Autumn Lake Healthcare At Baltimore Washington

Based on observation, interviews, facility policy review, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 (Resident #8) out of 2 residents reviewed for respiratory care during the survey. The findings include: Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. On 2/8/26 at 9:11 AM, the surveyor observed that Resident #8 was utilizing oxygen via nasal cannula. The nasal cannula was attached to an oxygen concentrator (a machine that extracts and filters nitrogen from ambient air to deliver 85-95% pure oxygen). The surveyor noted that 3 liters of oxygen per minute were being delivered to the resident from the oxygen concentrator. Resident #8 stated that he/she was supposed to have 4 liters of oxygen however, the machine was unable to maintain 4 liters and could only be turned as high as 3. On 2/11/26 at 9:08 AM, the surveyor reviewed Resident #8's care plan. The review revealed a care…

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

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management medication for resident 31. This was evident for 1 of 1 residents reviewed for pain management during the recertification surveyOn 2/8/2026 at 9:09 AM, the surveyor interviewed Resident #31. During that interview the resident stated that they had been diagnosed with Rheumatoid Arthritis approximately 20 years ago and had been in constant pain since. The resident stated that they were not receiving their pain medication correctly. On 2/9/2026 at 10:45 AM , the surveyor reviewed Resident #31 's medical records. The review revealed that Resident #31 had a standing order for Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg to be given every 8 hours. Further review of the medical record on 2/12/2026 at 9:12 AM revealed that on the Medication Administration Record that on 2/11/2026 the 6:00 AM dose was not signed for indicating that the dose had not been given. Hydrocodone-Acetaminophen 7.5-325mg is a controlled regulated substance that each tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with facility staff and family, it was determined that the primary medical provider failed to review the total program of care when the plan when a code status changed. This was found evident for 1 (Resident #1) out of 44 residents selected for review during the survey. The findings include: On [DATE] at 8:19 AM, the surveyor reviewed Resident #1's paper medical record. The review revealed a MOLST dated [DATE] that indicated Resident #1 wanted CPR based on instructions in the patient's advanced directives. On [DATE] at 1:45 AM, the surveyor reviewed a newer MOLST dated [DATE] provided by the DON that indicated Resident #1's surrogate decision maker elected to not have CPR performed in the case of cardiac arrest. The declination was Do Not Intubate (DNI). (This still allows limited ventilatory support by CPPAP or BIPAP). On [DATE] at 8:22 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked for documentation that…

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

Based on medical record review and interview, it was determined that the facility failed to address medication regimen review (MRR) recommendations made by the consulting pharmacist. This was found to be evident for 2 (#35 and #75) out of 5 residents reviewed during the recertification survey. The findings include:Medication Regimen Review (MRR) is a comprehensive, ongoing, or monthly evaluation of a patient's medication list by a pharmacist to identify, prevent, and resolve medication-related problems. It involves reviewing all prescribed and over the counter medications, nutritional supplements, and lab results for interactions, duplications, inappropriate doses, and adverse effects to improve patient safety. This process is critical in the long-term care settings to maintain safety and reduce the risk of harm related to medication mismanagement. 1) On 02/10/26 at 11:50 AM, the surveyors reviewed Resident #35's MRR, dated 05/28/2025, which stated: Please initiate albuterol MDI 2 puffs every 6 hours PRN for shortness of breath. Wait 1 minute between puffs. Although the MRR…

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

Based on record reviews and interviews, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed unnecessary duplicate orders for medications. This finding was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications during the survey. The findings include: On 2/11/26 at 9:30 AM, the surveyor reviewed Resident #8's medical record. The review revealed trazodone (an antidepressant) was ordered for Resident #8 on 3/19/25 and stated, give trazodone 50mg by mouth at bedtime for depression. On review of the August 2025 Medication administration this was last given on 8/6/25 (the order discontinued on 8/7/25). On further review an additional order for trazodone was written on 8/5/25 and stated, give trazodone 50mg (three tabs to equal 150mg) by mouth nightly for insomnia. On review of the MAR this dose was given on 8/6/25 and 8/7/25 then discontinued on 8/7/25. Trazadone was given twice on 8/6/25 due to duplicate order. The surveyor next reviewed Resident #8's current medication orders. The review revealed an…

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

Based on observations and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 2 of 3 observations for Resident #8. The findings include: On 2/8/26 the surveyor observed that Resident #8 had an inhaler next to him/her. The surveyor asked Resident #8 when the last time he/she used the inhaler. Resident #8 stated that he/she had taken a dose in the night when his/her breathing felt tight. The surveyor noted the inhaler was albuterol (a rapid-acting bronchodilator often called a rescue inhaler, used to treat or prevent bronchospasms) On 2/12/26 at 11:28 AM, the surveyor along with Unit Manager (UM) #10 both observed Resident #8 with his/her albuterol inhaler next to the resident. After leaving the room the surveyor asked UM #10 if Resident #8 was supposed to have medication at the bedside. UM#10 stated Resident #8 did not have an order or assessment completed to ensure self-administration of the inhaler was appropriate. She further stated she would remove the inhaler and pursue the step needed to identify…

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, observation and record review it was determined that the facility failed to follow up on dental care recommendations. This was found to be evident for 1 (#131) of 1 residents reviewed during the recertification survey. The findings include:On 02/08/26 at 8:40 AM, the surveyor interviewed Resident #131. The resident stated they had no teeth or dentures and had experienced discomfort from chewing on their gums. The surveyor observed the resident had no teeth while they ate breakfast. On 02/10/26 at 8:15 AM, a review of Resident #131's notes revealed dental/oral evaluations from 10/19/25, 01/23/26, and 01/26/26. The evaluations or dental notes did not mention a pending consult. The resident's last appointment was on 08/19/24 for dental extractions. On 02/12/26 at 9:34 AM, a review of Resident #131's dental consultation recommendations from 03/18/2024 stated Please call the attached number (410- - ) to schedule dental surgery. The process to start making dentures (5 appointments total) can be done 1-2 months after surgery. On 02/13/26 at 8:11 AM, the 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 observation, an interview and record review the facility failed to maintain proper infection control procedures, specifically regarding staff's use of beard nets in the kitchen. This was evident during the follow-up tour of the kitchen. The findings include: On 2/11/2026 at 12:32 PM Staff #16, the [NAME] entered the kitchen with a hair net, washed their hands and went to the walk-in refrigerator and removed lettuce, tomatoes and ham. Staff #16 put on gloves and began cutting tomatoes, lettuce and ham. On 02/11/2026 at 12:41 PM Staff # 15, the Kitchen Director in Training went over to Staff #16, the [NAME] and assisted them with putting on a beard net. On 2/11/2026 at 2:00 PM Staff #17, the Kitchen Director, was interviewed and asked if it was required for kitchen staff to wear hair and beard nets while in the kitchen. Staff #17 replied yes hair and beard nets are required in the kitchen. Then Staff #17 was informed that Staff #16, the [NAME] was not wearing a beard net to cover their beard while cutting, tomatoes, lettuce and ham. Staff #17 did acknowledge that Staff #16…

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

Based on facility staff interviews and surveyor record reviews it was determined that the facility failed to maintain Resident medical records that were accurate and reflective of the Residents' care. This finding was found to be evident in 2 (Resident #19 and #126) out of 7 Residents reviewed for Resident records - identifiable information.The findings include:Anticoagulant medication, or blood thinners prevent dangerous blood clots in veins, arteries, and the heart, reducing stroke and heart attack risk. These medications work by inhibiting specific clotting factors in the blood, with major side effects including increased bleeding.Antiplatelet medication is a drug that prevents blood cells called platelets from sticking together to form dangerous blood clots, reducing the risk of heart attacks, strokes, and cardiovascular events. These medications are crucial for patients with coronary artery disease, stent placement, or prior vascular events.Care Plan is a tailored document summarizing a person's health conditions, care needs, medications, and goals with interventions to ensure…

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 record reviews, it was determined that the facility failed to 1) maintain infection prevention control practices for the storage of linen and 2) have a process to identify residents who required transmission based precautions. This was found to be evident in 2 (27 and 112) out of 2 rooms and 1 out of 3 nursing units reviewed for infection prevention and control during the recertification survey. The findings include: 1) At 7:40 AM on 2/11/2026 the surveyor conducted a random observation of the nursing unit. Outside of room [ROOM NUMBER], the nursing unit's clean linen cart was uncovered with folded linen observed on the three shelves of the cart. Additionally, employee #9 was observed administering medications to Residents and 2 Geriatric Nursing Assistants (GNAs) observed removing linen from the clean linen cart but did not cover the linen cart with the plastic pink cover that was attached to the cart. In an interview with employee #24 at 7:50 AM on 2/11/2026, the surveyor…

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

Based on observation and staff interview it was determined the facility failed to assure that a heating unit and oxygen concentrator were fully operational while in use in Resident care areas. This was found evident in 1 (Resident # 122's room) out of 55 rooms reviewed and 1 (Resident #8) out of 2 residents reviewed for oxygenation. The findings included: On 2/8/26 at 9:11 AM, the surveyor observed that Resident #8 was utilizing oxygen via nasal cannula (a tube placed in the nares used to deliver supplemental oxygen). The nasal cannula was attached to an oxygen concentrator (a machine that extracts and filters nitrogen from ambient air to deliver 85-95% pure oxygen). The surveyor noted that 3 liters of oxygen per minute were being delivered to the resident from the oxygen concentrator. Resident #8 stated that he/she was supposed to have 4 liters of oxygen however, the machine was unable to maintain 4 liters and could only be turned as high as 3. On 2/11/26 at 11:48 AM, the surveyor reviewed Resident #8's orders. On 11/5/25 an order was written for Resident #8 to have 4 liters/minute…

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

Based on observation and interview it was determined the facility failed to 1) ensure a resident had access to the call bell and 2) ensure a call device was accessible in each shower. This was evident for 2 of 3 observations for (Resident #1) and also during the environmental tour of the facility conducted during the recertification survey.The findings include:1) On 2/8/26 at 8:25 AM, the surveyor observed Resident #1's soft touch call bell on the floor next to Resident #1's bed. On 2/8/26 at 8:27 AM, the surveyor conducted an interview with Resident #1's Geriatric Nursing Assistant (GNA) #5. During the interview GNA #5 stated that the call bell must have fallen out of bed when the previous shift repositioned him/her. The surveyor asked GNA #5 if it was expected to check the resident to make sure that they have the call bell in reach before leaving. GNA #5 stated that was her practice. On 2/12/26at 6:22 AM, the surveyor observed GNA #29 providing care to Resident #1. The surveyor also observed the call bell on the ground. On 2/12/26 at 6:57 AM, the surveyor returned to Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to maintain a safe, functional, sanitary and comfortable environment for the residents, facility staff and the public. This was found to be evident in the facility reviewed for a safe, functional, sanitary and comfortable physical environment.The findings include:1a. On 2/8/26 at 8:16 AM, the surveyor made an observation in room [ROOM NUMBER] and noted that the hand sanitizer in room [ROOM NUMBER] was not able to dispense any hand sanitizer. On 2/8/26 at 8:20 AM, the surveyor walked into room [ROOM NUMBER] and again the hand sanitizer would not dispense. On 2/8/26 at 8:28 AM, the surveyor conducted an interview with Geriatric Nursing Assistant (GNA) #5. During the interview GNA #5 confirmed that the hand sanitizer in room [ROOM NUMBER] was not working and stated that on Friday she told housekeeping about it. The surveyor also informed GNA #5 of room [ROOM NUMBER]'s hand sanitizer not working. On 2/8/26 at 9:19 AM, the surveyor observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, it was determined that the facility failed to keep the premises free of pests. This deficient practice had the potential to impact all residents. The findings include: On 02/08/26 at 8:40 AM, the surveyors interviewed Resident #131 and they stated I see roaches in my room all of the time. On 02/08/26 at 10:02 AM, the surveyors observed a dusty pest trap under the wall mounted ventilation unit, cobwebs, and a dead spider on the window in room [ROOM NUMBER].On 02/10/26 at 9:01 AM, the surveyors observed a bug crawling on the floor near Station 1. On 02/10/26 at 9:03 AM, the surveyor interviewed LPN #10, who stated there have been roach sightings throughout the facility. On 02/13/26 at 11:40 AM, the surveyors interviewed the Administrator, who acknowledged the pest control concerns.

Based on record reviews and interviews it was determined that the facility staff failed to ensure maintenance care was provided to a resident's tube feeding device. This was evident for 1 (#8) of 1 resident reviewed for tube feedings. The findings include:Percutaneous Endoscopic Gastrostomy (PEG) tube is a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall. It provides a way to deliver nutrition and medications directly into the stomach when a person cannot eat or drink orally.During a review of complaint # 2599868 on 10/27/25 at 7:52 AM it was reported that flushes were not being completed daily on the PEG tube for Resident #8.During a review of medical records on 10/27/25 at 12:14 PM it was discovered that the Resident #8 had a PEG Tube placed on 7/25/25 and was in place upon his/her admission to the facility on 8/12/25. During additional review of the orders for Resident #8 It was revealed that there were no orders placed for monitoring or flushing the PEG tube upon admission to the facility. There were orders added for the PEG tube 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 reviews of a complaint and a medical record, and interviews with facility staff, it was determined that the facility failed to notify the resident's physician regarding the incorrect documentation of a Resident's weight. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey. The findings include: Review of complaint MD00201378 on 04/28/25 revealed an allegation Resident #6 is not receiving care and services to heal a sacral wound. Review of Resident #6's clinical record on 04/28/25 revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that include: quadriplegia, recent placement of a gastrostomy tube on 02/19/25, a sacral pressure ulcer, malnutrition, and contractures of the right and left ankles. On 02/20/25 the nursing staff obtained a readmission mechanical lift weight of 113.8 pounds for Resident #6. On 02/26/25 at 7:01 AM, the nursing staff obtained a mechanical lift weight of 119.4 pounds for Resident #6. Review of Resident #6's care plans…

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 complaint, observations of a resident's wound care, and staff interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed for 1 (Resident #6) of 8 complaints reviewed during a complaint survey. The findings include: Review of complaint MD00201378 on 04/30/25 revealed an allegation that the facility was malodorous and unkept. During an observation of Resident #6's wound care dressing change in room [ROOM NUMBER]-A, on 05/02/25 at 10:45 AM, the nurse surveyor observed the following: 1) The privacy curtain was in disrepair and hanging on the floor and could not completely give Resident #6 privacy during care. 2) The bedside table was in disrepair and 2 of the 3 drawers were observed to be in disrepair and would not close. 3) The closet door was observed in disrepair and would not close completely. After the staff completed Resident #6's dressing change on 05/02/25 at 10:45…

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 complaint, reviews of clinical records and all pertinent administrative records, reviews of a hospital record, and staff interview, it was determined that the facility staff failed to immediately report an allegation of suspected resident abuse to the administrator and the State Survey Agency within 2 hours. This was evident for 1 (Resident #4) of 8 residents reviewed during a complaint survey. The findings include: Review of complaint MD00212137 on 04/21/2025 at 10 AM revealed an allegation that Resident #4 was hurt by a facility staff member while being lifted in a Hoyer (mechanical) lift because Resident #4 was not secured correctly in the Hoyer lift. In an interview with the facility Director of Nurses (DON) on 04/23/25 at 11:35 AM, the DON stated that there were allegations of abuse, facility reported incidents, or complaints regarding Resident #4. The DON stated that S/he would look in the administrative forms for a completed grievance form regarding Resident #4. Review of Resident #4's physical therapy progress notes on 04/25/25 revealed a physical therapy assistant…

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, facility investigation review, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's allegation of being physically injured by nursing staff members. This was evident for 1 (Resident #4) of 8 residents reviewed during the complaint survey. The findings include: Review of complaint MD00212137 on 04/21/2025 at 10 AM revealed an allegation that Resident #4 was hurt by a facility staff member while being lifted in a Hoyer (mechanical) lift because Resident #4 was not secured correctly in the Hoyer lift. In an interview with the facility Director of Nurses (DON) on 04/23/25 at 11:35 AM, the DON stated that there were allegations of abuse, facility reported incidents, or complaints regarding Resident #4. The DON stated that S/he would look in the administrative forms for a completed grievance form regarding Resident #4. Review of Resident #4's physical therapy progress notes on 04/25/25 revealed a physical therapy assistant (PTA#1) progress notes dated Monday, 10/21/24 at 3:53 PM that indicated Resident #4…

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 complaint, reviews of all pertinent documentation and clinical records, and staff interview, it was determined that facility staff failed to implement parts of a comprehensive care plan for a resident. This was evident for 2 (Resident #6, #7) of 8 residents reviewed during a complaint survey. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1) Review of complaint MD00201378 on 04/28/25 revealed an allegation Resident #6 was not receiving care and services to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint and a medical record, and interviews with facility staff, it was determined that the facility failed to maintain or improve a resident's nutritional status after having a feeding tube placed. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey. The findings include: Review of complaint MD00201378 on 04/28/25 revealed an allegation Resident #6 is not receiving care and services to heal a sacral wound. Review of Resident #6's clinical record on 04/28/25 revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that include: quadriplegia, recent placement of a gastrostomy tube on 02/19/25, a sacral pressure ulcer, malnutrition, and contractures of the right and left ankles. On 02/20/25 the nursing staff obtained a readmission mechanical lift weight of 113.8 pounds for Resident #6. On 02/26/25 at 7:01 AM, the nursing staff obtained a mechanical lift weight of 119.4 pounds for Resident #6. Review of Resident #6's care plans revealed a…

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

Based on reviews of closed and active medical records, reviews of all pertinent administrative records, and staff interviews, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 2 (Residents #1, #4) of 8 residents reviewed during the complaint survey. The findings include: Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, observation, reviews of all pertinent documents and clinical records, and resident interview, it was determined that the facility staff failed to ensure that a resident's bed could adequately meet the resident's needs. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey. The findings include: Review of complaint MD00201378 on 04/28/25 revealed an allegation Resident #6 was not being groomed, bathed, or shaved. Resident #6 also had a bed sore. Review of Resident #6's clinical record on 04/28/25 revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that include: quadriplegia, gastrostomy tube, and contractures of the right and left ankles. On 01/11/25 the staff obtained a height of 73 inches. On 04/04/25 the nursing staff obtained a wheelchair weight of 113.0 pounds. During an observation of Resident #6 on 05/02/25 at 10:45 AM with the facility director of nurses (DON), the surveyor observed Resident #6's right and left feet hanging over…

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 the surveyor's observation and interview with staff, it was determined that the facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. This has the potential to affect all residents. The findings include: Full-time means working 35 or more hours a week. Part-time employees typically work fewer hours in a day or during a work week than full-time employees. The U.S. Department of Labor, Bureau of Statistics uses a definition of 34 or fewer hours a week as part-time work. On 08/19/24 at 08:29 AM, interview with food service manager, staff # 51, revealed that he/she has a serve safe certificate, but does not have an active certified dietary manager (CDM) certificate. He/She was certified with CDM before, but it expired due to not maintaining the required CEUs. He/she sent transcripts to the program to start taking classes. Staff # 51 also revealed that the Registered Dietician (RD), staff #12, works part time 16 hrs, and Consultant Registered Dietician, staff # 53, works 8 hrs. 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 record review it was determined the facility failed to: ensure an effective process was in place to report pest issues, ensure pest issues were effectively and timely managed, and ensure the environment was free from pests. This was evident during the surveyor's review of complaints and during the facility's recertification/complaint survey and has the potential to affect all residents. The findings include: On 8/19/24 at 10:33AM Resident #92 reported to the surveyor that there were lots of flies/gnats in their room and especially in their bathroom. On 8/19/24 at 10:50AM Resident #32 reported to the surveyor their observations of pests within the room which included gnats. On 8/19/24 at 10:55AM Resident #354 reported to the surveyor the presence of flies within their bathroom. On 8/20/24 at 10:46AM Resident #7 reported to the surveyor in the hallway of station one, that their skin had become very itchy including their scalp. The resident was observed to be actively itching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain a clean, homelike environment. This was evident throughout the facility in some resident rooms and common areas during the recertification/complaint survey. The findings include: During surveyor's initial tour on 8/19/24 at 8:36AM the surveyor observed various resident belongings within three cardboard boxes and two plastic bags amongst other items including a plastic urinal, stacked up against the baseboard heating. Further observation of the room revealed splattered food like material, debris, and crumbs present across the resident's wall below their window, and across their wall air conditioning unit, and a full trash receptacle next to the resident's bed. The floor was observed to have sticky soiling and debris present in various areas and extending from the corner of the room to underneath bedside furniture. The mirror affixed to the wall was observed to have a cloudy appearance. An interview was conducted on 8/19/24 at…

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

1c) On 8/29/2024 at 10:50 AM, review of Facility Reported Incident (FRI), MD00182377, revealed that Resident #158's daughter stated since she reported a CNA (Certified Nursing Assistant) was rough with Resident #158, the resident has been neglected and was not being changed timely. Further review of the facility investigation report of the incident revealed staff training on abuse done in February 2022 after the incident and staff sign-in sheet on file. Staff and resident interviews were on file. However, the CNA mentioned in the FRI was not identified and there was no statement from her/him regarding the incident. On 8/29/2024 at 1:10 PM, additional review of the investigation report of the FRI revealed an email from the then Director of Nursing dated 2/15/2022 at 9:43 AM which stated that I made the daughter aware on Sunday when I was here, and she insisted on talking to me. Now that I know which GNA (Geriatric Nursing Assistant) it is, she's off their assignment however I have 2 staff going in to care for them, even when the family is there. However, the GNA was not identified…

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 a review of resident medical records and interviews with residents and facility staff, it was determined that the facility failed 1) to provide care timely when the resident had injuries after a fall, 2) to administer medication when the resident had a sore in the mouth 3) to follow up with resident with a new change in condition, 4) to document blood sugar as ordered and to implement an order for pressure relief, and 5) to ensure residents receive medications as ordered by the physician. This was evident for 5 (Resident #187, #175, #190, #49, and #160) ) of 78 residents reviewed during the recertification/complaint survey. 1) On 8/28/24 at 11:09 AM, the surveyor reviewed complaints. The review revealed that a complainant reported a few concerns regarding Resident #187's care: when the resident's family members went to the facility to pick the resident up for his/her dental appointment on 10/28/22, they observed that Resident #187 was rocking back and forth in a wheelchair with pain. The resident had a…

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

Based on observation and interview with residents and staff, it was determined that the facility failed to promote care of residents in a manner and in an environment that maintains or enhances each resident's dignity and respect by failing to serve residents seated at the same table food at the same time. This was identified for two residents (Resident #356, #90) when observing dining during a recertification/complaint survey. The findings include: On 08/19/24 at 12:06 PM a dining observation in the main dining hall revealed that three alert and oriented residents were seated at table #2. Food was served for two of the residents and third resident was served food after 12 minutes. Additionally, two alert and oriented residents were seated at table #4. Food was served for one resident and the other resident was served food after 12-14 minutes. On 08/19/24 at 12:48 PM Resident #356, stated that he/she told the staff before he/she comes to the dining room every day, and the staff keeps messing up his/her food. Of the 19 residents seated in dining room, 4 residents were served food…

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 a review of complaints, medical record reviews, and interviews with complainants and staff, it was determined that the facility staff failed to protect the privacy of residents' medical information by giving a resident's medication to a different resident upon their discharge. This was evident one (Resident #161) of 78 residents reviewed during a recertification/complaint survey. The findings include: The surveyor reviewed complaints on 8/27/24 at 1:00 PM. The review revealed that on 11/22/22, a complainant reported their concerns regarding the facility's possible medication error, evidenced by the facility giving another resident's medication to Resident #161 when he/she was discharged . In a phone interview with the complainant on 8/27/24 at 2:50 PM, the complainant said, When [Resident #161] was discharged from the facility on 11/15/22, they gave me a bottle of [medication name] with another resident's name on. I felt like it was a very dangerous situation. They did not know who took what medication. I still have that bottle. The surveyor requested the complainant to…

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

Based on record review and interview it was determined the facility staff failed to 1) report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ), 2) failed to report residents' injuries of unknown origin to OHCQ, and 3) failed to submit initial reports of the facility-reported incidents to OHCQ. This was evident for 2 (Resident #155, #158) of 13 residents reviewed for abuse and 4 (Residents #187, #162, #170, #171) of 14 residents reviewed for complaints and self-reported incidents during a recertification/complaint survey. The findings include: 1a) On 8/28/2024 at 9:50 AM, review of the investigation report of Facility Reported Incident (FRI), MD00182673, revealed Resident #155 reported on 8/18/2022 that the nurse bent their finger back while giving them meds. On 8/28/2024 at 11:00 AM, surveyor requested from the Director of Nursing (DON) the email/fax receipt of the initial and final (5-day) report of the FRI to the state agency (OHCQ). On 8/28/2024 at 12:28 PM, surveyor received the email receipt for 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 medical record review and staff interviews it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#49) of 4 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: On 8/19/24 at 2:39 PM review of resident #49's medical record revealed that resident was sent out to the hospital on 7/8/22 and again on 12/26/22 for a change in medial condition. Further review of the nurses' notes for the 7/8/22 hospital transfer and the 12/26/22 did not reveal that a notice of transfer was given. Continuing review of the medical chart failed to produce a copy of the notification for transfer that was given to the resident on the two hospital transfers. The administrator was asked to find the missing documents on 8/28/24 at 12:33 PM. He came back to report that it was not there and could not be found. 08/28/24 12:34 PM the Director of Nursing (DON) -in an interview was asked about the expectation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of medical records and staff interviews, it was determined that the facility failed to provide the resident and or their representative with a summary of the baseline care plan. This was evident for 1 (Resident # 10) of 1 resident reviewed for baseline care plans, during a recertification/complaint survey. The findings include: On 08/27/24, at 09:40 AM, medical record review revealed that the Resident #10 was admitted to the facility on [DATE]. Further review of medical records failed to reveal that a copy of the baseline care plan summary was offered to Resident #10 or the resident's representative during the care conference held on 7/30/2024 at 11:52am. In accordance with the Code of Federal Regulations 42 CFR 483.21(a)(3), the facility must provide the resident and the representative with a written summary of the baseline care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include Initial goals for 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 the review of medical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-centered care plan, that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. This was evident for four (Resident # 191, #7, #254, #10) out of 78 residents reviewed for during the recertification/complaint survey. The findings include: A wound vacuum, also known as a vacuum -assisted closure (VAC) device, is a treatment that uses a suction pump to help heal wounds. 1)On 9/5/24 at 2:57 PM review of a complaint incident MD00183891 stated that Resident #191 went for her doctor's appointment and ended up being admitted for septic wound infection. The complaint alleged s/he was told by the hospital physician that the infection resulted from the wound not being managed properly by the facility. Review of Resident #191's plan of care on 9/5/24 at 3:11pm failed to produce a care plan for the resident's multiple wounds. Only a risk for skin breakdown care plan 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, record review and interviews, it was determined that the facility failed to revise and update resident's comprehensive care plans. This was evident for 2 (Resident #46, #10) of 78 residents reviewed during a recertification/complaint survey. The findings include: 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) On 8/19/24 at 9:20 AM, during the initial observation tour of the facility, Resident #46 was observed in bed in their room. The resident was not on oxygen therapy and did not have a tracheostomy, an opening into the trachea where a tube is inserted to assist with breathing. Review of the care plan with revision date of 10/6/23 on 8/22/24 at 9:11 AM had, Resident has oxygen therapy related/to (r/t), Pneumonia (PNA), respiratory failure. The goals were that resident will have no sign/symptoms of poor oxygen absorption through the review date. Further review also revealed a second care plan with revision date of 10/12/23 that had Resident has a…

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

Based on observation, interview and record review, it was determined that the facility staff failed to follow professional standards of nursing practice when administering medications to residents by 1) not verifying current order before administering, 2) not documenting controlled medications use on the count sheet and Medication Administration Records, and 3) mishandling Insulin pen. This was evident for 4 (Resident #86, #66, #21, #8) of 5 residents reviewed for medication administration during the recertification/complaint survey. The findings include: Nurses follow several professional standards when administering medications, including: verifying the right patient, right medication, right dose, right route, right time, and right documentation. [Simple nursing June 2024] A controlled medication utilization record (known as a count sheet) is a form to record controlled medication dispense. It documents the details for each use of any controlled substance amount removed from its original containers, including date, time, the dose given, the signature of the nurse administering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to meet the resident's rehabilitation needs and failed to provide the necessary care which the facility had to ensure and not diminish the resident's functional abilities and skills. This was evident for 2 (Residents #41 & #65) of 3 residents reviewed for rehabilitation and restorative services during a recertification/complaint survey. The findings include: ADLs are activities related to personal care with adaptive ability. They include grooming, bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. 1) Observation, on 08/19/24 at 10:01 AM, found that Resident #41 crawled up in the bed and was semi- dozing off. During an interview, the resident shared that I used to get up and ambulate myself but I could not walk after months of hospitalization. Then I was discharged over here, had some physical therapy (PT)/occupational therapy (OT), then they stopped, but did not tell me why. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the complaint, record review, and interview, it was determined that the facility failed to provide appropriate care and treatment to a resident with a pressure ulcer. This was evident for 1 (Resident #182) of 9 residents reviewed for pressure ulcers during a recertification/complaint survey. The findings include: A pressure ulcer, a bedsore or pressure sore, is an open wound that occurs when skin is damaged by prolonged pressure. Pressure ulcers can range in severity from discoloration to open sores that expose bone or muscle. They can be painful and take a long time to heal. Pressure ulcers often develop on bony areas of the body, such as the heels, ankles, buttocks, hips, tailbone, and back. They can occur in people who are bedridden or use a wheelchair and are more likely to develop in areas where the body rests against the chair or bed On 9/3/24 at 1:17 PM, a review of a complaint dated 12/7/2022 revealed that Resident #182 was admitted to the facility on [DATE]. The family member…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure a resident room was maintained free from accident hazards. This was evident for one( Resident #7) out of one resident reviewed for resident to resident interaction duing a recertification/complaint survey. The findings include: On 8/20/24 at 10:46AM the surveyor was approached by Resident #7 who reported their concerns for the environmental conditions that existed behind their bed located in room [ROOM NUMBER]. At this time, Resident #7 requested for the surveyor to observe the concerns. On 8/20/24 at 10:48AM the surveyor observed three sharp metal screws, each approximately 1 inch in length with sharp edges exposed protruding upward from a broken, separated area of the baseboard heat cover which additionally had sharp edges exposed among other environmental concerns. On 8/20/24 at 10:48AM the surveyor conducted an observation in room [ROOM NUMBER] with Unit Manager #20, and Director of Social Work #5, who acknowledged 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 1) ensure a resident admitted to the facility with a suprapubic catheter received care and develop a care plan which included the use of the catheter and associated interventions, 2) evaluate a foley catheter when a resident had repeated clogged foley catheter issues, and 3) ensure a resident with a foley catheter had a medical order for care of the catheter. This was evident for 3 (Resident #156, #254 and #154) of 4 residents reviewed for bowel and bladder incontinence during the recertification/complaint survey. The findings include: A suprapubic catheter is a tube that drains urine from the bladder through a small incision in the lower abdomen. It's used when other methods of draining urine aren't possible, desirable, or clinically feasible. A Foley catheter is a type of urinary catheter that drains urine from the bladder into a collection bag outside the body. It's also known as an indwelling urinary catheter (IDC). 1)During an review of complaints on 8/27/24 at 10:50 AM it was noted 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 observation, medical record review, and interview it was determined that the facility staff failed 1) to maintain the resident's meal proportions to assure a desirable body weight. The inadequate meal proportions resulted in severe weight loss of more than 12% in 6 months, and 2) to notify the Physician regarding the resident's significant weight loss and revised their care plan. This was evident for 2 (Resident #60 and #175) of 5 residents reviewed for nutrition during a recertification/complaint survey. The findings include: 1) During a floor rounding, on 8/20/24 at 10:20 AM, Resident #60 was observed running in the hallway attempting to take apple sauce from the medication cart. The resident kept saying I'm hungry. GNA Staff #22 carried some food in her hands and the resident followed her back to his/her room. Further observation, on 8/28/24 at 09:00AM, found that Resident #60's tray had 3 scoops of pureed diet and no other foods were on the tray. Again, resident was seeking for food after eating. Record Review, on 8/28/24 at 1:55PM, revealed that Resident #60 had a…

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

Based on observation, record review, and interview, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feeding. This was evident for one (Resident #88) of three residents reviewed for tube feeding during the recertification/complaint survey. The findings include: A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is enteral feeding or tube feeding. Osmolite is therapeutic nutrition that provides complete, balanced nutrition for long-or short-term tube feeding for patients with caloric requirements of less than 2000 calories per day or for patients with increased protein requirements. It is used for tube feeding and as supplemental or sole-source nutrition. On 8/20/24 at 8:18 AM, the surveyor observed Resident #88's Osmolite bottle of tube feeding hanging on a pole but not running. On 8/22/24 at 10:40 AM, the surveyor observed another Osmolite bottle 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and medical record review, it was determined that the facility failed to ensure that pain management is provided to residents who require such services. This was evident for two (Residents #161, #10) out of four residents reviewed for pain management during a recertification/complaint survey. The findings include: 1)During a review of complaints on 8/28/24 at 7:36 AM, it was revealed that a complainant expressed concerns regarding Resident #161's care: the resident was suffering in great pain but did not receive pain medication timely. A review of Resident #161's medical records on 8/28/24 at 7:45 AM revealed that the resident was admitted to the facility on [DATE] after a right knee replacement. Per the hospital discharge records, the resident's pain was managed by Oxycodone (Oxycodone is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) 5mg- 10mg as needed. The 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.

Based on observation, interview, and record review, it was determined that the facility staff failed to ensure a registered nurse had the skills to provide necessary care for residents who needed insulin. This was evident for 1 (Registered Nurse #9) of 3 Nurses observed for medication administrations during a recertification/complaint survey. The findings include: An insulin pen is a device that looks like a pen used to inject insulin into the body. It is a type of insulin therapy for people with diabetes. Insulin pens have a cartridge filled with insulin and a dial on the outside to set the dose. The pen has a single-use needle that injects the insulin into the subcutaneous tissue, the innermost layer of skin. On 8/27/24 at 10:06 AM, RN #9 was observed drawing insulin from the insulin pen using a one cubic centimeter (cc) syringe and drawing 25 units of insulin. When asked why he/she used a separate syringe to draw the insulin, he/she stated that he/she drew from the pen because he/she felt that the resident didn't get the exact dose if a pen was used. The insulin was administered…

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 a review of employee records and interviews, it was determined that the facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was evident for 1 (GNA #30) of 3 randomly selected GNAs' records reviewed for annual training requirements during the recertification/complaint survey. The findings: On 8/27/24 at 8:40 AM, a review of randomly selected GNA's records revealed that GNA #30 was hired on 2/15/22. Further review of her personal file failed to produce a record of her annual performance review. On 9/9/24 at 10:15 AM In an interview the Director of Nursing (DON) was asked if the facility have a process for performance review for nurse aides. She said it's done yearly or every 90 days. She was asked who does the evaluation and she said it was done by the department heads such as herself, the Unit Managers and the Supervisors. She said that Human Resources (HR) department tracks it and would alert them on who was due for their annual evaluation review. She was made aware that GNA #30's evaluations could…

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

Based on record review and interview, it was determined that the facility failed to ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed reconciliation of dispensed and administered medication. This was evident for 3 (Resident #86, #66, and #21) of 5 residents reviewed for medication administration during a recertification/complaint survey. The findings include: Oxycodone and Oxycontin are narcotic medications used to treat moderate to severe pain. It is at high risk for addiction and dependence. It can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol or other illicit drugs such as heroin and cocaine. Percocet is a combination medication used to help relieve moderate to severe pain. It contains an opioid pain reliever (oxycodone) and a non-opioid pain reliever (acetaminophen). Oxycodone works in the brain to change how the body feels and responds to pain, while acetaminophen can also reduce a fever. On 8/27/24 at 1:20 PM, a review of the facility's document…

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

Based on record review and staff interviews, it was determined that the facility failed to follow up on a pharmacy recommendation for a resident. This was evident for 1 (#46) of 5 residents reviewed for unnecessary medication during a recertification/complaint survey. The Findings include: On 08/23/24 at 1:15 PM a review of the Medication regimen review records from January to August 2024 was conducted for resident #46 and revealed that on 1/2/24 the pharmacist made a recommendation which stated, resident had an order Divalproex (use to treat bipolar disorder and epileptic seizures) started that was not in their electronic medical records (PCC). He recommended to have the order added to PCC if resident was receiving it. Further review did not reveal that the recommendation was addressed by the attending physician. This medication was later started on 6/4/24 for this resident. On 08/27/24 at 8:24 AM the Director of Nursing (DON) was asked in an interview who was responsible for addressing pharmacy recommended reviews. She stated that it goes to nursing, and they pass it over to the…

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

Based on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 1 (#86) of 5 residents reviewed for unnecessary medications during a recertification/complaint survey. The findings include: On 8/21/2024 at 9:56 AM, review of Resident #86's medical record revealed the resident was admitted to the facility in January 2024 with medical diagnosis that included but not limited to low back pain, bladder cancer, Type 2 Diabetes Mellitus, fibromyalgia, osteoarthritis, rheumatoid arthritis, and chronic pain. On 8/21/2024 at 11:24 AM, review of physician orders revealed an active order with a start date of 6/27/2024 for Oxycodone tablet 15 mg, give 1 tablet by mouth every 4 hours as needed for chronic pain 6-10. Further review of the orders revealed orders for non-pharmacological interventions 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.

Based on interview and record review it was determined the facility failed to ensure monitoring for side effects of psychotropic medication use. This was evident for one (Resident #254) out of twenty-two residents reviewed for abuse during the facility's recertification/complaint survey. The findings include: Review of the medical record for Resident #254 on 8/30/24 at 10:39AM revealed no medication side effect monitoring was in place for use of the following antipsychotic medication: Quetiapine Fumarate. An active medical order was observed for the medication to be administered twice daily. On 8/30/24 at 10:42AM the surveyor conducted an interview with Licensed Practical Nurse #44 who observed the medical record and confirmed with the surveyor that no monitoring was ordered for antipsychotic medication side effects. On 8/30/24 at 10:48AM the surveyor shared the concern with the Director of Nursing who acknowledged and confirmed understanding of the concern. On 8/30/24 at 10:50AM the surveyor reviewed the August 2024 treatment administration record (TAR) for Resident #254 which…

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

Based on observation and interview it was determined the facility failed 1) to ensure the secure storage of medications, 2) to ensure that medications were properly labeled and stored, and 3) to provide safe and secure storage to minimize loss or diversion of narcotic medications. This was evident for three residents (Resident #31, #56, #79) observed to have medications in their room, 2 (station 2 and station 3) of 3 medication rooms, 3 (station 3 cart 1, station 1 cart 3 and station 2 cart 1) of 6 medication carts, and 2 residents (Resident #170 and #162) reviewed for safe medication storage and labeling during the facility's recertification/complaint survey. The findings include: 1) During the surveyor's initial tour on 8/19/24 at 8:32AM an open uncapped bottle of Dakins topical antiseptic wound solution and tube of Santyl ointment was observed to be present on the windowsill next to Resident #31, and no staff were present in the room. Further observation of the room revealed the resident's wound care supplies was present on their furniture next to their television. The following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the surveyor's observation, interview with facility staff, and medical record review, the facility failed to maintain medical records on each resident in accordance with professional standards and practices that are: i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. This was evident for three residents (Resident #187, #31, # 10) out of 78 residents reviewed during the recertification/complaint survey. The findings include: 1)On 8/28/24 at 11:09 AM, the surveyor reviewed complaints about residents' care at this facility. One complainant reported that Resident #187 did not receive appropriate care regarding his/her health condition. A review of Resident #187's medical records on 8/28/24 at 11:15 AM revealed that the resident was transferred to the hospital on [DATE] around 1-2 PM for further evaluation after the fall and was not readmitted to the facility. However, blood pressure was documented on Resident #187's electronic medical record vital sign…

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

Based on observation and interview, it was determined the facility failed to ensure staff performed hand hygiene prior to administering medications and used appropriate handling to prevent infection. This was evident for one (a Licensed Practical Nurse #13) out of three nurses observed administering medications during the recertification/complaint survey. On 8/27/24 at 9:11 AM, during medication administration, the Licensed Practical Nurse (LPN #13) was observed not performing hand hygiene when he/she prepared the medications of Resident #21. LPN #13 was also observed poking the blister pack of medication with a pen to get the tablet. The surveyor asked LPN #13 if it was standard practice in the facility to use a pen to get the medications out of a blister pack; he/she stated that he had a hard time opening the pack, so he/she had to find a way. She added he/she did not do it all the time, only when it was hard to open. During an interview with the Director of Nursing (DON) and a corporate nurse (Staff #10) on 8/27/24 at 2:20 PM, they stated that nurses were expected to do hand…

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

Based on observation and interview it was determined the facility failed to ensure two handrails were firmly secured. This was evident during the surveyor's environmental tour during the facility's recertification/complaint survey. The findings include: On 8/27/24 at 11:11AM the surveyor observed two handrails located against the wall next to the facility's kitchen that were off centered in appearance. Upon closer observation, the surveyor noted that two metal screws were observed to be loose which protruded through the handrail and into a block of wood, and then into the wall. At this time, the handrails were utilized and found to be movable and not firmly secured. On 8/27/24 at 11:31AM the surveyor conducted an environmental tour and shared the concerns with the facility's Director of Maintenance #38 who observed, acknowledged and confirmed understanding of the surveyor's concern. The Director of Maintenance reported being unaware of the loose condition of the handrails. On 9/9/24 at 10:49AM the surveyor shared concerns with the facility Administrator who acknowledged 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to complete a discharge summary on a resident to include a recapitulation of the resident's stay in the facility. This was evident in 3 of 45 residents (Resident #80, #81, #82) reviewed during the investigative portion of the survey. The findings include: 1. Review of the closed medical record for Resident #80 on 10/11/19 08:24 AM revealed the resident was transferred to the hospital on 8/6/19 for a change in condition. The resident did not return, was not admitted to the hospital and passed away in the emergency room. Further review of the resident's medical record failed to reveal any physician review of the resident's stay while in the facility. The Director of Nursing (DON) was interviewed on 10/11/19 at 9:12 AM and confirmed that there was no further documentation available from the physician regarding the resident's stay in the facility or regarding his/her discharge. 2. Review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it was determined that the facility failed to have adequate ventilation to ensure good air circulation to keep all parts of the facility odor free. This was evident during the initial tour of the facility. The findings include: On 10/7/19 at 9:00 AM the surveyors entered and began the initial tour of the facility. Immediately upon entering the building, a distinct smell of ammonia was observed by all surveyors and was persistent throughout Station 1 of the facility. This finding was confirmed by Nurse #11 working on Station 1 at the time of the observation. Upon checking the function of the two exhaust fans with the Maintenance Director it was revealed that the first exhaust vent outside room [ROOM NUMBER] was only the intake face of the exhaust system and did not include duct work. The second exhaust system outside room [ROOM NUMBER] was operational but covered with dust and needed to be clean. All nursing care centers must provide for adequate and functional…

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 administrative record review and interviews with facility staff it was determined the facility failed to thoroughly investigate allegations of abuse. This was evident for when 2 facility reported incidents (Resident #57 and #181) reviewed during the survey. Findings include: 1. On 10/10/19 a facility reported incident investigation was reviewed. The information provided in the self-report indicated that on 4/22/19 Resident #57 complained of left knee discomfort and after an x-ray was obtained it showed a mildly displaced fracture of the distal femur (broken knee bone). The facility investigated Resident #57's injury of unknown origin. The facility's investigation revealed a form that contained typed questions used for the staff that were interviewed. None of the staff interviewed signed the form and there were no written statements from staff included in the facility's investigation. Additionally, there were no resident interviews conducted. 2. On 10/10/19 a facility reported incident investigation was reviewed. According to the facility's investigation Resident #181…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information. This was found to be evident for 1 out of 4 residents (Resident #55) reviewed for hospitalization. The findings include: On 10/9/19 review of Resident #55's medical record revealed the resident had been originally admitted to the facility in early May 2019. The resident was discharged from the facility to the hospital the end of May 2019. Further review of the medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the resident or the resident's responsible party. On 10/9/19 the Director of Nursing confirmed that they currently do not have a process in place to provide the required transfer information. The concern regarding the failure to have a system in place to ensure resident or responsible party is notified about transfer in writing…

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

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failure to accurately document a residents discharge location and 2) failure to correctly assess a residents dental status. This was evident for 2 out of 45 residents (Resident #81, #18) reviewed during the investigation stage of the survey. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Resident #81's medical record was chosen for review as it was reported from its MDS as a hospital discharge. Review of the medical record for Resident #81 on 10/10/19 at 12:35 PM revealed the resident was in the facility for 5 days and transferred back out to the hospital according to a physician discharge summary…

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

Based on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered individualized comprehensive care plan as evidenced by failure to develop a care plan to address resident activities. This was evident for 1 out of 45 residents (Resident #230) reviewed during the investigation stage of the survey. 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. On 10/9/19 Resident # 230's medical records were reviewed and revealed the resident was readmitted to the facility in September 2019 for rehabilitation and with diagnoses which included Diabetes, increased cholesterol and weakness. Further review of the medical records revealed that the resident's primary language was non-English and that the resident requested an interpreter due to the resident understanding very little English. Review of the initial activity assessment revealed that the following were very important to the resident: participation…

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, interview and medical record review it was determined the facility failed to provide activity services as indicated in accordance to the resident's care plan and assessments. This was found to be evident for 2 out of 6 residents (Resident #36, and #230) reviewed for activities during the survey. Findings include: 1. An observation was made of Resident #36 on 10/7/19 at 10:40 AM and again on 10/8/19 at 9:31 AM. The resident was lying in bed on each day. Review of the Activities Initial Review Form for 8/7/19 revealed although the resident enjoys watching television, the resident does wish to participate in group activities, go on outings,1:1 activity with staff and independent activities (reading, puzzles, etc.). Review of the activity form for Resident #36 for August 2019 indicated an (A)= Active for the resident on the following dates: August 1, 2, 12, and 13, 2019. For September 2019, the activity form was completely blank. An interview was conducted with the Activities Manager (AM) #1 on 10/11/19 at 11:00 AM. She was asked to explain why the resident…

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

Based on observation and interview, the facility staff failed to apply TED stockings and to elevate legs on a pillow when in bed for Resident #18 this was evident for 1 of 45 residents during the investigative portion of the survey. The findings include: Medical record review for Resident #18 revealed on 9/24/19 the physician ordered: compression stockings (X-large) apply in AM remove in PM, and to elevate legs on a pillow when in bed. Compression stockings lower your chances of getting deep vein thrombosis (DVT), a kind of blood clot, and other circulation problems. Surveyor observation of Resident #18 on 10/07/19 at 10:30 AM, 10/08/19 at 08:45 AM and 10/11/19 at 12:30 PM, revealed Resident #18 lying on his/her bed however, the facility staff failed to apply the TED stockings or to elevate the resident's legs on a pillow. The Director of Nursing was made aware of these findings on 10/10/19 at 12 PM.

Based on medical record review and staff interview it was determined the facility failed to provide supervision to Resident #18 who was known to smoke cigarettes. This was evident for 1 of 45 residents reviewed for safety/supervision during this complaint survey. The findings include: A Resident Smoking Policy with a review date of November 2017 noted smoking hours are posted by the facility and smoking materials are secured in a locked area when not in use by the resident. Medical record review revealed Resident #18 had a Smoking Assessment completed on 8/23/2019, and indicated the resident was an independent smoker requiring supervision. The resident's care plan revealed that Resident #18 can smoke with direct supervision only. On 10/07/19 from 11:00 AM to 12:00 PM Resident #18 was observed smoking multiple cigarettes in the courtyard without supervision and on 10/08/19 08:45 AM Resident #18 was observed in his/her room with smoking paraphernalia. The Administrator and Director of Nursing were made aware of these findings on 10/8/2019.

Based on administrative record review, medical record review and interview with facility staff, it was determined that the facility 1) failed to properly manage and administer pain medication to a resident who was noted to have pain and 2) failed to initiate pain medication for a resident that was assessed as having pain on his/her daily pain assessment in addition to having pressure ulcers and pain medication ordered on a hospital discharge summary. This was evident in 2 of 6 residents reviewed for pain (Resident #181, and #183) during the review of a complaint and during the review of 1 of 2 residents (Resident #181) selected for the review of pain during the survey. The findings include: 1. Medical record review on 10/11/19 revealed Resident #181 was seen by the Medical Director on 3/14/19 for a change in condition and complaints of pain to the pelvic region. After an x-ray was done and a non-displaced fracture could not be excluded, a CT (computerized tomography) scan was recommended. The results of the CT scan showed no visible acute fracture. Review of the physician order…

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

Based on record review, observation and interview, it was determined the facility staff failed to obtain a medication error rate below 5%. Review of medication pass on 10/15/19 at 8:30 AM revealed the medication administration error rate was 5.71% for Resident (#330). This was evident for 2 out of 35 opportunities for error and 1 out of 4 residents observed for medication administration. The findings include: 1A. The facility staff failed to administer the correct amount of medication to Resident #330. Medical record review for Resident #330 revealed that on 10/2/19 the physician ordered: Lactulose 20 cc, three times a day for constipation. Lactulose is a synthetic sugar used to treat constipation. It is broken down in the colon into products that pull water out from the body and into the colon. This water softens stools. Lactulose is also used to reduce the amount of ammonia in the blood of patients with liver disease. It works by drawing ammonia from the blood into the colon where it is removed from the body. Review of medication pass on 10/15/19 at 8:30 AM revealed Staff #10…

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 upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evident for 1 of 45 residents (Resident #18) reviewed during the investigative portion of the survey. The findings include: An interview was conducted with Resident #18 on 10/07/19 at 10:54 AM when asked if the resident was experiencing any dental or oral issues the resident responded I have missing teeth and tooth pain. I told them I wanted to see a dentist. Medical record review revealed Resident #18 had a Dental Consult on 5/15/19 that revealed 2 retained roots that was causing discomfort for Resident #18. Further review of the medical record revealed that Resident #18 was complaining of tooth pain in the month of June 2019, at that time the physician ordered a Dental Consult for toothache on 6/26/19. There was no further Oral or Dental Assessment entered in the Resident's Medical Record. Interview with the Director of Nursing on 10/10/19 at 11:10 AM confirmed the facility staff failed…

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 6 newly hired employees, it was determined the facility staff failed to screen those 6 employees for MMR and Varicella. This was evident for 6 of 6 employee records (Staff #4, #5 #6, #7, #8, #9) reviewed during the annual survey. The findings include: Measles is a very contagious infection caused by a virus. It causes a total-body skin rash and flu-like symptoms. Once quite common, measles can now almost always be prevented with a vaccine Mumps is a viral infection that primarily affects saliva-producing (salivary) glands that are located near your ears. Mumps can cause swelling in one or both glands. Rubella - commonly known as German measles or 3-day measles - is an infection that mostly affects the skin and lymph nodes. It is caused by the rubella virus (not the same virus that causes measles). Most people who get rubella usually have a mild illness, with symptoms that can include a low-grade fever, sore throat, and a rash that starts on the face and spreads to the rest of the body. Varicella-chickenpox is an acute and very contagious disease caused by the…

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

Based on observation, resident and staff interviews and review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning fly control involving Resident's #18 but has the ability to impact all residents, staff and visitors in the facility. The findings included: On 10/7/19 at 10:00 AM it was noted Resident #18 was eating breakfast and 2 flies were flying around the food. Resident #18 was swatting the flies away with his/her hand while eating breakfast. The facility's pest control logs were reviewed on 10/9/2019 and showed that a pest control company services the facility approximately once a month for flies. The facility's pest control logs also revealed that Resident #18's room had flies in his/her room on 9/13/19 related to the mattress soaked in urine. The Administrator and Director of Nursing were made aware of these findings on 10/15/19 during the exit conference.