Glen Meadows Retirement Com.

Based on review of facility records and interview with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assessment and Assurance (QAA) meetings. The findings include: On 3/24/25 during the Entrance Conference with the Nursing Home Administrator (NHA), he provided the survey team a binder that included the QAA committee information and noted the committee members as: Medical Director, Healthcare Administrator, Director of Nursing, MDS Coordinator, Assistant Director of Nursing, Rehab Manager, Social Worker/Admissions, Community Life Director, Director of Environmental Services, Laundry Manager, Director of Food Services, Human Resources Manager, Dietician and GNA designee. On 3/31/25 at 2:22 PM review of the facility's QAA monthly attendance records for 2/2024 to 2/2025 revealed the following: 1. The Medical Director failed to attend 1 of 12 meetings (June 2024). 2. The Director of Nursing failed to attend 2 of 12 meetings (March 2024, July 2024). 3. The Infection Preventionist failed to attend…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and a review of resident records, it was determined that the facility failed to 1) ensure that each resident was offered an influenza immunization during an active flu season and 2) monitor/document each eligible resident's pneumococcal vaccine status. This was evident for 2 (Residents #15 and #84) of 5 residents sampled for immunization review during the recertification/complaint survey. The findings include: Pneumococcal vaccine help prevents pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous…

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 interviews, it was determined that the facility failed to ensure employees' COVID-19 vaccination status. This was evident for 1 (Registered Nurse, RN #14) of 5 employees' immunization records reviewed during the recertification/complaint survey. The findings include: A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease. During a portion of the infection control task on 3/27/25 at 11:00 AM, the surveyor randomly selected five employees to review their immunization records. The review revealed that the employee health file of RN #14 (hired in November 2024) did not have his/her COVID-19 vaccination record. In an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and corporate supporting manager (Staff #10) on 3/27/25 at 2:07 PM, ADON stated that the Human Resources department managed employees' health files, including their immunization data. The surveyor asked whether the facility monitored/tracked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's investigation file and medical records and interview with facility staff, it was determined that the facility failed to ensure a resident remained free of abuse. This was evident for 1 (Resident #18) of 4 residents reviewed for abuse during the recertification/complaint survey. The findings include: The facility's investigation file related to facility reported incident MD#00209055 was reviewed by the surveyor on 3/24/2025 at 4:00 PM. Review of facility reported incident MD#00209055 revealed the following: On Friday, 8/23/2024 at approximately 7:30am Staff #4 observed Resident #18 reach for a laundry basket and Geriatric Nursing Assistant (GNA #25) allegedly open hand smacked Resident #18 on her left forearm. Included in the investigation file was a document titled, Interview Questions for the Facility Abuse Coordinator and had Staff #4's name and title along with the date and time (8/23/24 at 9:53 AM) that documented, at approximately 7:30 AM on 8/23, I [Staff #4's first 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 review of facility reported incidents, record review, and interview with staff, it was determined that the facility failed to timely report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (Resident #18 and #11) of 4 residents reviewed for abuse during the recertification/complaint survey. The findings include: The OHCQ is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse, serious bodily injury, and misappropriation of resident property are to be reported to the OHCQ in a timely manner (within 2 hours for the initial report and within 5 working days for the final report). 1) The facility's investigation file related to facility reported incident MD#00209055 was reviewed by the surveyor on 3/24/2025 at 4:00 PM. Review of facility reported incident MD#00209055 revealed the following: On Friday, 8/23/2024 at approximately 7:30am Staff #4 observed Resident #18 reach for a laundry…

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

Based on review of facility reported incidents, medical record review, and interview with facility staff, it was determined that the facility failed to thoroughly investigate 1) an allegation of abuse by failing to perform an assessment of the alleged victim, 2) an elopement, and 3) failed to follow through on appropriate corrective action to prevent further instances of medication errors. This was evident for 3 (Resident #11, Resident #16, Resident #85) of 19 residents reviewed during the recertification/complaint survey process. The findings include: 1) The facility's investigation file related to facility reported incident MD#00215348 was reviewed by the surveyor on 3/24/2025 at 5:00 PM. Review of facility reported incident MD#00215348 revealed the following: A family member of Resident #11 reported that one evening in the middle of February, s/he came to visit his/her family member [Resident #11] and s/he observed a male caregiver, who was later identified as GNA #16, push Resident #11 away from the door and hit him/her on the upper shoulders with closed hands twice. 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 interviews with facility staff and review of resident medical records and the facility incident report, it was determined that facility nursing staff failed to follow professional standards of nursing practice when performing controlled medication counts. This practice was noted for one (Resident #84) of two residents reviewed for controlled medication administration and one self-reported incident, MD00212528, reviewed during this recertification/complaint survey. The findings include: Controlled medications are drugs that have the potential for abuse and addiction and are, therefore, regulated by the government. They are classified into five schedules (I to V) based on their medical use, potential for abuse, and risk of dependence. As a result, it is a standard of nursing practice to administer narcotic medication only from sources that can be both accounted for and reconciled. This practice discourages the diversion of abusable medication and ensures that narcotic medication is tracked according to federally mandated standards. a) During a review of the facility…

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 and staff interview and medical record review, it was determined the facility failed to have documentation which indicated care plans were reviewed and evaluated. This was evident for 1 (#1) of 1 residents reviewed for edema, and 2 (#10, #5) of 5 residents reviewed for unnecessary medication. 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 5/4/21 at 1:35 PM, a review of Resident #7's medical record was conducted. Review of Resident #7's care plans revealed multiple care plans, including a care plan [Resident #7] has an alteration in cardiac status and potential for cardiac complications related to Diastolic CHF (congestive heart failure, Pulmonary HTN (hypertension), A-fib (atrial fibrillation), HTN (hypertension) and HDL (hyperlipidemia) resulting in bilateral edema and requiring a diuretic daily. History of Occipital Stroke, NSTEMI (non-ST segment elevation myocardial infarction) (heart attack) and s/p (status/post) aortic stent,…

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, interview, and documentation review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to implement an effective system to ensure that symptomatic staff, visitors and vendors did not enter the facility during a declared health emergency. The findings include: According to the Centers for Disease Control and Prevention (CDC) published updated guidance on COVID-19 symptoms. In addition to fever, cough, and shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, persistent pain or pressure in the chest, trouble breathing, new confusion, inability to arouse, and bluish lips or face, the CDC added gastrointestinal symptoms including nausea, vomiting and diarrhea. On 5/3/21 at 7:15 AM, two surveyors entered the facility through the unlocked, main entrance doors. At that time, the receptionist desk was unmanned, and there was no one observed to be in the lobby. An employee was observed on the lower level of the facility and assistance was…

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

Based on observation, resident and staff interview, it was determined that facility staff failed to have a call bell within reach for a resident who was dependent on staff for activities of daily living. This was evident for 2 (#10, #66) of 15 residents observed in the initial resident pool. The findings include: 1) On 5/3/21 at 12:49 PM, an observation was made of Resident #10, sitting in a chair located on the left side of the bed. The resident's call bell was observed hanging down on the right side of the resident's bed and not within reach of Resident #10. This observation was confirmed by a second surveyor on 5/3/21 at 1:00 PM. On 5/3/21 at 1:21 PM, the Director of Nurse's was made aware of the finding and confirmed that Resident #10's call bell was not within the resident's reach. 2) On 5/4/21 at 1:53 PM, an observation was made of Resident #66, sitting in a wheelchair located on the right side of the bed and in front of a bedside table. At that time, during an interview, Resident #66 indicated that he/she had poor range of motion in his/her arms and was getting therapy. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical record, review of Minimum Data Set (MDS) assessments and transmission, and interview with facility staff, it was determined that the facility failed to ensure that a required subset of MDS information was encoded within 7 days and transmitted within 14 days of a resident's death. This was evident for 1 (Resident #1) out of 2 residents reviewed during the survey who had died. The findings include: The MDS (Minimum Data Set) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. That information must be encoded in the form of an MDS Assessment within 7 days of when an assessment of a resident is completed, including (among other events) at the time of the death of a resident. It is also a requirement that MDS information be transmitted to the Centers for Medicare and Medicaid (CMS) System within 14 days of when an assessment of a resident is…

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

Based on 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 (#7) of 2 residents reviewed for edema. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 5/4/21 at 1:15 PM, an observation of Resident #7 revealed the resident had edema (swelling) in both lower extremities and the resident was wearing TED stockings (compression stockings). On 5/5/21 at 2:02 PM, a review of Resident #7's medical record was conducted. Review of Resident #7's February 2021 MAR (medication administration record) revealed two 8/6/20 physician orders for Furosemide (Lasix)…

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

Based on review of resident records and interview with facility staff, it was determined that the facility failed to develop baseline care plans for residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was evident for 1 (Resident #14) of 1 resident who was a new admission to the facility and 1 (Resident #5) of 5 residents reviewed for unnecessary medications. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare with the information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. That information must be resident-specific and person-centered, and must address the resident's initial goals based on admission orders, the physician orders, the dietary orders, the therapy services and social services the resident will require, and a PASARR recommendation (if applicable). 1) Resident #14's medical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement person centered care plans and failed to follow the care plan. This was evident for 2 (#10, #11) of 5 residents reviewed for unnecessary medications and 1 (#16) of 2 residents reviewed in the closed records sample. 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 5/7/21 at 10:52 AM, a review of Resident #10's medical record was conducted and revealed documentation that Resident #10 had diagnosis that included depression. Review of Resident #10's May 2021 MAR (medication administration record) revealed an order for a 7/28/20 physician order for Sertraline (Zoloft) (antidepressant) by mouth once daily that was documented as given every day in May 2021. Review of Resident #10's most recent quarterly assessment, with a reference date of 3/3/21, Section I…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional stands of practice as evidenced by the application of compression stockings to a resident without a physician's order. This was evident for 1 (#7) of 2 residents reviewed for edema. The findings include: On 5/4/21 at 1:15 PM, an observation of Resident #7 revealed the resident had edema (swelling) in both lower extremities and the resident was wearing TED stockings (compression stockings) on both lower legs. On 5/5/21 at 2:02 PM, a review of Resident #7's medical record was conducted and failed to reveal a physician's order for TED stockings. On 5/6/21 at 1:00 PM, a second observation of Resident #7 revealed the resident was wearing TED stockings on each of his/her lower legs. On 5/6/21 at 1:45 PM, accompanied by the surveyor, Staff #5 confirmed Resident #7 was wearing TED stockings. The surveyor asked Staff #5 if there was an order for the TED stockings, Staff #5 looked in Resident #7'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 the facility staff 1) failed to ensure the physician review the resident's total program of care, including medications, at each visit, and 2) failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications. The findings include: 1) A review of Resident #5's medical record was conducted on 5/10/21 at 9:51 AM. Review of Resident #5's physician progress notes revealed that, on 8/5/20 and 9/5/20, the physician wrote that the resident's assessment/plan (A/P) included: Ativan (Lorazepam) (anxiolytic medication) ordered PRN, and, on 1/1/21, 1/27/21, and 5/2/21, the physician wrote the resident's A/P included: Anxiety disorder: Ativan ordered PRN. Continued review of Resident #5's medical record failed to reveal evidence that Resident #5 had been prescribed Ativan since his/her admission to the facility in August 2020. The Director of Nurses (DON) and Nursing Home Administrator (NHA) 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 medical record review and staff interview, it was determined that the facility failed to ensure that residents weree seen by a physician at least one every 30 days for the first 90 days. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications. The findings include: A review of Resident #5's paper medical record was conducted on 5/10/21 at 9:51 AM and revealed documentation that Resident #5 was admitted to the facility in the beginning of August 2020. Review of Resident #5's physician progress notes revealed a physician note dated 9/15/20 and physician note dated 1/1/21. There was a lapse of 107 days between the two physician visits and no other physician progress notes found to indicate the resident had been seen by the physician at least once every 30 days for the first 90 days after admission. On 5/11/21 at 12:30 PM, the Director of Nurses confirmed, that between the dates of 9/15/20 and 1/1/21, no other physician progress notes were found for Resident #5.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that the attending physician documented in the resident's medical record what actions had been taken, if any, based on irregularities identified during the medication regimen review. This was evident for 2 (Residents #2 and #10) of 5 residents reviewed for unnecessary medication. The findings include: Medication regimen reviews are performed by a consultant pharmacist and include a monthly review of the medication regimen of all residents. During the review, the consultant pharmacist identifies any irregularities in a resident's medication regimen and makes recommendations to the resident's attending provider. The provider is then responsible for responding to the recommendation in a timely manner with either actions to be taken based on the recommendation, or a rationale if no action is required. 1) Resident #2's medical record was reviewed on 5/10/21 at 9:56 AM. During the review, a document entitled 'Consultant Pharmacist Communication to Physician',…

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

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' medication regimen did not include unnecessary medication as evidenced by Resident #13 having an as-needed acetaminophen order that, when combined with a scheduled acetaminophen order, exceeded the physician-ordered limit of 3 grams of acetaminophen per day. This was evident for 1 (Resident #13) of 1 resident reviewed for pain management. The findings include: Acetaminophen (Tylenol) is a analgesic medication that is available over the counter and used to treat mild to moderate pain. Because excessive acetaminophen can cause liver toxicity, it is a standard of practice as well as a recommendation of the FDA to not exceed 4 grams of acetaminophen per day. This limit is sometimes lowered to 3 grams per day for the elderly or those with diseases affecting the liver. In 2012, the FDA suggested, but did not mandate, a maximum daily dose for adults of 3 grams of acetaminophen with no more than 650 miligrams every 6 hours. Excessive amounts 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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by 1) failing to adequately monitor a resident for behavior, side effects, or adverse consequences related to psychotropic medication, and 2) failing to evaluate a resident for a gradual dose reduction of a psychotropic medication. This was evident for 1 (#10) of 5 residents reviewed for unnecessary medications. The findings include: On 5/7/21 at 10:52 AM, a review of Resident #10's medical record was conducted and revealed documentation that Resident #10 had diagnoses that included depression. Review of Resident #10's May 2021 MAR (medication administration record) revealed a physician order for Sertraline (Zoloft) (antidepressant) by mouth once daily that was initiated on 7/28/20 and documented as given every day in May 2021 Continued review of the resident's medical record failed to reveal evidence that the facility staff monitored Resident #10 for changes in behaviors that necessitated the use of…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that hot entrees being prepared for refrigeration were rapidly cooled from 135 degrees (Fahrenheit) to 70 degrees within 2 hours, and then cooled from 70 degrees to 41 degrees within 4 hours for the prevention of foodborne illness. This was evident for 1 of 2 tours of the kitchen and had the potential to affect all residents eating cooked and cooled foods. The findings include: During an observation of the kitchen that took place on 5/10/21 at 10:40 AM, the temperature log for the cooling of hot foods was reviewed. It was noted to contain cooling logs for only two food items in the month of May, the most recent being on 5/6/21. The Food Service Director (FSD), who was present for the tour, stated at that time that most entrees are cooked and served on the same day. The FSD stated that few entrees are kept as leftovers after a meal. The tour of the kitchen on 5/10/21 continued with an observation of the main refrigerator where it was found that between 10 and 30 chicken breast…

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

Based on medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications. The findings include: 1) On 5/10/21 at 9:51 AM, a review of Resident #5's medical record was conducted. Review of Resident #5's physician progress notes in the resident's paper medical revealed a physician progress notes for Resident #6, Resident #7, Resident #67, Resident #12 and Resident #9 were stapled together and filed under the progress notes tab in Resident #5's paper medical record. The Director of Nurses (DON) was made aware of these findings and, on 5/11/21 at 12:30 PM, the DON indicated that the physician progress notes written for the other residents had been erroneously filed in Resident #5's medical record by the physician.

Based on medical record review and interview, it was determined the facility staff failed to administer medication as ordered by the physician to Resident #123. This was evident for 1 of 29 residents selected for review during the survey process. The findings include: Medical record review for Resident #123 revealed on 9/21/18 the physician ordered: Fentanyl 50 mcg/hr. patch, apply 1 patch topically every 72 hours. Fentanyl patches are used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. Fentanyl is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. Transdermal fentanyl comes as a patch to apply to the skin. The patch is usually applied to the skin once every 72 hours. Review of the Medication Administration Record revealed the facility staff failed to administer the patch on 9/22/18 as due. Further record review revealed the facility staff documented on 9/22/18 at 4:27 PM: called pharmacy…

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.