Mountain City Rehab Center

Based on medical record review and interview it was determined that the facility failed to ensure staff completed physical assessment of resident after they returned from dialysis treatment. This was found to be evident for one (Resident #5) out of one resident reviewed for dialysis.The findings include:The intent of this requirement is that the facility assures that each resident receives care and services for the provision of dialysis consistent with professional standards of practice including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.Review of Resident #5's medical record revealed the resident was admitted to the facility more than 6 months ago, has a diagnosis of end stage renal disease (ESRD) and receives dialysis at a facility offsite three times a week. The resident has an order, in effect since July 2025, for dialysis Monday, Wednesday and Fridays at 11:40 AM. ESRD occurs when the kidneys are no longer functioning well enough to meet the body's needs.…

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

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure medications were labeled and discarded when expired. This was evident in 2 of 3 medication carts observed during medication storage and labeling inspection. The findings include:A total of 3 medication carts were inspected on 3/3/26 from 10:39 AM to 11:36 AM. 2 of the 3 medication carts had concerns identified and they were: The medication cart labeled as 100 hall 100-111 assigned to staff nurse (Nurse #5) was inspected on 3/3/26 at 10:39 AM. The inspection revealed a) an bottle of Geri-Kot (laxative) that was opened on 11/8/25 with an expiration date of 1/2026, b) Spiriva-Respimat (inhaler) for Resident #9 had no indication or label from when it was opened with instructions to discard 3 months after inserting the cartridge, and c) Breo-Ellipta (inhaler) for Resident #71 had no indication or label from when it was opened with instructions to discard 6 weeks after opening. On 3/3/26 at 10:57 AM, Nurse #5 indicated that she would discard and replace the expired laxative.Nurse #5…

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

Based on interviews and record reviews, it was determined that the facility failed to offer and administer covid-19 immunization to residents. This was evident for 2 (Resident #11 and #59) of 5 residents reviewed for immunizations. The findings include:The Facility's Infection Preventionist (IP) nurse (Staff #12) was interviewed regarding immunizations on 3/6/26 at 10:27 AM. During the interview, Staff #12 explained her process and documentation. She indicated that resident immunization records are kept in the electronic health record and hard copies for consents and declination forms are kept in a binder in her office. Staff #12 then reported that she would provide the binder to the surveyor for review. While waiting for Staff #12, a review of resident electronic health records for immunizations was conducted on 3/6/26 at 10:38 AM. The review revealed the following concerns:Resident #11 had no documentation to indicate Covid-19 immunization was administered or declined in 2025.Resident #59 had no documentation to indicate Covid-19 immunization was administered or declined in 2025.…

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 facility policy review, record review, facility document review, and interview, the facility failed to report allegations of abuse, including injury of unknown origin, to the state survey agency within the required timeframe, which affected 6 (Residents #14, #15, #4, #7, #19, and #10) of 12 residents reviewed for abuse or resident-to-resident altercations.Findings included: A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, Reporting included, I. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, which included, A. The State licensing/certification agency responsible for surveying/licensing the facility. The policy continued, II. An alleged violation is considered by, but not limited to neglect, exploitation, mistreatment, physical abuse, sexual abuse, mental abuse, injuries of an unknown…

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 facility policy review, record review, facility document review, and interview, the facility failed to conduct a thorough investigation or maintain evidence of a thorough investigation. The facility also failed to protect residents from potential further abuse by allowing an alleged abuser to remain in the building. The deficiencies affected 6 (Residents #14, #15, #16, #4, #7, and #19) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.Findings included: A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, Reporting included, I. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, which included, A. The State licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, Abuse Investigating and Reporting,…

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 facility document review and interview, the facility failed to ensure their Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies identified related to falls. This deficient practice affected 3 (Residents #7, 12, and #18) of 9 sampled residents reviewed for accidents during the complaint survey.Findings included:The facility's QAPI meeting documentation from June 2025 to September 2025 indicated that falls were reviewed each of the months. The documents revealed that in May, the facility documented that there were 25 falls with 22 residents and that two of the residents accounted for five of the falls. A review of the facility's documents revealed no evidence of corrective actions being developed to address the concern nor evidence of a good faith effort to address the concerns.During an interview on 10/15/2025 at 3:54 PM, Registered Nurse (RN) #26 stated that she had never been to a QAPI meeting and had never been asked to contribute to a performance improvement project (PIP). She stated that there were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, and interview, the facility failed to ensure staff communicated all pertinent information to a physician, which affected 1 (Resident #4) of 4 residents reviewed for abuse. Findings included:A facility policy titled, Change in a Resident's Condition or Status, dated 02/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [exempli gratia; for example], changes in level of care, billing/payments, resident rights, etc. [et cetera; and so forth]. The policy revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an), which included, a. accident or incident involving the resident, d. significant change in the resident's physical/emotional/mental condition, and g. need to transfer the resident to a hospital center. The policy also indicated, 3. Prior to notifying 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 facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (Resident #4) of 4 residents sampled for abuse during the complaint survey. Findings included:A facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised 11/06/2024, revealed, An owner, licensee, administrator, licensed nurse, employee, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment neglect, or misappropriation shall immediately report to the Nursing Home Administrator.An admission Record revealed the facility admitted Resident #4 on 12/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and aphasia (an inability to understand or produce speech) following cerebral infarction (a stroke),…

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, record review, and facility policy review, the facility failed to implement their policies regarding investigating, documenting, and reporting an incident of resident-to-resident abuse, for one (Resident #14) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.Findings included:A facility policy titled, Resident-to-Resident Altercations, revised 09/2022, indicated Policy Statement - All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. The policy also indicated, 4. If two residents are involved in an altercation, staff: a. separate the residents, and institute measures to calm the situation; b. identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; and c. notify each resident's representative and attending physician of the incident. The policy continued, i. complete a Risk…

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, record review, facility policy review, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #4) of 19 residents reviewed for accuracy of MDS assessments during the complaint survey.Findings included:A facility policy titled, Certifying Accuracy of Resident Assessment, revised 11/2019, revealed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.The CMS Long-Term Care Facility RAI 3.0 User's Manual, Version 1.19.1, dated October 2024 indicated:- Section J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA [Omnibus Budget Reconciliation Act] or Scheduled PPS [Prospective Payment System]), whichever is more recent, revealed, Code 0, no: if the resident has not had any fall since the last assessment, and Code 1, yes: if the resident has…

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 facility policy review, record review, and interview, the facility failed to ensure staff accurately assessed a resident following a change in condition and failed to respond appropriately during the change of condition, which affected 1 (Resident #4) of 4 residents reviewed for abuse during the complaint survey. Findings included:A facility policy titled, Acute Condition Changes-Clinical Protocol, dated 03/2018, indicated, 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The policy also indicated, 8. The nursing staff will contact the physician based on the urgency of the situation. For…

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

Based on record review and interview it was determined that the facility failed to submit their Payroll Based Journal (PBJ) information to Medicare. This was evident in the off-site preparation portion and during the on-site recertification survey. The findings include: During the off-site preparation for the recertification survey, the survey team was provided a copy of the facility's Payroll Based Journal Report which indicated that no data was submitted. On 11/12/24 at 9:31 AM during the entrance conference with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) the surveyor provided the [NAME] report and PBJ staffing Data Report which indicated that no data was submitted for the 3rd quarter which ended June 30, 2024. The NHA indicated he would investigate. On 11/19/24 at 10:07 AM in an interview with the DON, she confirmed the facility deficiency that the PBJ was not reported. She further explained that the previous owner submitted the report one day late. She said the NHA was also aware of the deficiency. On 11/26/24 at 11:29 AM in an interview with 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.

2) On 11/12/24 review of Resident #31's medical record revealed a Decision Making Capacity form, signed by the physician on 4/10/24, that indicated the resident was able to make health care decisions. Review of the Social Service 72 Hour Meeting Form, signed by the Social Worker (SW Staff #10), revealed the question: Does the resident have an Advance Directive? was marked as No. Further review of the medical record failed to reveal documentation to indicate there was follow up with the resident about initiating an Advance Directive. On 11/13/24 at 3:42 PM the SW #10 indicated if the answer to the Advance Directive question is No she does not follow up. On 11/14/24 review of the admission packet used by the facility revealed a blank Advance Directive form. On 11/14/24 the admission Director (Staff #42) reported she just includes the paperwork and that SW would address the Advance Directives. On 11/19/24 at 3:15 PM surveyor reviewed with Director of Nursing the concern regarding failure to address establishing an Advance Directive for Resident #31. Based on medical record review 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 medical record review and interview it was determined that the facility failed to ensure a primary care provider was notified of an abnormal lab result. This was found to be evident for 1 (Resident #53) out of 5 resident reviewed for unnecessary medications. The findings include: On 11/20/24 review of Resident #53's medical record revealed the resident was admitted in 2022 and whose diagnosis includes, but is not limited to, hypothyroidism. The resident receives Synthroid for the treatment of the hypothyroidism. The resident's current order was for Synthroid 125 mcg one time a day since 9/20/24. Review of the Treatment Administration Record (TAR) revealed that an ordered lab for a TSH (thyroid stimulating hormone) was obtained on 11/14/24. Further review of the medical record failed to reveal documentation of the results of this TSH level. On 11/21/24 at 11:26 AM, after surveyor inquired about this lab result, nurse #35 printed off the results and provided copy to the surveyor. Review of the TSH results revealed the level was high at 17.98 (reference range was 0.45 - 4.50).…

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) report allegations of abuse, and 2) timely report allegations of abuse. This was evident for two residents (Resident #1 and #12) identified during a review of an employee file and 4 residents (Residents #55, #72, #245, and #51) reviewed in relationship to 25 facility reported incidents reviewed during the survey. The findings include: 1.) On 11/14/24 at 5:15 PM a random sample of employee records were requested from the Nursing Home administrator (NHA). On 11/15/24 at 9:15 AM the records were received from the Director of Human Resources (Staff #28). On 11/15/24 at 11:08 AM a review of the employee file for Geriatric Nursing Assistant (GNA #15) was conducted. The file included a notice of discipline and termination dated 3/14/24 due to an allegation of verbal abuse of Resident #1 and Resident #12. On 11/15/24 at 1:20 PM in an interview with the Staffing Coordinator (Staff #29) confirmed that GNA #15 was terminated in March 2024 for an allegation of verbal abuse of two residents. When asked if there…

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 interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (Resident #16) of 3 residents reviewed for vision/hearing; and 1 (Resident #57) of 4 residents reviewed for dementia care. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1) In an observation on 11/12/24 at 11:53 AM, Resident #16 was noted with difficulty hearing and stated to the surveyor, I have bad hearing. They are supposed to be working on hearing aid for me. A record review on 11/19/24 at 2:45 PM contained a care plan focus initiated on 6/16/22 and revised on 10/19/23. The care plan stated, [Resident #16] is at risk for a communication deficit related to being hard of hearing. A 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 medical record review staff interview, it was determined the facility failed to provide a resident and/or a resident's representative with a summary of the baseline care plan. This was evident for 3 Residents (#82, #237, #255) of 50 residents reviewed during the survey. The findings include: A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident and/or representative. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 11/19/2024 at 8:45 AM during record review, it was revealed that Baseline Care Plans were not discussed with Residents (#82, #237, #255) or their representatives. On 11/20/2024 at 10:20 AM, during an interview, the Director of Nurses (DON) stated that baseline…

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

Based on interviews and medical record review, it was determined that the facility failed to invite alert and oriented residents to their care plan meetings. This was evident for 2 (#52, #136) of 2 residents reviewed for care planning. {or include the additional 2 for 4 out of 50} The findings include: Care plans are developed to guide residents' care in the facility. They must be created within 7 days of completion of a resident's admission comprehensive Minimum data set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team, including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable). 1) In an interview on 11/12/24 at 11:17 AM, Resident #52 was asked if he/she participated in his/her care plan meeting and responded, I don't think I've had any meeting yet. A record review on 11/15/24 at 8:18 AM showed that Resident #52 was admitted to the facility in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure staff reviewed/acknowledged specialists recommendations; failure to ensure assessment were completed accurately and failed to follow physician orders. This was found to be evident for five (Resident #31, #256, #16, #11 and #83) out of 50 residents reviewed during the survey. The findings include: 1) On 11/19/24 review of Resident #31's medical record revealed the resident had a care plans addressing fall risk and actual falls since April 2024. Further review of the medical record revealed the resident sustained a fall on 9/8/24 which resulted in a fracture to the fifth metacarpal (bone that connects pinky finger to wrist). The resident was seen by an orthopedist on multiple occasions for follow up. The resident had a cast until it was removed on 9/26/24 when a hand brace was initiated. Review of the Report of Consultation for an orthopedic visit on 10/31/24 revealed the following recommendation: Patient should be…

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

Based on observations and interviews, it was determined that the facility failed to store medications in accordance with professional standards by failing to discard expired medications; failing to ensure medicated creams were kept in the locked medication carts or storage rooms; and failure to ensure discontinued controlled medications were removed and discarded. This was evident in 1 of 3 medication carts observed during medication storage and labeling inspection; and 3 (Resident #30, #44 and #66) of 50 residents reviewed during the survey. The findings include: 1) On 11/15/24 at 1:47 PM, the medication cart for the Haven unit was inspected. An opened Fluticasone Propionate and Salmetrol inhalation powder 100-50 mcg. was labeled with Resident #7's name and had an opened date of 10/1/24. According to the manufacturer's instructions, the medication should be discarded 1 month after opening the foil pack. The Registered Nurse (RN Staff #8) was present during the inspection of the medication cart. Staff #8 confirmed that the medication should have been discarded on 11/1/24. 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 interviews, pertinent document reviews and observations it was determined that the facility failed to respond in a timely manner to a resident request for assistance. This was evident for 2 (Resident #24, #18) observed during a random observation on Nursing unit 1. The findings include: On 11/8/24 during a phone interview the facility ombudsman reported that she had received numerous complaints regarding the time it took for facility staff to respond to the residents calls for assistance. She reported the concerns of alleged call response times as 45-60 minutes. On 11/12/24 the intakes #MD00194596, #MD00208397, and # MD00208682 were reviewed. The review revealed concerns regarding the time it took for the staff to answer the residents' requests for assistance. On 11/14/24 at 1:05 PM the Surveyors were invited to attend a resident council meeting. During the meeting the residents voiced concerns that the call light system had not always functioned properly and sometimes they (the residents) had to wait 30-40 minutes for the call light to be answered. On 11/19/24 at 10:53 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 review of pertinent documentation and interviews it was determined that the facility failed to ensure resident's were provided advance notification of the date Medicare would not cover their skilled services. This was found to be evident for 1(Resident #14) out of 3 residents reviewed for beneficiary protection notification review. The findings include: On 11/14/24 at 10:30 AM review of the list, provided by the facility, of residents who were discharged from Medicare covered Part A stay with benefit days remaining in the past 6 months revealed that Resident #14 was discharged from services and remained at the facility. Surveyor provided the Beneficiary Protection Notification Review form to the Social Worker (Staff #10) for Resident #14. Review of the Beneficiary Protection Notification Review form revealed the last covered day of Part A Service was 8/7/24 and that the facility had initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident was provided both a Notice of Medicare Provider Non-Coverage (NOMNC) and a Skilled…

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 and facility investigation documentation and interviews it was determined that the facility failed to protect the residents from verbal abuse and misappropriation of narcotics. This was found to be evident for two (Resident #57 and # 53) out of 19 residents reviewed for abuse. The findings include: 1) Resident #57 was admitted to the dementia unit of the facility in 2023. A facility reported incident (FRI) related to MD00191982 that involved the resident, regarding verbal abuse, was submitted to the Office of Healthcare Quality. The facility's investigation packet for the FRI was reviewed on 11/20/24 at 12:37 PM. The review revealed that the facility substantiated verbal abuse by a Geriatric Nursing Assistant (GNA Staff #37). The verbal abuse was witnessed by other staff members (Certified Occupational therapist Assistant [COTA Staff #38] and GNA Staff #39) including a family member of another resident residing in the dementia unit. Details from the facility's investigation revealed the following: At approximately 4:15 PM, the perpetrator ,Staff #37, 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 thoroughly investigate allegations of abuse. This was evident for 2 facility reported incidents (#MD00187641 and #MD00201779) of 25 facility reported incidents investigated during the recertification survey. The findings include: 1) On 11/21/24 at 9:50 AM a review of the facility reported incident #MD00187641 revealed an allegation that Licensed Practical Nurse (LPN #31) physically and verbally abused Resident #247 on 1/09/23. On 11/21/24 at 10:01 AM a review of the facility's investigation file revealed that although there were other staff witness statements, and interview statements with other residents, there was no statement written by or received from the alleged perpetrator, LPN #31. On 11/21/24 at 10:20 AM an interview was conducted with the Director of Nursing (DON) who reviewed the facility investigation file and agreed and confirmed that there was no witness statement from the alleged perpetrator and agreed that this was an incomplete investigation. On 11/26/24 at 11:29 AM an interview 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 notify the resident and the resident's representative(s) of the transfer in writing. This was evident in 1 (Resident #29) of 1 resident reviewed or hospitalization. The findings include: Resident #29 had been residing in the facility since late 2022. A review of the resident's medical records on 11/13/24 at 11:50 AM, indicated that s/he was sent to the hospital in July of 2024. Further review of the resident's medical records failed to reveal evidence that a written notification of transfer was provided to the resident and/or resident representative (RP). On 11/15/24 at 9:27 AM, the Social Services Director (Staff #10) was interviewed regarding transfers and hospitalizations. Staff #10 reported that she does not handle notifications with transfers and hospitalizations and indicated that the nursing department is the one who handles these kinds of notifications. On 11/18/24 at 11:05 AM, the Licensed Practical Nurse (LPN Staff #9) was interviewed about her process when a resident needs to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications review. 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 nursing home should complete a significant change in status MDS assessment within 14 days when there's a significant decline or improvement in a resident's status. A medical record review on 11/13/24 at approximately 2:07 PM showed that Resident #10 had lived in the facility since December 2022, and his/her diagnoses included Parkinson's disease. 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, interview and observations it was determined that the facility failed to ensure staff assisted resident with wearing eyeglasses. This was found to be evident for 2 out of 3 residents reviewed for vision and hearing. The findings include: On 11/12/24 review of Resident #31's medical record revealed an order, in effect since 10/15/24, for: Nurse to collect glasses at bedtime and place in black cases in med cart every night shift. On 11/12/24 at 3:03 PM Resident #31 was observed sitting in a wheelchair, dressed for the day. Surveyor noted the resident was not wearing eye glasses at the time of this observation. On 11/19/24 review of Resident #31's 10/14/24 Minimum Data Set assessment revealed corrective lenses (eye glasses) where used during the assessment that the resident had adequate ability to see fine details such as regular print in newspapers or books. Review of the care plan revealed a plan addressing the resident's impaired visual function related to dry eye syndrome and glaucoma but failed to address the use of eye glasses. 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 provide residents with care for activities of daily living. This was evident for 1 complaint (#MD00205800) of 13 complaints reviewed during the recertification survey. The findings include: On 11/12/24 at 3:01 PM a review of complaint #MD00205800 revealed multiple allegations of neglectful care by the facility which included that Resident #242 had mouth sores and no care for them. On 11/12/24 at 3:16 PM a telephone call interview was conducted with the complainant who alleged that facility staff did not clean Resident #242's dentures. On 11/14/24 at 4:15 PM a review of Resident #242's clinical record related to dental care concerns was conducted. The clinical record contained a personal belonging inventory list which indicated that the resident had dentures. A review of the Geriatric Nursing Assistant care documentation failed to reveal any documentation of care for the resident's dentures. On 11/14/24 at 4:15 PM an interview 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 observations, medical record reviews, and staff interviews, it was determined that the facility failed to provide an activities program to meet the needs and preferences of residents. This was evident for 2 (Resident #10 and #34) of 2 residents reviewed for activities. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Several observations were made of Resident #10 lying in bed on 11/13/24. The room was quiet, with no activities going on, and there was no TV or radio on. Throughout the day on 11/14/24, several observations were made of Resident #10 lying in bed, awake, with no activities, and with no TV or radio on. A record review on 11/14/24 at 2:50…

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

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 2 (Resident #16 and #40) of 4 residents reviewed for position and mobility. The findings include: 1) In an observation on 11/12/24 at 11:44 AM, Resident #16 was noted with left foot drop and stated, I have limitation in my left hand and on my left foot, I should wear some device, but I haven't had it on for weeks. In a subsequent observation on 11/19/24 at 9:45 AM, Resident #16 was observed in bed, and had no device in place to his/her left extremity. A record review on 11/19/24 at 9:52 AM contained November 2024 order summary report for Resident #16 which recorded an attending provider's order dated 3/3/2015 and reviewed on 11/12/2024 for a brace to Resident #16's left foot drop every shift. Continued review noted an Minimum Data Set (MDS) assessment for Resident #16 dated 10/7/24. Minimum…

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 that the facility failed to consistently document the reasons for administering an as-needed (PRN) pain medication and failed to document pain assessment to include the location of the pain and type of pain for a Resident reporting pain. This was evident for 1 (Resident #10) of 5 Residents reviewed for unnecessary medications review. The findings include: A medical record review on 11/13/24 at 2:07 PM showed that Resident #10 had been residing in the facility since December 2022 with diagnoses including chronic back pain. The continued review contained a care plan for pain for Resident #10 that was initiated on 12/20/2022 with revision on 11/11/2024. The interventions on the care plan included but were not limited to Assess and Document non-pharmacological interventions before administering PRN pain medication such as, but not limited to, food, social interactions, positioning, movement, heat/cold, massage, music, administer [pain medicine] as per orders; evaluate effectiveness and consult with [attending provider]…

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 interviews, it was determined that the facility staff failed to obtain pre-dialysis treatment records for a resident. This was evident for 1 (Resident #37) of 1 resident reviewed for dialysis. The findings include: A record review for Resident #37 on 11/21/24 at 11:43 AM contained a hospital Discharge summary dated [DATE] that recorded that the resident had a diagnosis of end-stage renal disease and required hemodialysis. Hemodialysis, also known as dialysis, is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. A continued review found an attending provider's order dated 11/2/23 for Resident #37 to receive dialysis three times a week on Mondays, Wednesdays, and Fridays at 0640. Further review showed dialysis communication forms for October 1- November 20, 2024, and instructions for filling the forms. The forms included areas for the facility to document the resident's name, the date, vital…

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 employ competent nursing staff. This was evident during the Staffing task investigation, and for 1 complaint (#MD00205800) of 13 complaints reviewed during the recertification survey. The findings include: On 11/12/24 at 3:01 PM a review of complaint #MD00205800 revealed an allegation that facility staff were not competent when they gave Resident #242 care. On 11/15/24 at 9:15 AM employee records were requested from the Director of Human Resources (Staff #28). On 11/15/24 at 11:08 AM the requested employee files were received and reviewed. The review of the records for Registered Nurse (RN #25) failed to reveal any evidence of a competency or skills evaluation. On 11/19/24 at 10:17 AM an interview was conducted with the Director of Nursing (DON), and she was asked for evidence of any skills competency evaluation for RN #25. The DON said she would look and let me know. On 11/19/24 at 11:46 AM in another interview with the DON she explained that the facility did not do competency/skills evaluation when…

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

Based on medical record review and interview it was determined that the facility failed to ensure ordered 15 minute checks for suicidal ideation; and failed to report increase in agitation that resulted in the administration of Ativan without an order. This was found to be evident for 2 (Resident #234 and #66) out of 50 residents reviewed during the survey. The findings include: 1) Review of Resident #234's medical record revealed the resident was admitted to the facility in December 2021 with multiple psychiatric diagnosis which included paranoid schizophrenia. In November 2022 the resident was receiving multiple psychoactive medications including an antipsychotic, an antidepressant and antianxiety medications. The resident had a court ordered guardian of person since 2016. On 10/8/22 the resident was deemed by two facility providers, unable to make health care decisions. Review of the progress notes revealed on 11/10/22 nurse #53, documented: This writer was informed by social services that resident made suicidal ideations toward staff. Resident was placed on 15 min checks 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 records review, observations and interviews, it was determined that the facility failed to ensure services provided to a resident with dementia are based on their choices and preferences. This was evident in 1 (Resident #57) of 4 residents reviewed for dementia care. The findings include: Resident #57 was admitted to the facility in early 2023. The resident was observed in the dementia unit on multiple occasions throughout the survey process. In these observations, the resident was watching TV with no other meaningful activity being provided. The observation dates include: 11/13/24 at 12:16 PM, 11/15/24 at 12:55 PM, and 11/19/24 at 2:48 PM. A review of Resident #57's preference evaluations was conducted on 11/21/24 at 10:25 AM. The review revealed that the most recent evaluation was done by an Activities Assistant (Staff #13) dated 11/6/24. The questions in the evaluation were all marked as No response or non-responsive. Further review of the resident's medical record revealed the next date that the preference evaluation was conducted was on 8/6/24 and was done by the same…

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

Based on medical record review, observations and staff interviews, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure that an attending provider's orders for a resident's topical anesthetic medication included a time to remove it; and failed to provide adequate monitoring and indications for use of biological creams. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications; and 1 (Resident #30) of 3 reviewed for pressure ulcers during this survey The findings include: 1) A record review completed for Resident #10 on 11/13/24 at 2:07 PM, contained an attending provider's order dated 11/8/24 for Aspercreme Lidocaine External Patch 4% (Lidocaine) Apply to back topically two times a day for pain Apply in AM and remove every PM. Lidocaine Patch is used to manage pain. Depending on the product, the patch may be left on the skin for up to 8 or 12 hours. Applying too many patches or topical systems or leaving them on too long may cause serious side effects. Further review of 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 interviews, it was determined that the facility failed to document the specific reasons for administering a psychotropic medication and failed to implement non-pharmacological interventions (NPI) before administering the medicine as needed (PRN). This was evident for 1 (#10) of 5 Residents reviewed for unnecessary medications review. The findings include: A record review for Resident #10 showed attending provider's orders dated 9/17/24 to 10/1/24 and 10/1/24 to 10/10/24, for antianxiety medication to be administered to Resident #10 every 8 hours PRN for anxiety, then 10/10/24 to 11/20/24 two times daily for anxiety/agitation. A review of Resident #10's medication administration record (MAR)for September 1, 2024, to November 15, 2024, was completed. The MAR had recorded that the nurses administered the PRN antianxiety medication to Resident #10 on 9/26/24 and 10/5/24, and the post-medication assessment for both days stated: ineffective. The resident had also received the drug every day from October 10, 2024, to November 15, 2024. However, the review…

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

Based on observations and records review, it was determined that the facility failed to ensure that medication error rates were below 5% during the completion of the medication administration facility task. This was evident for 2 of the 36 opportunities observed for the medication administration. The findings include: On 11/14/24 at 7:13 AM, the Registered Nurse (RN Staff #8) was about to begin her morning medication (med) pass. The surveyor requested to observe Staff #8 in her med pass, and she agreed. Staff #8 was observed from 7:13 AM until 7:42 AM and had a total of 36 opportunities for medications administered with different routes, for 5 residents. Later, at 8:14 AM, the medical records of the 5 residents were reviewed to verify the accuracy of the medications that Staff #8 had administered. The review revealed the following concerns: 1) On 11/14/24 at 7:32 AM, Staff #8 administered 1 tablet of Calcium 600 mg. with 10 mcg. of Vitamin D to Resident #33. The review of the medical record revealed the order was for 1 tablet of Calcium 600 mg. with 200 mg of Vitamin D. 2) 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 that the facility failed to ensure a resident was free from a significant medication error. This was found to be evident for one (Resident #66) out of three resident with orders for as needed controlled medications reviewed during the investigation of drug diversion. The findings include: Resident #66 diagnosis includes, but is not limited to, Alzheimer's disease and depression. Review of the 10/17/24 nurse practitioner (Staff #49) note revealed: .has a history of falls thought related to lorazepam given for severe episodes of agitation . On 11/21/24 at approximately 12:15 PM during the investigation of drug diversion surveyor randomly picked three residents with as needed narcotics from the drug control book. Resident #66's as needed lorazepam Controlled Drug Administration Record was one of the three selected for review. Review of Resident #66's Controlled Drug Administration Record revealed a prescription, dated 10/17/24, for Lorazepam 1 mg every 12 hours as needed; and a supply of 30 tablets was received. The supply…

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 timely radiological services to its residents. This was evident for 1 facility reported incident (#MD00190908) of 25 facility reported incidents investigated during the recertification survey. The findings include: On 11/21/24 at 10:45 AM a review of the facility reported incident MD00190908 revealed that Resident #245 was found to have a fractured pelvis when a CT scan (computed tomography scan) was performed on 3/24/23. The fracture was reported to the facility on 3/29/23. On 11/21/24 at 11:01 AM Resident #245's clinical record was reviewed. The record contained a scanned document of an oncologist consult visit on 2/14/24. The oncologist recommended an MRI (Magnetic Resonance Imaging) due to the resident's complaint of left hip pain. This portion of the scanned consult note was circled in a pink color. Further review of the resident's clinical record failed to reveal any order for an MRI. On 11/21/24 at 11:10 AM review of the facility investigation file revealed the explanation that the…

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

Based on review of facility staffing data and staff interviews, it was determined that the facility failed to ensure compliance with The Code of Maryland Regulations for Nursing Services - Staffing, 10.07.02.19 which states that A nursing home shall employ supervisory personnel and a sufficient number of support personnel to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week. by failing to ensure staffing at or above 3 hours of bedside care per patient per day (PPD). This was found to be evident for 63 out of 167 days reviewed. The findings include: 1.) On 11/12/24 at 11:15 AM a review of complaint #MD00192372 submitted on 5/16/23 revealed the allegation that the facility was short staffed. On 11/13/24 the Staffing Coordinator (Staff #29) was asked to provide the survey team with the facility's staffing data and actual nursing assignment sheets for April and May 2023. On 11/19/24 at approximately 1:10 PM the facility's staffing data for April and May 2023 was received and reviewed. A review of the PPD data for April and May 2023 revealed 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 records review and interviews, it was determined that the facility failed to have a facility assessment that was accurate and complete. This practice has the ability to affect all residents of the facility. The findings include: On 11/20/24 at 2:29 PM a review of the facility assessment was conducted by the surveyor. The review indicated that the facility put not applicable (N/A) in the section where they were asked about the number of beds in the specialty unit. However, in the section where they were asked about the average daily census in the specialty unit, the facility answered 30 beds. On 11/21/24 at 12:37 PM during an interview with the Director of Nursing (DON), she confirmed that the facility was licensed as having a specialty unit and referred to their Dementia unit. After confirming the floorplan with the DON, she confirmed that the Dementia unit only had 22 beds. The concern about the discrepancies were brought to the DON's attention and she indicated that she would look into it. On 11/26/24 at the time of survey exit at approximately 2 PM, no further…

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 accurately document resident records. This was evident for 2 (Resident #57, and #252) out of the 50 residents reviewed during the survey. The findings include: 1) Resident #57 resided in the dementia unit of the facility and was observed on multiple occasions throughout the survey process. A quick review of the resident's orders on 11/13/24 at 11:11 AM indicated for the nurse to put glasses on the resident when s/he wakes for the day, and a separate order to take the glasses before bedtime to be kept in the treatment room for the night. On the same day, the resident was observed at different times, awake and out of bed, but not wearing eyeglasses for vision. The documented observation times of Resident #57 awake and not wearing his/her eyeglasses for vision include: 11/13/24 at 11:04 AM, 12:16 PM; 11/15/24 at 12:55 PM; and 11/19/24 at 2:48 PM. A review of the facility's visitor sign-in sheet located at the front desk on 11/20/24 at 9:23 AM indicated that the resident's spouse last visited on 11/18/24…

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.

Based on medical record review, observation and interview it was determined that the facility failed to ensure staff completed hand sanitation between dressing changes; and failed to have a physical barrier between the clean and soiled areas of the laundry room to prevent cross-contamination. This was found to be evident for one (Resident #34) out of three residents reviewed for pressure ulcers; and one out of one laundry room observed. The findings include: 1) On 11/13/24 review of Resident #34's medical record revealed the resident has resided at the facility for several years and whose diagnosis includes but is not limited to dementia. The resident had two unhealed pressure ulcers, one on the left foot and one on the right foot, with orders for daily dressing changes. On 11/21/24 at 8:55 AM surveyor observed the nurse (Staff #35) prepare to complete the resident's dressing changes, this included hand sanitation and donning a pair of gloves. The nurse completed the dressing change to the wound on the right foot and then proceeded to complete the dressing change to the wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and pertinent document review the facility failed to have a process in place to ensure an automated external defibrillator (AED), was maintained in a working order. This was evident for one automated external defibrillator out of 2 AEDs available in the facility. The findings include: An automated external defibrillator (AED) is a lightweight-portable device. It delivers an electric shock through the chest to the heart when it detects an abnormal rhythm and changes the rhythm back to normal. On [DATE] a review of intake MD#00194596 revealed a concern that the AEDs were not checked regularly and restocked after use. On [DATE] at 1:12 PM an observation was made of Nurse (Staff # 22) demonstrating how to use the AED hanging in the wall cabinet in the 200 hallway. During the demonstration of the AED an audible warming of low battery could be heard. On [DATE] at 1:13 PM during an interview with Nurse (Staff #22), she reported that she had not been told what to do if the battery was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and pertinent document review it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident during random observations and had the potential to affect all resident rooms. The findings include: On 11/8/24 during a phone interview the facility ombudsman reported that she had received numerous complaints regarding the time it took for facility staff to respond to the residents calls for assistance. She reported the concerns of alleged call response times as 45-60 minutes. On 11/12/24 the intakes #MD00194596, #MD00208397 and # MD00208682 were reviewed. The review revealed concerns regarding the time it took for the staff to answer the residents' call bells. On 11/14/24 at 1:05 PM the Surveyors were invited to attend a resident council meeting. During the meeting the residents voiced concerns that the call light system had not always functioned properly and sometimes they (the residents) had to wait 30-40…

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 facility documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to follow transmission based precautions and using gloves to handle resident medications. This was evident for 1 (#11) of 1 staff observed passing ice water and 1 (#10) of 4 staff observed for medication administration. The findings include: 1) On 9/17/19 at 8:40 AM, an observation in the 400 hallway revealed Feeding Assistant Staff #11 refilling resident's ice pitchers and cups from an ice chest. She proceeded to go into a resident's room who was on contact isolation. Staff #11 was observed going into the room with not personal protective equipment on and pick up the resident's pitcher and cup and take them into the resident's restroom and then brought them out to the cart and placed them on top of the ice chest. She then proceeded to fill them up and took them back into the room. She used hand sanitizer. Staff #11 was asked to stop passing ice until Director 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 investigation, resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of verbal abuse. This was true for 2 (Residents #28 and # 2) of 5 residents reviewed for abuse. The findings include: The facility's investigation related to facility reported incident #MD00135582 was reviewed by the surveyor on 9/19/2019 at 4:00 PM. In the investigation, the facility substantiated through witnesses (staff # 9) and (staff #12) that Geriatric Nursing Assistant (GNA) #10 used verbally abusive and inappropriate language while rendering care to resident #28 and 2. Review of facility reported incident MD00135582 on 9/19/2019 at 4:00 PM revealed the following: At approximately 4 pm on 1-14-19, Feeding Assistant (staff #9) reported to the Administrator that while s/he was providing 1:1 supervision to a resident on the Haven Unit on the 3-11 pm shift on 1-13-19, s/he overheard GNA (Geriatric Nursing Assistant), staff (#10) using inappropriate language on the care unit, specifically using…

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 document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 2 (#7, #58) of 2 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #7 on 9/20/19, revealed that, on 8/3/19 at 3:32 PM, Resident #7 was sent to the emergency room. There was no written documentation found in the medical record that Resident #7 was oriented and prepared for the transfer in a manner that each resident could understand and there was no documentation of the resident's understanding of the transfer. Discussed with the Director of Nursing on 9/20/19 at 10:30 AM who confirmed the findings. 2) During an interview with Resident #58 on 9/17/19 at 9:13 AM, it was reported that the resident had been in and out of the hospital frequently. A medical record review on 9/19/19 at 10:25 AM, revealed a progress note dated 7/25/19, that documented the resident was sent to the acute care hospital…

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 2 (#7, #16) of 12 residents observed with 31 medication administration opportunities which resulted in an error rate of 6.45% by 1 of 1 Licensed Practical Nurse and 1 of 3 certified medicine aides observed. The finding include: 1) During a medication observation with Licensed Practical Nurse (LPN) #6 on 9/18/19 at 3:05 PM, it was revealed that Resident #7 had a bottle of Ferrous Sulfate 220 milligrams (mg) in every 5 milliliters (mL) of solution. The prescription label #5860937 on the bottle documented to give 300 mg or 7 mL of solution. LPN #6 poured the medication and confirmed with surveyor that it was 5 mL poured to administer to the resident. She stated that was what the order stated in the electronic medical record on the medication administration record (MAR). The physician's order stated ferrous sulfate liquid 300mg/5mL; amount to administer: 300 mg (5mL); gastric tube. 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 observation and staff interviews, it was determined that the facility did not have a process in place to ensure that all resident care equipment is maintained and calibrated to be in safe operating condition. This was noted for 1 of 4 certified medicine aides observed administering medications. The findings include. On 9/20/19 at 8:02 AM, observations of certified medicine aide (staff #3) during medication administration revealed use of a Vivitar wrist blood pressure cuff. The certified medicine aide was asked if the wrist blood pressure cuff belonged to the facility. Staff #3 responded that the wrist cuff was her personal equipment. She indicated that the facility does supply blood pressure cuffs. Interview of the director of nursing on 9/20/19 at 12:49 PM revealed that the facilities' equipment is maintained and routinely checked for calibration, and that staff were not to be utilizing their own equipment.