Frostburg Rehab Center

Based on record review and interview, it was determined that the facility failed to protect residents from abuse. This was evident for 2 (#358494 and #358463) out of 16 facility reported incidents reviewed during the recertification survey.The findings include:1.) Resident #91 was admitted to the facility in 2022, was cognitively intact, and their own spokesperson/decision maker. On 6/08/25 Resident #91 and Resident #76 were involved in a verbal and physical altercation. A review of the facility reported incident (FRI #358494) revealed that the facility reported on 6/25/25 that Resident #91 complained that on 6/08/25 Staff #27 threatened to kick him/her out of the facility. The report further stated that the facility investigated the incident and determined that Staff #27 verbally and emotionally abused Resident #91. The report also included statements that due to the confirmation of abuse, the facility terminated Staff #27’s employment and reported Staff #27 to the state board of nursing. On 8/12/25 at 8:21 AM the Nursing Home Administrator was interviewed regarding the incident.…

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 reviews and interviews, it was determined that the facility failed to ensure appropriate information was communicated to the receiving healthcare institution. This was evident for 2 (Resident #110, #25) of resident reviewed for hospitalization.The findings include:1) Resident #110 was admitted into the facility in mid-2025. The medical record indicated that the resident was hospitalized on [DATE]. A review of the transfer form dated 6/29/25 was conducted on 8/5/25 at 10:28 AM. The review revealed section H, item 2 that read, (Skilled Nursing Facility) SNF to (Emergency Department) ED TRANSFER CHECKLIST: Print the following documents and include with this transfer form in the order listed. Send entire packet with the patient to the hospital. The documents listed had a boxed space before each number to mark with a check to indicate that it was printed. Numbers 1, 2, and 4 were checked. The following documents were listed as:1. MOLST2. Facesheet3. X-Rays4. Medication list5. Lab Results6. SBAR7.…

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 Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #25) of 1 resident reviewed for hospice care and 1 (Resident #5) of 12 residents reviewed for accidents.The findings include:The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) Resident #25 had been a resident of the facility since 2018. A review of the facility matrix indicated that the resident was under hospice care. On 8/1/25 at 12:05 PM, a subsequent review of Resident #25’s medical record revealed an MDS assessment for a significant change with an assessment reference date (ARD) of 3/17/25 coded the resident as receiving hospice care. The next MDS assessment was a quarterly assessment with an ARD of 6/17/25 that coded the resident as not receiving hospice care.…

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

Based on record reviews and interviews, it was determined that the facility failed to develop and complete a baseline care plan within 48 hours of a resident's admission. This was evident for 1 (Resident #96) of 12 residents reviewed for accidents.The findings include:Resident #96 was a newly admitted resident of the facility. Admitting diagnosis includes generalized muscle weakness and difficulty in walking.On 8/1/25 at 11:51 AM, a review of Resident #96's medical record revealed a fall risk assessment conducted on 7/22/25 by Licensed Practical Nurse (LPN #50), where the resident had a fall risk score of 9 (score of 10 and above indicated as high risk of falls).A subsequent review of Resident #96's medical record was conducted on 8/8/25 at 11:40 AM. The review revealed the following:a) Discharge summary from the hospital prior to the admission to the nursing facility indicated that the resident had generalized weakness with ambulatory dysfunction.b) Baseline care plan with sections A to M was initiated on 7/22/25. However, the only sections that had documentation were section J for…

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

Based on medical record review, interview and observations it was determined that the facility failed to ensure care was provided in accordance with professional standards of practice. This was evident for 3 (Resident # 114, #4, and #5) out of the 78 residents included in the sample. The findings include: 1) Review of Resident #114's medical record revealed the resident was admitted to the facility in 2023 with diagnosis that included, but not limited to, dementia and high blood pressure. Further review of the medical record revealed a Change in Condition note, with an effective date of 3/22/25 at 7:36 AM that was complete by a Licensed Practical Nurse (Nurse #39). This note revealed that the resident sustained a fall on 3/22/25 at 12:25 AM. The nurse documented that the resident was observed on the floor next to the bed sitting on his/her bottom and the resident had no explanation; the physician was notified at 3:00 AM. No documentation was found to indicate the nurse had completed a set of vital signs (heart rate, pulse, respirations, temperature) at the time of the 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 observations, record review and staff interviews, it was determined that the facility failed to administer oxygen as ordered by the physician. This was evident for 1 resident (Resident #5) reviewed as a complaint, #358479, during this survey.The findings include: Oxygen therapy is the administration of oxygen at concentrations greater than that in room air with the intent of treating or preventing hypoxia- low oxygen level in the blood.On 8/6/25 at 11:00 AM this surveyor observed Resident #5 lying in bed with oxygen (O2) via nasal canula (NC) at 4 liters (L). In an interview, Licensed Practical Nurse (LPN #10) confirmed O2 NC at 4L. On 8/7/25 5:49 AM a record review of Resident #5's Treatment Administration Record (TAR) revealed: Respiratory: Oxygen - Continuous at 5L NC every shift for Respiratory Failure. On 8/7/25 at 5:53 AM A record review of physician orders revealed 5Liters (L) oxygen (O2) continuous via nasal cannula (NC) every shift for Respiratory Failure.On 8/7/25 at 7:11 AM this surveyor observed Resident #5 asleep with 4L O2 NC. On 8/7/25 at 7:45 AM in an…

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

Based on observation, staff interviews, and record review, it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. This was evident for 2 of 4 narcotic books reviewed during the medication administration task during this survey. The findings include:Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of controlled medications by identifying loss or potential diversion of controlled medications. Controlled Medications are substances that have an accepted medical use, have potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications fall under US Drug Enforcement Agency (DEA) Schedules II-V.Standard practice for narcotic reconciliation is conducted at the end-of-shift. Two licensed personnel, the on-coming licensed personnel and the out-going licensed personnel, count all controlled medications verifying the count accuracy and documenting their initials in the narcotic book. On 7/31/25 at 8:51 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 record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure a) pharmacy recommendations were addressed by the attending physician in a timely manner, b) the attending physician documents his rationale for no action taken to a pharmacy recommendation, and c)the facility's medication regimen review (MRR) policy did not specify the timeframe for the steps in the MRR process. This was evident for 2 (Resident #9, #14) of 5 residents reviewed for unnecessary medications.The findings include:1) Resident #9 had been a resident of the facility since early 2017 with diagnoses that include muscle weakness and difficulty in walking.On 8/4/25 at 10:58 AM, a review of Resident #9's medical record was conducted. The review revealed a MRR was conducted for the resident dated 6/18/25 and indicated that irregularities were identified with instructions to see report. However, the resident's medical record did not contain the report.The Nurse Unit Manger (Staff #2) was interviewed on 8/4/25 at 12:40 PM. during the interview, Staff #2…

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

Based on 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 #114) of 15 residents reviewed for potential abuse.The findings include: Review of Resident #114's medical record revealed the resident was admitted to the facility in 2023 with diagnosis that included, but not limited to, dementia and high blood pressure. The resident had an order for Metoprolol extended release 25 mg give one tablet one time a day related to hypertension (high blood pressure) and to Hold if the pulse (heart rate) was less than 60 or if the SBP(systolic blood pressure - the top number of a blood pressure reading) was less than 130. This order was in effect from 9/26/24 until it was discontinued on 3/28/25.Review of the March 2025 Medication Administration Record (MAR) revealed the metoprolol was administered on the following dates when the blood pressure and or heart rate were within the parameters to hold the medication:3/1 SBP was 1263/6 SBP was 121; HR: 553/10 SBP…

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, the facility failed to maintain medications in a locked storage container until it was administered to residents. This was evident for 1 of 1 resident during a random observation.Findings include:On 8/11/25 at 9:10 AM, an observation in Resident #4's room revealed four white pills in a clear plastic cup on the bedside table. A breakfast tray with food was also on the table in front of the resident.On 8/11/25 at 9:11 AM, during a brief interview, Resident #4 stated the nurse gave her/him the pills and s/he took them after breakfast.On 8/11/25 at 9:16 AM, the surveyor and Director of Nursing (DON) observed the same pills in the clear plastic cup on the bedside table. The DON confirmed their presence.On 8/11/25 at 9:17 AM, the DON asked Resident #4 where s/he got the pills, and the resident confirmed they were given to her/him by the nurse.During a brief interview on 8/11/25 at 9:17 AM, the DON stated that medications should not be left at the bedside unless the care plan authorizes self-administration.On 8/11/25 at 9:26 AM, a review of the…

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

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 medical record documentation was complete. This was evident for 1 resident (Resident #1) of 2 residents reviewed for advance directives during the recertification survey.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.A review of Resident #1's medical record revealed that the resident was admitted to the facility in 2022. Further review revealed that on [DATE] the resident was deemed by a physician to be capable of making their own decisions.On [DATE] at 12:15 PM a review of Resident #1's paper chart was performed. The chart contained a MOLST form dated [DATE] that indicated No…

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 have an infection preventionist attend 2 consecutive quarters of the Quality Assessment and Assurance (QAA) meetings. This deficient practice had the potential to affect all residents of the facility.The findings include:On 8/12/25 at 12:45 PM, the attendance sheets for the last 12 months of QAA meetings were requested from the Nursing Home Administrator (NHA). It was reported at the beginning of the survey that the facility's infection preventionist (IP Staff #52) nurse was new and was hired in March of 2025A review of the attendance sheets revealed 6 out of the 12 months reviewed for QAA meetings were not attended by the IP nurse.On 8/12/25 at 2:53 PM, the NHA was interviewed, and she confirmed that the facility did not have an IP nurse for a couple of months prior to the hiring of Staff #52. The concern was discussed with the NHA that an IP nurse was required to attend, at a minimum, the quarterly QA meetings. The NHA verbalized understanding and acknowledge the concern.

Based on record review, observation, and interview, it was determined that the facility failed to provide proper infection control strategies for its residents. This was evident for one (Resident #22) of one resident reviewed for pressure ulcer during the recertification survey.The findings include:A pressure ulcer, also known as a 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 the their severity from Stage I - Stage IV, or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed).On 8/01/25 at 11:55 AM a record review revealed that Resident #22 had an order dated 6/25/25 for a dressing change for their left heel pressure ulcer.On 8/01/25 at 2:56 PM another record review of Resident #22's skin and wound notes from the medical record revealed a document from a wound specialist dated 7/30/25 that stated, in part, that the resident had a Left heel pressure ulcer/unstageable with necrosis…

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, interviews and record review, it was determined that the facility failed to ensure call systems devices were within reach to residents. This was evident for 1 (Resident #25) of 32 residents reviewed during the initial pool.The findings include: On 7/31/25 at 10:38 AM, during the initial tour of the facility, the surveyor observed Resident #25 in the resident's room, in bed and watching TV. The resident's call device was noted to be laying on the floor and not within the resident's reach.A second observation was made on the same day at 1:59 PM, and the call device of Resident #25 was still laying on the floor. The Geriatric Nursing Assistant (GNA #53) working in the unit was called by the surveyor to the resident's room. GNA #53 confirmed that the call device was not within the resident's reach, she picked it up from the floor and secured it with a clip to the resident's gown.A review of Resident #25's care plan on 8/5/25 at 8:37 AM was conducted. The review revealed interventions that include to be sure call device was within reach and encourage the resident…

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

Based on resident interview and review of the medical records it was determined the facility staff failed to implement comprehensive, resident centered care plans including measurable objectives. This was evident for 1 (#27) of 11 residents reviewed for Accidents and 1 (#35) of 4 residents reviewed for dementia care. 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) During an interview on 9/13/22 at 1:56 PM Resident #27 indicated that he/she had 2 recent falls neither of which resulted in injury. Review of the resident's medical record on 9/21/11 at 4:03 PM revealed that a plan of care was developed on 12/14/20 and revised on 4/8/22 with the focus: (Resident #27) is at risk for injury r/t (related to) High risk for falls, h/o (history of) falls, Gait/balance problems, incontinence, Poor safety awareness, episodic confusion, behaviors, delusional disorder, dementia, Vision problems - wears glasses, anticoagulant use, Psychoactive drug use. 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 medical record review and staff interview, it was determined that the facility staff failed to ensure physician progress notes were written, signed, and dated at each visit. This was evident for 4 (#41, #70, #31, and #52) of 38 residents reviewed during the survey. The findings include: 1.) A review of Resident #41's medical record on 9/14/22 at 12:37 PM revealed the Physician #22's progress note for a visit conducted on 6/28/22, had not been signed until 7/18/22, 20 days after the visit. Further review revealed a progress note for a visit that Attending Physician #22 conducted on 8/30/22 that was not signed until 9/16/22.2.) On 9/16/22 at 9:16 AM, a review of Resident #70's EMR (electronic medical record) revealed physician progress notes that were not written on the day the resident was seen. There was a) a readmission History & Physical physician's progress note, with a date of service of 8/2/22 was electronically signed by the physician on 8/17/22 at 8:07 AM, b) a progress note with a date of service of 8/9/22 was electronically signed by the physician on 8/22/22 at…

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

Based on review of facility and medical records and interview with staff it was determined that the facility staff failed to maintain medical records that were complete, accurately documented and readily accessible to all staff. This was evident for 4 (#57, #27, #70 and #35) of 38 residents reviewed during the survey. The findings include: 1) Resident #57's medical record was reviewed on 9/13/22. The record revealed a baseline Plan of Care was developed 7/30/22. The surveyor was unable to find documentation of the Care Plan meeting attendees in the medical record. An interview was conducted with Staff #15 a Social Worker on 9/20/22 at 1:55 PM. She indicated that a Care Conference progress note in the Electronic Medical Record reflected the resident and/or family's attendance at the meeting. She indicated that staff attendance was documented on a sign in sheet which was not kept in the resident's record but in a binder in the Social Service office. She added that the sign in sheets were maintained in the Social Service office until the resident was discharged , and that they 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 interview with residents and staff and review of resident records it was determined that the facility failed to promote and facilitate resident self-determination by failing to provide residents timely notification in order to adequately prepare for scheduled appointments. This was evident for 2 (#62 and #27) of 2 residents reviewed for Choices. The findings include: In an interview on 9/13/22 at 11:47 AM, Resident #62 indicated to the surveyor that the facility did not provide him/her with advanced notification regarding his/her appointments. The resident indicated that he/she likes to be prepared and get themselves cleaned up, dressed and ready prior going out. He/she indicated that he/she was not able to do this before his/her appointments, felt rushed and not put together. He/she indicated that this was happening with other residents as well. Resident #62's medical record was reviewed on 9/21/22 at 11:36 AM. The record revealed that Resident #62's diagnoses included but were not limited to need for assistance for personal care, history of falling, heart disease, anxiety…

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

Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 3 (#64, #76, #92) of 4 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is incapacitated. 1) On 9/13/22 at 3:30 PM, review of Resident #64's medical record failed to reveal evidence that the resident had an advanced directive, and there was no documentation found as to whether the resident/representative was informed of his/her right to formulate an advanced directive or wished to formulate an advanced directive. 2) On 9/13/22 at 3:36 PM, review of Resident #76's medical record failed to reveal evidence that the resident had an advanced directive, and there was no documentation found as to whether the resident/representative 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 record review and staff interview it was determined that the facility failed to develop and implement abuse policies and procedures as evidenced by the failure to report injuries of unknown origin to the state agency within the required time frames. This was evident for two residents (#12 and #34) reviewed during the annual survey. The findings include: A review of the facility's investigation documentation for self-report MD00182695 on 9/20/22 at 9:55 AM for Resident #12 was conducted. Review of the Situation, Background, Assessment, and Recommendation (SBAR) form completed on 8/22/22 at 1:56 PM revealed the facility was aware that Resident #12 had a broken leg at that time. Review the self-report form completed by the facility revealed no date and time was entered for the incident date and time section, however the email confirmation form revealed the facility had not reported the injury of unknown origin to the state agency until 8/23/22 at 8:46 AM. On 9/16/22 at 12:04 PM a review of the facility's investigation documents for the self-report MD00179345 regarding Resident…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, and their responsible party, received written notification of a transfer to the hospital, and failed to ensure all the required information was included when the written notification was provided. This was found to be evident for 4 (Resident #31, #104, #51 and #76) of 4 residents reviewed for hospitalization. The findings include: On 9/20/22 review of Resident #31's medical record revealed the resident has resided at the facility for several years. No documentation was found to indicate the resident was deemed not capable to make health care decisions. However, review of the 9/8/22 nurse practitioner (NP) note revealed the resident was disoriented, with altered mental status. Review of a nursing note, dated 9/8/22 at 6:00 PM, revealed the resident was very confused and did not know where he/she was, the NP was notified and there was an order to send the resident to the emergency department. Further review of the medical record 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 orient, prepare, and document a resident's preparation for a transfer to the hospital. This was evident for 1 (#76) of 4 residents reviewed for hospitalization. The findings include: On 9/21/22 at 10:00 AM, a review of Resident #76's medical record revealed the resident had been transferred to an acute care facility on multiple occasions and failed to reveal evidence Resident #76 was oriented and prepared for the transfers in a manner that the resident could understand and there was no documentation of the resident's understanding of the transfer in the medical record. a) The medical record documented Resident #76 was transferred to the ED (emergency department) on 7/22/22 and returned to the facility on 8/4/22. No documentation was found in the medical record to indicate Resident #76 was prepared for the hospital transfer, received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. b) Resident #76's medical record…

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 ensure residents were made aware of a facility's bed-hold and reserve bed payment policy when transferred to a hospital. This was evident for 1 (#76) of 4 residents reviewed for hospitalization. The findings include: On 9/21/22 at 10:00 AM, a review of Resident #76's medical record revealed documentation that the resident was transferred to an acute care facility on 7/22/22. There was no documentation found in the medical record that the resident and/or the resident's representative was given written notice of the facility's bed hold policy at the time of the resident's transfer, or in cases of emergency transfer, within 24 hours. On 9/21/22 at 10:31 AM, during an interview, the Corporate Clinical Specialist stated that when a resident is transferred to the hospital, a transfer notice form, along with the bed hold policy was given to the resident, and if the resident is not capable, the transfer form, along with the bed hold policy would be sent to the resident's representative. Continued…

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

Based on record review and staff interview it was determined that the facility failed to conduct an initial comprehensive assessment that included an assessment of a resident's preferences for customary routines and activities. This was evident for 1 (#70) of 4 residents reviewed for dementia. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 9/16/22 at 9:16 AM, a review of Resident #70's medical record revealed the resident was readmitted to the facility in the beginning of August 2022 following a stay at a facility for behavior health management, and had diagnosis not limited to dementia, depression, and insomnia. Review of Resident #70's 5-day MDS with an ARD…

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 (#70) of 4 residents reviewed for dementia. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 9/16/22 at 9:16 AM, a review of Resident #70's medical record revealed the resident was readmitted to the facility in the beginning of August 2022 following a stay at a facility for behavior health management, and had diagnosis not limited to dementia, depression, and insomnia. Review of Resident #70's September 2022 MAR (medication administration record) revealed an 8/1/22 order for…

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

Based on medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 (#35) of 6 residents reviewed for unnecessary medications. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A 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 9/19/22 at 12:18 PM, a review of the resident's medical record revealed Resident #35 was admitted to the facility in April 2022 following an acute hospitalization with multiple diagnosis 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 interview it was determined the facility failed to have an effective system in place to ensure restorative nursing interventions were implemented and incorporated into the resident's care plan. This was evident for 2 (#21 & #52) of 2 residents reviewed for activities of daily living. The findings include: 1) On 9/13/22 at 2:15 PM the review of the medical record revealed: the resident was diagnosed with renal failure, diabetes, and bilateral lower extremity amputations and received dialysis services three days per week. The resident had an original admission date of 11/11/2019 and a readmission date of 7/09/2022. The most recent hospital stay was, 5/30/22 and 6/11/2022. On 9/13/22 at 1:55 PM the Resident was observed sitting in the bed with the head elevated. Resident #21 stated that the inability to attend group activities is directly related to the inability to get out of bed. Resident #21 also stated that his/her inability to sit up straight, independently negatively impacts the staff willingness to get the resident out of bed to the chair 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.

Based on medical record review and staff interview it was determined that the facility staff failed to provide an activity program to meet the needs and preferences of each resident. This was evident for 3 (#70, #61, and #21) of 4 residents reviewed for Activities. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1.) On 9/13/22 at 11:50 AM, Resident #70 was observed lying in bed, appeared to be sleeping and the TV was on. Further, intermittent observations of Resident #70 were made on 9/14/222, 9/15/22 and 9/16/22 found Resident #70 in his/her room, lying in bed. Continued surveyor observations failed to reveal evidence that Resident #28 received 1:1 (one to one) activity staff visits, attended activity programs or that the resident was offered the opportunity to observe or participate in an activity program. On 9/16/22 at 9:16 AM, a review of Resident #70's medical record revealed the resident was readmitted to the facility in the beginning of August 2022…

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

Based on medical record review and interview with staff it was determined the facility failed to ensure staff obtained daily weights as ordered. This was evident for 2 (Resident #31 and #352) of 38 residents reviewed during the survey. The findings include: Review of Resident #31's medical record revealed a diagnosis of congestive heart failure (CHF). On 9/12/22 there was a physician order for Daily Weights at 6 am for CHF monitoring; Notify provider of weight change greater than 2 lbs in 24 hours or 5 lbs in 5 days. On 9/21/22 at 10:47 AM review of the medical record revealed the following weights: 9/12 at 6:39 AM: 179.2 9/13 at 5:04 AM: 177.4 9/14 at 5:39 AM: 177.7 9/15 at 5:32 AM: 176.4 9/16 at 5:16 AM: 174.8 9/17 at 5:39 AM: 173 9/18 at 7:33 AM: 167 9/18 at 8:03 AM: 169.6 Further review of the medical record failed to reveal documentation to indicate the physician was made aware of the more than 2 lbs weight change between 9/17 and 9/18; or the more than 5 lbs weight change between 9/13 and 9/18 as indicated in the physician order. Further review of the medical record on…

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

Based on medical record review and interview it was determined the facility failed to have an effective system in place to ensure wound specialist recommendations were reviewed and implemented. This was evident for 1 (#52) of 3 residents reviewed for pressure ulcers. The findings include: On 9/15/22 review of Resident #52's medical record revealed the resident was originally admitted to the facility in June 2022 with diagnosis of, but not limited to, chronic pain, osteoarthritis, and diabetes. In July 2022 the resident developed an unstageable pressure injury to the left heel. A care plan was established to address this pressure area on 7/6/22. The interventions included, but not limited to: treatments as ordered - monitor for effect and follow up with MD as needed; and [name of wound specialist practice] eval and treat as needed. Further review of the medical record revealed progress notes from the wound specialist that indicated the resident was seen weekly starting 7/10/22. On 9/21/22 further review of the medical record revealed a current order, with a start date of 8/1/22, 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 medical record review and interviews it was determined the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of narcotic pain medication and failed to ensure the physician implemented orders for non-narcotic pain medications as indicated in progress notes and confirmed through interview. This was evident for 1 (#52) of 2 residents reviewed for pain. The findings include: On 9/15/22 review of Resident #52's medical record revealed diagnosis of, but not limited to, chronic pain and osteoarthritis. The resident was originally admitted in June of 2022 with a re-admission in July after a brief hospitalization. There was a current physician order, in effect since 7/31/22, for oxycodone 10 mg give 1 tablet every 6 hours as needed for pain. Further review of this order failed to reveal parameters for when staff could administer the oxycodone other than for pain. Oxycodone is a narcotic pain medication. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and 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 observation, record review, and interview it was determined that facility staff failed to ensure that before side rails were used for a resident; the resident was assessed for appropriateness and safety and the resident and/or resident representative were fully informed of the risk for entrapment with use of side rails. This was evident for 1 (#12) of 2 resident reviewed for side rails. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely…

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

Based on medical record review and interviews it was determined the facility failed to ensure the primary care physician effectively supervised resident care when the physician 1) failed to ensure acetaminophen order was put in place as indicated in the physician's note; 2) failed to ensure recommendations for treatment changes for a pressure ulcer were addressed, ordered and implemented; and 3) failed to review or acknowledge that the resident was not receiving therapy as evidenced by documenting that the resident was continuing to receive therapy that the resident was not actually receiving. This was evident for 1 (#52) of 2 residents reviewed for pain and 1 (#52) of 3 residents reviewed for pressure ulcers. The findings include: On 9/15/22 review of Resident #52's medical record revealed the resident was originally admitted to the facility in June 2022 with diagnosis of, but not limited to, chronic pain, osteoarthritis, and diabetes. The resident was discharged to the hospital in July and was re-admitted a few days later. 1) Further review of Resident #52's medical record…

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 with achievable care plan goals for residents with dementia This was evident for 2 (#70, #35) of 2 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. 1) On 9/16/22 at 9:16 AM, a review of Resident #70's medical record revealed the resident was readmitted to the facility in the beginning of August 2022 following a stay at a facility for behavior health management, and had diagnosis not limited to dementia with behavioral disturbance, depression, a history of a CVA (cerebral vascular accident) (stroke), dysphagia (swallowing difficulty), and had a g-tube (gastrostomy tube) (feeding tube). Review of Resident #70's most recent assessment with an assessment reference date of 8/7/22 revealed Resident #70 had a BIMS (Brief Interview of Mental Status) of 1. A BIMS…

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

Based on review of medical records, Narcotic Count sheets and interviews it was determined that the facility failed to: 1) ensure staff completed the controlled drug count at the change of shift as evidenced by documentation by nursing staff that the count had been completed prior to the end of the shift, as well as failure of each nurse to sign that the count was completed at the change of shift and 2) failed to ensure narcotics removed from a resident's supply were documented as administered to the resident. This was evident for 2 out of 3 Narcotic Count sheets reviewed and 1 (#52) of 2 residents reviewed for pain management during the survey. The findings include: 1) On 9/12/22 at 9:00 PM surveyor reviewed the Narcotic Count sheets for 3 medication carts. Narcotic Count sheets revealed columns for the Date, Time of Count, Count Correct Y/N [yes or no], Signature 1/Signature 2. There were additional columns for nursing staff to document the specific number of boxes, bottles, cards and sheets as well as spaces to indicate if the count for each specific item was correct. The final…

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 for medication regimen reviews, as evidenced by, the failure to ensure that irregularities noted were reviewed by the Medical Director and the Attending Physician, the failure to ensure that the Attending physician documented the irregularity and action taken or not taken in the resident's medical record, and failure to establish time frames for each step in the process. This was evident for 2 (#41 & #27) of 6 residents reviewed for unnecessary medications and has the potential to effect all residents in the facility. The findings include: 1) Resident #41's medical record was reviewed on 9/14/22 at 12:37 PM. During the review, it was found that a pharmacy review had been conducted with a recommendation to perform a gradual dose reduction (GDR) on 2 psychoactive medications that Resident #41 had been prescribed. Certified Nurse Practitioner (CRNP) had signed the document that she disagreed with the recommendation. Further review of the medical record…

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: On 9/27/22 at 8:30 AM a review of the facility's annual survey that concluded on 10/25/18 and complaint surveys in the past 4 years revealed that the facility had repeat deficiencies noted during this annual survey that had been cited in the past. The deficient practice was related to 1) resident care not supervised by the attending physician, 2) care plans were not resident - centered, 3) care plan goals were not quantitative, 4) failure to provide appeal information for resident being discharged or transferred, 5) activities for residents had not been based on their needs and preferences, and 6) incomplete and inaccurate medical records. Review of the Quality Assessment and Assurance (QAA) Program with the Corporate Clinical Nurse, 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 reviews and staff interviews it was determined that the facility failed to have a fully trained infection preventionist on duty. This is evidenced by the current staff member in the position had not completed the training requirements as stipulated by federal and state regulations. The findings include: During the entrance conference on 9/12/22 at 6:51 PM, the surveyor was introduced to the ADON in the conference room. The employee stated that she was the infection control preventionist, however she is not certified yet. Furthermore, she has been in the position of ADON, staff educator, and infection preventionist for three months. The employee was asked by the surveyor when she planned to complete her training. The infection control preventionist responded within the next month. The surveyor requested that the staff member provide documentation related to the infection control training that she had received thus far. The ADON agreed to comply with the surveyor request. During an interview on 9/23/22 at approximately, 10:30 AM the corporate clinical specialist stated…

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 observation and interview it was determined that the facility failed to ensure regular inspections of all bed side rails. This was evident for 1 (Resident #20) of 11 residents reviewed for accidents but has the potential to affect any resident using bed side rails. The findings include: On 9/13/22 at 2:09 PM surveyor observed Resident #20 in bed with two quarter side rails in the raised position. The rails were noted to be at a more than 90 degree angle to the bed. The resident confirmed that he/she uses the rails to assist with turning. On 9/13/22 at 2:20 PM the unit nurse manager #13 reported they will refer to maintenance if there was an issue with the side rail fit. Surveyor then informed the unit nurse manager of the observation of the side rails not at a 90 degree angle. On 9/16/22 at approximately 1:50 PM surveyor observed the side rails were at a 90 degree angle. The resident confirmed they do come in and adjust the rails occasionally and indicated they came in the day of the previous interview (9/13/22). On 9/20/22 at 12:24 PM interview with the maintenance director…

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