but no later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including state survey agency) in accordance with the state law. Item…

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 records review and interviews, it was determined that the facility failed to 1) have an effective system in place to ensure that all allegations of abuse are reported to the state agency, 2) to ensure that reports are sent within the mandated timeframe, and 3) to report the results of the investigation no later than 5 working days after the incident. This was evident in 6 (Resident #19, #9, #6, #25, #67, and #92) of 21 residents reviewed for abuse. The findings include: 1) On 8/26/24 at 2:50 PM, a review of facility reported incident MD00200510 revealed that, on the morning of 12/12/23, Resident #25 reported to a staff member that a GNA (geriatric nursing assistant) had made a movement like s/he was going to hit the resident. On the self-report form, the facility documented the date of the incident was 12/11 to 12/12/23 and reported by the resident on 12/12/23. The facility's initial self-report indicated the allegation of abuse was reported to the state agency on 12/12/23 at 12:40 PM and the final report was reported to the state agency on 12/19/23 at 1:50 PM. During an…

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

Based on record review and staff interview, it was determined that facility staff failed to conduct a thorough investigation of abuse and maintain evidence of the investigation. This was evident for 7 (#424 #19, #9, #41, #92 #322, #67 ) of 21 residents reviewed for abuse and for 3 facility reported incidents reviewed for abuse (FRIs) (#MD00194834, and #MD00207292, and #MD00191798), of 34 FRIs investigated during the recertification survey. The findings include: 1). On 8/27/24 at 12:03 PM a review of the Office of Health Care Quality (OHCQ) report #MD00194834 revealed an allegation that staff mistreated Resident #322 on 7/27/23 when they ripped the remote control from the resident's hand. On 8/27/24 at 12:10 PM, the facility's investigation file was obtained and reviewed. Although the file contained a suspension notice for a Geriatric Nursing Assistant (GNA #38), the file lacked 1) any staff witness statements, 2) evidence that Resident #322 had a physical assessment done after the incident, and 3) assignment sheets of staff on duty at the time of the incident. 4) demographic and…

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

Based on record review and interview, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) had annual performance evaluations. This was evident for 3 GNAs (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed during the Sufficient and Competent staffing task portion of the recertification survey. This had the potential to impact all residents. The findings include: On 8/20/24 at 10:00 AM, the annual performance evaluations were requested for GNA #11, GNA #13, and GNA #14 for 2019 through 2023. On 8/20/24 at 1:00 PM, the requested files were received and reviewed and revealed that each file lacked evidence of a performance evaluation in 2022, and GNA #13's file also lacked evidence of performance evaluations in 2020, 2021, and 2023. On 8/23/24 at 9:27 AM, an interview with the Director of Nursing (DON) and the Director of Human Resources (Staff #24) was conducted. They both confirmed the lack of evidence that GNA #11, GNA #13, and GNA #14 had performance evaluations in 2022, and that there was no evidence that GNA #13 had performance…

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 post actual hours of nursing staffing. This was evident for 31 of 31 days in July 2024 and 21 of 21 days in August 2024 during the Sufficient Staffing task investigation during the recertification survey. The findings include: On 8/22/24 at 3:54 PM, staff posting documents for July and August 2024 (to date) were requested. On 8/23/24 at 8:33 AM, a record review of staff posting documents for July 1-31, 2024, and August 1-22, 2024, revealed that there were blank spaces on each form where the actual hours for each nursing discipline was to have been recorded. On 8/23/24 at 11:55 AM in an interview with the DON regarding the staff posting documents for July and August, she confirmed that none of the staff posting documents listed actual hours worked and she confirmed that this was a deficiency.

Based on record review and interview, it was determined that the facility failed to ensure adequate administrative oversight of 1) nursing staffing, 2) reporting of allegations of abuse, 3) Geriatric Nursing Assistant (GNA) and Licensed Practical Nurse (LPN) training, and 4) clinical services. This was evident for 1) non-compliance with 2 (S670, S680) of 2 state staffing regulations, 2) 6 residents (#6, #9, #19, #25, #67, #92) of 6 residents who alleged abuse, and 3) 6 staff (GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12) of 6 staff reviewed for required in-service training, and 4) 2 complaints (#MD00208809 and #MD00208775) of 7 complaints and for 5 (#MD00206318, #MD00202094, #MD00182597, #MD00205031, MD#00205130) of 34 facility reported incidents (FRIs), reviewed during the recertification survey. These findings had the potential to affect all residents. The findings include: On 8/27/24 at 2:52 PM, the survey team identified substandard quality of care which triggered an extended survey investigation. On 8/27/24 at 3:19 PM, an interview with the Nursing Home Administrator…

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's nursing staff failed to follow basic infection control procedures and standard precautions during medication administration as evidenced by 1) failing to perform routine cleaning and disinfection of resident care equipment shared among residents, and 2) failing to follow standard precautions when performing routine testing of blood glucose. This was evident for 3 (#16, #19, #23) of 5 nurses observed for medication administration. The findings include: 1) On 8/26/24 at 8:58 AM, during an observation of medication administration, the surveyor observed Staff #16, Licensed Practical Nurse (LPN) remove a blood pressure (BP) monitor with an attached BP cuff from the medication cart. Staff #16 was then observed using the BP monitor to check Resident #92's blood pressure. Staff #16 then returned the BP monitor to the medication cart. No observation was made of Resident #16 sanitizing the BP cuff prior to use or following its use on Resident #92. On 8/26/24 at approximately 9:10 AM, during an observation of medication…

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 Geriatric Nursing Assistants (GNAs) and Licensed Practical Nurses (LPNs) were offered to receive and be educated about COVID-19 immunization. This was evident for 6 staff (GNA #11, GNA #13, GNA #14, LPN # 9, LPN #10, and LPN #12) of 6 staff reviewed for immunizations during a portion of the infection control investigation during the recertification survey. The findings include: On 8/20/24 at 10:00 AM, the immunization records for GNA #11, GNA #13, GNA #14, LPN # 9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, a review of the immunization records for GNA #11, GNA #13, GNA #14, LPN # 9, LPN #10, and LPN #12 revealed that none of the staff had any evidence that they had received a COVID-19 vaccine or education regarding COVID-19. On 8/22/24 at 4:25 PM, an interview was conducted with the Director of Human Resources (Staff #24) who confirmed that there was no evidence that COVID vaccines were offered or that education on COVID-19 was provided for GNA #11, GNA #13, GNA #14, LPN…

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

Based on record review and interview, it was determined that the facility failed to provide communication training to staff. This was evident for 3 Geriatric Nursing Assistants (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed, and 3 Licensed Practical Nurses (LPN #9, LPN #10, and LPN #12) of 3 LPNs reviewed during the extended survey investigation of the recertification survey and had the potential to affect all residents. The findings include: On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, the requested employee training records were received and reviewed for the competent staffing investigation portion of the survey. On 8/27/24 at 2:52 PM, it was determined that there was a situation of substandard quality of care and the extended survey task was triggered. On 8/27/24 at 3:37 PM, a review of the employee training records revealed that GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, nor LPN #12 had evidence of the federally required communication training. On 8/27/24 at 3:53 PM, an interview…

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 staff were trained about resident rights. This was evident for 2 Geriatric Nursing Assistants (GNA #11, GNA #13) of 3 GNAs reviewed, and 3 Licensed Practical Nurses (LPN #9, LPN #10, and LPN #12) of 3 LPNs reviewed during the extended survey investigation of the recertification survey and had the potential to affect all residents. The findings include: On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested as part of the Sufficient and Competent Staffing portion of the standard survey. On 8/27/24 at 2:52 PM, it was determined that substandard quality of care existed and the extended survey task was triggered. On 8/27/24 at 3:37 PM, a review of the employee training records revealed that GNA #11, GNA #13, LPN #9, LPN #10, nor LPN #12 had evidence of resident rights training in 2022, 2023, or 2024. On 8/27/24 at 3:53 PM, an interview with the Human Resources Director (Staff #24) was conducted and she was asked for any evidence 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 record review and interview, it was determined that the facility failed to ensure that staff members complete abuse and neglect training. This was evident for 4 Geriatric Nursing Assistants (GNA #11, GNA #13, GNA #14, and GNA #34) of 4 GNAs reviewed, and 3 Licensed Practical Nurses (LPN #9, LPN #10, and LPN #12) of 3 LPNs reviewed during the annual and extended survey investigation. The findings include: 1) On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, a review of the employee training records revealed that staff lacked annual abuse and neglect training. GNA #11 and GNA #13 lacked abuse and neglect training in 2022. LPN #10 and LPN #12 lacked abuse and neglect training in 2021 and 2022. GNA #14 lacked abuse and neglect training in 2022, and 2024. And LPN #9 lacked abuse and neglect training in 2020, 2021, 2022, 2023, and 2024. On 8/27/24 at 3:53 PM, an interview with the Human Resources Director (Staff #24) was conducted and she was asked for any additional evidence of abuse and…

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

Based on record review and interview, it was determined that the facility failed to provide Quality Assurance Performance Improvement (QAPI) training to staff. This was evident for 3 Geriatric Nursing Assistants (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed, and 3 Licensed Practical Nurses (LPN #9, LPN #10, and LPN #12) of 3 LPNs reviewed during the extended survey investigation of the recertification survey and had the potential to affect all residents. The findings include: On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, the requested employee training records were received and reviewed for the competent staffing investigation portion of the survey. On 8/27/24 at 2:52 PM, it was determined that there was a situation of substandard quality of care and the extended survey task was triggered. On 8/27/24 at 3:37 PM, a review of the previously provided employee training records revealed that neither GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, nor LPN #12 had evidence of the federally…

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

Based on record review and interview, it was determined that the facility failed to provide behavioral health training to staff. This was evident for 3 Geriatric Nursing Assistants (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed, and 3 Licensed Practical Nurses (LPN #9, LPN #10, and LPN #12) of 3 LPNs reviewed during the extended survey investigation of the recertification survey and had the potential to affect all residents. The findings include: On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, the requested employee training records were received and reviewed for the competent staffing investigation portion of the survey. On 8/27/24 at 2:52 PM, it was determined that there was a situation of substandard quality of care and the extended survey task was triggered. On 8/27/24 at 3:37 PM, a review of the employee training records revealed that neither GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, nor LPN #12 had evidence of behavioral health training. On 8/27/24 at 3:53 PM, an interview with…

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

Based on record review and staff interviews, it was determined that the facility failed to notify the primary care provider when there was a resident change of condition or a potential need to alter treatment. This was evident for 1 (Resident #28) of 6 residents reviewed for unnecessary medication. The findings include: Review of Resident #28's medical record on 8/29/24 revealed that the resident had a diagnosis of hypothyroidism and has had an order for levothyroxine once a day since 7/10/24. On 8/29/24 at 11:15 AM, review of Resident #28's medication administration revealed that the resident refused levothyroxine on 15 days between 7/12/24 and 8/3/24. Levothyroxine is a thyroid medication that is used to treat an underactive thyroid gland. The thyroid gland makes thyroid hormones which help to control energy levels and growth. When the medication is not taken, the thyroid level can be out of normal range. On 08/29/24 at 11:57 AM, review of Resident #28's medical record failed to reveal that the primary care provider was notified of the repeated medication refusal. On 8/29/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#95) of 3 residents reviewed for pressure ulcers, 1 (#112) of 4 residents reviewed for accidents and and 3 (#1, #33, #6) of 3 residents reviewed for Resident Assessment. 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. MDS assessments must be accurate to ensure that each Resident receives the care they need. The last day of this observation period is the Assessment Reference Date (ARD). This is the end date of the observation period and provides a common reference point for all team members participating in the assessment. In completing sections of the MDS that require observations of a resident over specified periods such as 7, 14, or 30…

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

Based on observation, medical record review and staff interview, it was determined the facility failed conduct care plan meetings and review and revise resident care plans after each assessment. This was evident for 1 (#25) of 3 residents reviewed for communication/sensory, 1 (#95) of 2 residents reviewed for respiratory and 1 (Resident #6) of 2 residents reviewed for care planning. The findings include: 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 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 residents care. 1) On 8/15/24 at 5:15 PM, Resident #95 was observed to be receiving oxygen via a nasal cannula (device that delivers extra oxygen through a tube and into your nose), which was connected to an oxygen concentrator. At that time, Resident #95 was also observed 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 interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 4 errors identified out of 25 opportunities for error, resulting in a 16% medication administration error rate. The findings include: 1) On 8/26/24 at 9:10 AM, during an observation of medication administration, the surveyor observed that Staff #16, Licensed Practical Nurse (LPN) dispensed 9 medications into a medication cup, including Acetaminophen 500 mg (milligram), 1 tablet for Resident #41. At that time, Staff #16 reported to the surveyor that Resident #41 had an order for a multi-vitamin which included minerals and iron, that was not available in the medication cart. Staff #16 indicated that s/he would notify the person responsible for ordering the stock medications of the need to obtain the multi-vitamin form that was ordered for the resident. 1a) Following the medication observation, a review of Resident #41's August 2024 MAR (medication administration record) revealed a physician's order…

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 the conditions of the facility were safe, clean, and without unaddressed concerns. This was found to be evident for 1 ([NAME] Creek 2 unit) out of 4 units observed throughout the survey. The findings include: 1) On 08/15/24 at 10:27 AM, an initial observation on the [NAME] creek 2 unit revealed an area about 10 inch wide where wallpaper was torn, and some pieces of drywall were noted to be crumbled right above the floor, behind the entry door of room [ROOM NUMBER]. On 08/15/24 at 12:26 PM, further observation on the [NAME] Creek 2 unit revealed about 5 inches of wallpaper peeled off about one third of the way to the ceiling outside of the dining room doorway, about a 6 foot tea-like stain on the floor in front of the water fountain, a section of the bottom corner of the nurses station which looked to be damaged, and a rolling chair at the nurses station where several pieces of the outside material had been stripped. 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 records review and interviews, it was determined that the facility failed to protect residents from abuse. This was evident in 4 (Resident #9, #28, #104, and #424) of 21 residents reviewed for abuse. The findings include: 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. 1) On 8/22/24 at 8:53 AM, a review of the facility's investigation file for the facility reported incident #MD00182597 revealed a self-report form that documented a staff member had witnessed Resident #424 being abused on 4/20/22 at 2:30 PM by another staff member. Review of Physical Therapist (PT) #52's handwritten statement, dated 4/20/22, revealed that she had answered Resident #424's call light and the resident asked to go to bed. PT #52 reported that she asked the resident's assigned geriatric nursing assistant (GNA) #53 to assist her with the transfer. She stated that the resident…

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

Based on observation, medical record review and resident and staff interview, it was determined the facility failed to implement interventions based on a resident's comprehensive care plan. This was evident for 1 (#25) of 3 residents reviewed for communication/sensory and 1 (#108) of 4 residents reviewed for accidents. 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 8/16/24 at 11:16 AM, during an interview, Resident #25 appeared hard of hearing and had difficulty hearing the surveyor. When asked if the resident attended activity programs, Resident #25 stated s/he did not attend activity programs because s/he could not hear. Resident #25 also reported that the resident could not hear at all in one of his/her ears, and s/he was hard of hearing in the other ear. Resident #25 also reported s/he had hearing aids that had not been worn since forever. On 8/21/24 at 11:25 AM, a review of Resident #25's medical record revealed a communication care plan,…

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

Based on record review, observation and interview, it was determined that the facility failed to ensure activities were provided to residents based on their preferences and as indicated in their care plan. This was found to be evident for 2 (Resident #113 and #28) out of 5 residents reviewed for activities. The findings include: 1) Review of Resident #113's medical record revealed a Minimum Data Set (MDS) assessment, with an assessment date of 6/7/24, that revealed the resident was interviewed in regard to Activity Preferences and that the resident had indicated it was very important to listen to music that s/he likes and to be around animals such as pets. Review of the care plan for activities, created on 6/6/24, revealed several approaches including: Provide activity calendar and review some of the programs and available materials and equipment available for use; Staff will meet with resident to see if enjoyment is gained from activities or self-directed routine; Staff will assist resident in participating in favorite activities such as watching tv; Staff will encourage resident…

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

Based on record review and interview, it was determined that the facility failed to 1) have a process in place to monitor resident's air pressure mattress settings and ensure that they were appropriate for the resident's current weight which resulted in a harm to Resident #3 and 2) ensure that a resident's change in condition was evaluated by a primary care provider. This was evident for 1 (#3) of 8 residents reviewed for falls and 1 (#110) of 2 residents reviewed for skin conditions. The findings include: Low air loss mattresses are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown. Air continually flows through tiny laser-made air holes in the top of the mattress surface so that the user floats on a soft cushion of air. (https://homecarehospitalbeds.com). A control box is placed on the footboard that controls the air flow into the mattress. 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) A medical record review 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 observation, medical record review and resident and staff interview, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. This was evident for 1 (#25) of 3 residents reviewed for communication/sensory. The findings include: On 8/16/24 at 11:16 AM, during an interview, Resident #25 appeared hard of hearing and had difficulty hearing the surveyor. When asked if the resident attended activity programs, Resident #25 stated s/he did not attend activity programs and indicated it was because s/he could not hear. Resident #25 also reported that s/he could not hear at all in one of his/her ears, and hard of hearing in the other ear. When asked if the resident had hearing aids, Resident #25 responded that s/he had hearing aids, but reported that the hearing aids had not been worn since forever. On 8/21/24 at 11:25 AM, a review of Resident #25's medical record was conducted. Review of Resident #25's July 2024 Medication Administration Record (MAR) revealed a 1/24/23 physician order to place hearing…

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

Based on record review, observation, and interview, it was determined that the facility failed to ensure that a process was in place to ensure that recommendations made by therapy were communicated to and implemented by nursing. This was evident for 1 (Resident #37), out of 1 resident reviewed for position and mobility and 1 (Resident #28) of 3 residents reviewed for activities of daily living. The findings include: 1) On 08/23/24, Resident #37's medical records were reviewed. The review revealed that Resident #37 was a long-term resident of the facility with a history of stroke, right-sided weakness, and decreased right-sided function. On 8/23/24 at 1:27 PM, Resident #37's Occupational Therapy (OT) documents were reviewed. The review revealed an OT evaluation and treatment certification, dated 6/20/24-8/18/2024. Further review revealed a section titled Recommendations: The recommendations included the following: Splint/Orthotic recommendations. It is recommended that the patient wear a hand roll and finger separators on the right hand for up to 6 hours a day, in order to improve…

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 evaluate and implement measures to address the resident's nutritional needs as evidenced by 1) failing to ensure that resident weights were obtained timely and as recommended by the dietician following a significant weight loss and 2) failing to ensure the physician was notified timely following a resident's significant weight loss. This was evident for 1 (#15) of 4 residents reviewed for nutrition. The findings include: On 8/16/24 at 12:16 PM, a review of Resident #15's electronic medical record (EMR) revealed documentation that, on 7/11/24 at 12:25 PM, the resident's weight was 296.4 pounds (lbs), and, on 8/7/24 at 1:51 PM, Resident #15 weight was 246.3 lbs which was a 50 lb (16.89 %) weight loss in 1 month, and indicated Resident #15 had a significant weight loss. Further review of the resident's medical record revealed that, on 8/12/24 at 3:10 PM, in a dietary progress note, the dietician wrote that Resident #15's weights were reviewed, that the resident's documented weight of 246.3 lbs…

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 pertinent document review and interviews, it was determined that the facility failed to provide physician services to a resident at least once every 120 days. Based on record review and interview, it was determined that the facility failed to ensure that residents received timely physician visits. This was evident for 1 resident (Resident #92) of 2 residents reviewed for pain management and 1 (Resident #37), out of 6 Residents reviewed for Unnecessary Medications during the recertification survey. The findings include: 1) On 8/23/24 at 10:44 AM, record review revealed that Resident #37 was a long-term resident of the facility. The review of physician notes in Resident #37's record revealed that the resident was seen by a physician twice between 8/01/23 and 8/26/24. On 08/26/24 at 11:36 AM, the Assistant Director of Nursing (ADON) was interviewed regarding the expectations of how often a Physician visits a resident in the facility. The ADON reported that the expectation was that all residents are seen at least every 120 days by a physician. A nurse practitioner usually see…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed (PRN), had an end date that was limited to 14 days. This was evident for 1 (#95) of 1 residents reviewed for hospice. The findings include: On 8/20/24 at 3:30 PM, a review of Resident #95's medical record revealed the resident was readmitted to the facility in April 2024 following an acute hospitalization. Resident #95 was admitted to hospice in mid-June 2024 with a terminal diagnose of Chronic Obstructive Pulmonary Disease (COPD), and a diagnosis of heart failure. Review of Resident #95's August 2024 Medication Administration Record (MAR) revealed a 6/17/24 order for Lorazepam (Ativan) concentrate by mouth every 4 hours PRN (as needed) for generalized anxiety disorder. The psychotropic medication prescribed to be administered as needed was not limited to 14 days duration, and there was no documented rationale for continuing the order beyond 14 days found in the resident's medical record. The concern with the Lorazepam as…

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

Based on observation, it was determined the facility failed to properly store medication as evidenced by failing to discard expired medications, failing to date medications when opened, and failing to return resident medication to a proper location after adminstration. This was evident for 2 of 5 medication carts, 1 of 1 treatment carts observed during the survey, and 1 complaint (#MD00207855) of 5 complaints reviewed during the recertification survey. The findings include: 1) On 8/23/24 at approximately 2:15 PM, an observation was made of a Potomac 1 medication cart that revealed expired medication: 1a) There was 1 opened bottle of Lantaprost Opthalmic Solution (eye drops) labeled with Resident #108's name and marked an opened date of 6/6/24. Per the Mayo Clinic, an opened bottle of Lantaprost may be kept in the refrigerator or at room temperature for up to 6 weeks. Based on the date the Lantaprost was opened, the medication was expired. The facility failed to discard the discard eye drops 6 weeks after opening. 1b) There was a Bevespi inhaler that was labeled with Resident #15's…

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

Based on observations, records review and interviews, it was determined that the facility failed to ensure that potentially hazardous food items were cooled according to acceptable standards. This was found to be evident in 2 out of 2 kitchen observations. The findings include: On 8/15/24 at 9:54 AM, an inspection of the kitchens walk-in refrigerator was conducted with the dietary manager (Staff #3). During this inspection, 2 cooked food items were observed with no label. Staff #3 reported that they were chicken fried steak from last night's dinner and sausage patties from this morning's breakfast. Staff #3 indicated that she would label them to fix the concern. Shortly after at 9:57 AM, Staff #3 was asked if the 2 cooked food items were cooled down per regulation. Staff #3 reported that they should have been and indicated that the documentation should be in a binder close to the entrance of the kitchen. After reviewing the binder that contained the cool down log for potentially hazardous foods, Staff #3 stated, it's not done. Then proceeded to instruct a kitchen staff to pull the…

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

Based on medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records as evidenced by an accurate indication for a medication and clinical assessment documentation. This was evident for 1 (#15) of 6 residents reviewed for unnecessary medication and 1 resident (Resident #51) of 1 resident reviewed for dialysis care and services. The findings include: On 8/19/24 at 1:07 PM, a review of Resident #15's medical record revealed that the resident was initially admitted to the facility in June 2019 for long term care, then, readmitted to the facility in April 2024 following an acute hospitalization. The medical record also documented that Resident #15 had multiple diagnoses including extrapyramidal (involuntary muscle movements caused by some psychiatric drugs) and movement disorders, unspecified edema (swelling from build up of fluid in the body), major depressive disorder, and retention of urine (condition of being unable to completely empty the bladder). A review of Resident #15's August 2024 Medication Administration…

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

Based on observation and interviews, it was determined that the facility failed to maintain essential equipment in a safe operating condition. This was evident for 1 kitchen observed during the survey. The findings include: On 8/15/24 at 9:47 AM, a tour of the kitchen was conducted with the dietary manager (Staff #3). During the tour, the walk-in freezer was inspected and was observed with icicle formation from the overhead fans extending about 3 feet long. Ice had also formed on the floor below the icicle at about 6 inches high and 5 inches in diameter. Staff #3 confirmed the observation and was taking notes and indicated that she would let maintenance know so that it could be taken care of. On 8/29/24 at 11 AM, the observation was discussed with the Director of Nursing, Assistant Director of Nursing, and the Corporate Clinical Nurse (Staff #2) that the amount of ice buildup in the walk-in freezer did not accumulate overnight and that staff failed to maintain the freezer in a safe operating condition. All staff verbalized understanding and acknowledged the concern.

Based on observation, record review and interview, it was determined that the facility failed to accurately assess staff training needs relative to the needs of the resident population of the facility. This was evident for the Facility Assessment reviewed during the extended survey portion of the recertification survey and had the potential to affect residents who receive dialysis care. The findings include: A copy of the Facility Assessment was requested on 8/15/24 during the survey entrance conference. On 8/16/24 at 9:32 AM, an observation and interview with Resident #51 was conducted as the resident wheeled down the hallway. The resident stated they were on their way to a dialysis center. On 8/28/24 at 9:20 AM, a review of the Care Program and Services section of the Facility Assessment indicated that the facility does not care for residents receiving dialysis. A review of the staff education needs portion of the Facility Assessment revealed that dialysis was not listed. On 8/28/24 at 11:36 AM, an interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON),…

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

Based on record review and interview, it was determined that the facility failed to provide infection control training to staff. This was evident for 1 Licensed Practical Nurse (LPN #9) of 3 LPNs reviewed during the extended survey investigation of the recertification survey. The findings include: On 8/20/24 at 10:00 AM, training records for GNA #11, GNA #13, GNA #14, LPN #9, LPN #10, and LPN #12 were requested. On 8/20/24 at 1:18 PM, the requested employee training records were received and reviewed for the competent staffing investigation portion of the survey. On 8/27/24 at 2:52 PM, it was determined that there was a situation of substandard quality of care and the extended survey task was triggered. On 8/27/24 at 3:37 PM, a review of the employee training records revealed that LPN #9 lacked any evidence of infection control training. On 8/27/24 at 3:53 PM, an interview with the Human Resources Director (Staff #24) was conducted and she was asked for any evidence of the infection control training for LPN #9. On 8/29/24 at 11:14 AM, an interview with the Director of Nursing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with staff, it was determined the facility failed to properly label beverages for resident consumption in 3 of 4 nourishment rooms and failed to properly clean and air dry dishes in the main kitchen. The findings include: On 10/3/19, the surveyor observed the nourishment rooms located on each of the 4 facility nursing units. On 10/3/19 at 11:07 AM, the refrigerator in the nourishment room on [NAME] Creek 1 was observed. 1 - 46 oz. (ounce) carton of Thickened Cranberry juice cocktail approximately ¼ full was labeled with 9/29. It did not have a second date. Several cartons of unopened med pass and juice were also labeled 9/29. On 10/3/19 at 11:12 AM, LPN (Licensed Practical Nurse) #12 confirmed the date reflected when the juice was received in the kitchen, not when it was opened. A carton of thickened water was on top of the medication cart, opened labeled 10/1/19. LPN #12 indicated that she wrote the date on it when she opened it. She added that sometimes when 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 staff interview and review of facility documentation, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from previous surveys. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assessment and Assurance (QAA) Program with the QAA Coordinator, Staff #8 on 10/4/19 at 1:50 PM revealed that effective processes were not put in place regarding repeat deficiencies. The facility's action plans did not resolve quality deficiencies identified during the last recertification survey which concluded on 6/7/18 with a plan of correction date of 7/19/18. The repeat deficiencies reviewed included areas of 1) maintenance and housekeeping services, 2) accurate MDS assessments, 3) PASSAR Screening, 4) development and implementation of comprehensive care plans, 5) care plan timing and revision, 6) medication storage, 7) food storage, 8) accurate and complete medical records, 9) essential equipment, safe operating…

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

Based on record review, observation, and staff interview, it was determined that facility staff failed to update care plans when there were changes in resident needs or preferences, failed to ensure that a care plan meeting was held after each assessment and failed to thoroughly evaluate/review and revise resident plans of care after each assessment. This was evident for 2 (#118, #108) of 5 residents reviewed for dementia care, 1 (#41) of 5 residents reviewed for pressure ulcers, and 2 (#17, #270) of residents reviewed for accidents. The finding include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) Observations conducted by surveyors of Resident #118 on 9/22/19 at 10:57 AM, 9/23/19 at 2:10 PM, 10/1/19 at 9:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and interview with the resident and facility staff, it was determined the facility staff failed to ensure that resident's environment was free from accident hazards as is possible by 1) failing to ensure an outside exit door was securely latched for 1 of 2 ground floor nursing units, and 2) failing to maintain safe storage of resident smoking materials for 1 (#17) of 10 residents reviewed for accidents. The findings include: 1) On 9/22/19 at approximately 7:10 AM, the survey team attempted to enter the facility via the front door but found it locked. The surveyors walked around the right side of the building to the patio outside of the [NAME] Creek 1 dining/day room. A doorbell was observed on the wall beside the door, however, the door was unlatched and ajar. The survey team was able to open the door and enter the building without ringing the doorbell for assistance. No residents were observed in the dining/day room at that time. Staff were in the nurses station…

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, resident interview, medical record review, and staff interview, it was determined that the facility staff failed to obtain a physicians' order for a resident to have 4 side rails up while in bed. This was evident for 1 (#78) of 1 residents reviewed for side rails. The findings include: Observations of Resident #78 on 9/22/19 at 3:01 PM, 9/23/19 at 2:30 PM and 3:45 PM, revealed the resident lying in bed with 4 side rails up. Another observation, on 10/3/19 at 1:09 PM, revealed the resident lying in bed with 4 side rails up. During an interview with Resident #78 on 10/3/19 at 1:09 PM, with a family member present, it was revealed that he/she had been in the bed since 12/2018 and the side rails had been attached when he/she switched to the bed. His/her family member stated they had not signed a consent form for the side rails until recently when he/she moved this room. Resident reported that prior to using this bed, he/she was able to sit on the side of the bed. A record review for Resident #78 on 10/3/19 at 12:51 PM, revealed on the 9/2019, physicians' order…

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

Based on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 3 (#37, #28, and #226) of 6 residents observed with 26 medication administration opportunities which resulted in an error rate of 34.62% by 2 (1 Licensed Practical Nurse and 1 (Registered Nurse) of 2 nurses observed. The findings include: 1) The Surveyor approached Licensed Practical Nurse (LPN) #15 on 9/26/19 at 7:30 AM, and was informed that surveyors would be observing her medication administration and informed her to continue her medication administration routine. She stated she had obtained vital signs (temperature, pulse, respirations, and blood pressure) on Resident #37 and was going to give him/her medications at this time. LPN #15 administered the following medications: Diltiazem 120 mg, 1 tablet, Lisinopril 5 mg 1 tablet, Ocuvite with Lutein 1 tablet, Gas Ban 1 tablet, Vitamin D3 2 tablets. She took them to Resident #37. A record review for Resident #37 on 9/26/19 at 10:15 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 medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records by failing to ensure that 1) a resident's use of bedside floor mats was accurately documented, 2) a resident's certification of incapacity was accurately completed by 2 physicians, and, 3) elopement risk assessments were accurate and complete. This was evident for 2 (#24, #40) of 5 residents reviewed for care plans and 5 (#70, #139, #2, #50 and #6) of 32 residents reviewed during the initial resident pool process. The findings include: An in room interview with Resident #24 was conducted at their request on 09/24/19 at 1:42 PM. Resident #24 stated that he/she had several falls and one time got a head injury that required 12 staples. The surveyor noted that, although there was a floor mat alongside the resident's roommate's bed, there were none at their bedside. When asked about the mats, the resident responded that they did not recall ever having fall mats. Review of Resident #24's medical record, conducted on 09/27/19 at 9:17 AM, revealed a plan of…

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

Based on review of facility records and interview with staff, it was determined that the facility failed to provide appeal rights information by failing to issue the Notice of Medicare Non-coverage (NOMNC); and failed to ensure that the resident, or their representative, of his/her potential liability for payment and related standard claim appeal rights by failing to issue the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). This was found to be evident for 2 of the 3 residents (Resident #410 and Resident #115) reviewed for Beneficiary Protection Notification review. The findings include: On 10/3/19, review of documentation provided by the facility revealed that Resident #115 and Resident #410 were both discharged from Medicare covered Part A stay with benefit days remaining and remained in the facility. 1) The NOMNC provides notice to the resident of his/her right to an expedited review of a service termination. Review of Resident #410's documentation revealed that a SNFABN had been given to the resident on 7/3/19 due to his/her therapy services ending 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 surveyor observation and interview with staff, it was determined the facility failed to provide maintenance services necessary to maintain a sanitary, orderly and comfortable interior. This was evident in the main kitchen and in 5 of 16 resident rooms on 2 of 4 nursing units observed during the initial survey pool observations. The findings include: 1) During the initial tour of the kitchen, on 9/22/19 at 8:45 AM, the surveyor observed large pieces of paint peeling from the walls to the left and right of the doorway to the hall in the area of the walk in refrigerator and dishwashing area of the kitchen. This was discussed with the Food Service Manager on 10/4/19 at 9:38 AM. He indicated that he didn't know why the paint was peeling, but the maintenance director was aware of it. 2) The following observations were made during initial observations of residents on 9/22/19, 9/23/19 and 9/24/19 and during environmental rounds with the Maintenance Director on 10/4/19 at 11:50 AM. In room [ROOM NUMBER], on the…

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

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#270) of 10 residents reviewed for accidents. 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. On 9/27/19 at 9:06 AM, review of Resident #270's medical record revealed documentation that Resident #270 was sent to the hospital following a fall which resulted in a right hip fracture and returned to the facility following his/her hospital stay. On 8/13/19 at 4:36 PM, in a progress note, the nurse wrote that Resident #270 returned from the hospital, following a fall with a right…

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 that the facility failed to screen two residents (#24) and (#135) to determine if the residents had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 2 of 2 residents found to have remained in the facility for greater than 30 days without a Preadmission Screening. Findings include: The intent for this regulatory requirement is to ensure each resident in the nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to meet their needs. Resident #24 was admitted to the facility 4/4/19. Resident #135 was admitted to the facility on [DATE]. Review of residents #24 and #135 medical record on 9/23/2019 revealed that the Preadmission Screening and Resident Review (PASRR) Level I ID Screen for MI, ID, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation and interview with facility staff, it was determined the facility staff failed to follow a resident's plan of care for smoking and failed to develop and implement resident centered care plans. This was evident for 3 ( #17, #24, #270) of 10 residents reviewed for accidents and 1 (#118) 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 9/24/19 at 11:05 AM, the surveyor accompanied Resident #17 to the [NAME] Creek 1 patio during his/her smoke break. Staff #9 (an Activity Assistant) assisted the resident. The surveyor observed Resident #17 placing a cigarette lighter into his/her bag after lighting a cigarette. Staff #9 indicated that the resident's all keep their smoking materials in their possession with the exception of 1 resident whose cigarettes are locked in the activity…

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 staff interview, it was determined that the facility failed to provide Activities of Daily Living (ADLs) for a resident who was dependent on staff to dress him. This was evident for 1 (#118) of 5 residents reviewed for ADLs. The findings include: ADLs are activities that people perform every day such as, getting dressed, taking showers or baths, cooking, and eating. Observations made of Resident #118 on 9/22/19 at 10:57 AM, 9/23/19 at 2:10 PM, 10/1/19 at 9:00 AM, and 10/2/19 at 9:01 AM and 10:07 AM, revealed the resident lying in bed and in a gown. A record review for Resident #118, on 9/27/19 at 10:48 AM, revealed a physician's statement, dated 6/11/18, that this resident had dementia, multiple sclerosis. A review of the current care plan revealed a focus (Resident #118) has an ADL Self Care Performance Deficit r/t (related to) Limited RoM (range of motion) , limited mobility, and impaired balance with a goal that the resident will maintain current level of function - he/she is dependent for bed mobility, transfers, eating, dressing, toilet…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that care was provided in accordance with professional standards as evidenced by failure to follow a physician's order for a resident with a history of falls, failure to administer a dietary supplement as ordered by the physician and failure to obtain a dietitian consult as ordered by the physician. This was found to be evident for 1 (#24) of 5 residents reviewed for care plans, 1 (#161) of 3 residents sampled for closed record review and 1 (#50) of 6 residents reviewed for nutrition. The findings include: #1) An in room interview with Resident #24 was conducted at their request on 09/24/19 at 1:42 PM. Resident #24 stated that he/she had several falls and one time got a head injury that required 12 staples. The surveyor noted that although there was a floor mat alongside the resident's roommate's bed, there were none at their bedside. When asked about the mats, the resident responded that they did not recall ever having fall mats. Review of Resident #24's medical record conducted on…

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

Based on observation, record review, and staff interview, it was determined that the facility staff failed to develop and implement a resident-centered dementia care plan for a resident. This was evident for 1 (#118) of 5 residents reviewed for dementia. 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. A record review for Resident #118 on 9/27/19 at 10:48 AM, revealed a physician's certified statement dated 6/2/14, which documented the resident had the following diagnoses; dementia, multiple sclerosis, and Parkinson's Disease. Review of the care plan revealed this resident had a dementia care plan with a goal that he/she will have improved quality of life by daily attempting to interact with others. Care plan had the following interventions: 1) instruct family/friends and staff in ways to support him/her 2) provide opportunities for resident to express feelings 3) provide opportunities for family and friend to encourage interactions with other residents. 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 surveyor observation, it was determined the facility staff failed to store resident care supplies in a sanitary manner. This was evident for 1 (#70) of 32 residents observed during the initial pool selection process and 4 of 5 medication carts observed during the survey. The findings include: 1) Resident #70 and his/her room were observed on 9/24/19 at 12:26 PM. In the bathroom were 1 closed and one opened package of disposable briefs on the floor between the left side of the toilet and the wall. A urine/feces specimen collection pan was lying across the top of the waste basket, it was not labeled as to whom it belonged, properly stored to prevent cross contamination, or properly disposed of. These resident care items were stored in an unsanitary manner placing the resident at risk of exposure to potentially harmful organisms. On 9/24/19 at 12:34 PM, Unit Manager #27 confirmed these findings. 2) During an observation of Potomac 2 Medication Cart #1 on 09/26/19 at 9:48 AM with Registered Nurse (RN) #16…

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.