Autumn Lake Healthcare At Glen Burnie

Based on interviews and record review it was determined that the facility failed to ensure that all staff received their annual training for the compliance and ethic program. This was evident for 5 of 9 (Staff #42, #43, #44, #46 and #47) reviewed during the Extended Survey investigation portion of the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for (Staff #42, #43, #44, #46 and #47). Staff #41 was asked if they have any additional employee training/ in-services other than what is currently in their files. Staff #41 said they would check their old education system and let the surveyor know tomorrow morning. On 02/24/25 at 2:20 PM the Director of Nursing (DON) was interviewed about employee files missing various training courses and that some staff had no name and no supervisor signature to verify the training. The DON said to check with the Director of Human Resources and that they would look into this issue. On 02/25/25 at 9:00 AM Additional staff…

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 with facility staff, and review of the medical record, it was determined that the facility failed to ensure that a resident's documented dining preference was honored. This was evident for 3 of 15 residents (#57, #524 and #525) reviewed for dining preference during the recertification/complaint survey. The findings include: On 2/26/25 at 7:41 AM the surveyor interviewed Registered Nurse (RN #28). During the interview RN #28 stated that breakfast trays arrive to the unit around 8:15 AM. On 2/26/25 at 8:10 AM dietary was observed delivering breakfast cart to the unit. The surveyor noted that there was only one resident in the common/dining area. On 2/26/25 at 8:12 AM in an interview with RN #28 when asked why there was only one resident in the dining area during breakfast time, she stated most of the residents stay in their rooms for breakfast and get out of bed after breakfast. When asked if that was their preference, she stated she did not know if that was their preference but this is a skilled unit and so they get up anyway to go to therapy and then…

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

Based on record review and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive. This was evident for 1 (Resident #81) of 3 residents reviewed for advanced directives during the recertification/complaint survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 2/18/25 at 1:33 PM in an interview with Unit Manager (UM #27) when asked where resident's advanced directives can be found, she stated if they have an advanced directive, it would be in their paper chart. On 2/18/25 at 1:38 PM review of Resident #81's paper chart and electronic medical record revealed no documentation related to advance…

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 investigating complaints, record review, and interviews, it was determined that the facility failed to follow the grievance process for residents. This was evident for 2 (Resident #9 and #151) of 34 residents reviewed for the grievance process during this recertification/complaint survey. The findings include: On 2/18/25, around 9 AM, the surveyor reviewed residents' complaints. The review revealed that at least three residents expressed concerns related to their laundry services, missing clothes, stolen items, and misplacement; a) Resident #433's family member stated that they observed that the resident put on other residents' clothing, b) an anonymous complainant reported that the residents' person item stolen and misplaced, and c) Resident #445 reported that the facility's laundry machine was broken and not properly washing. The surveyor asked about residents' grievance process during an interview with the Nursing Home Administrator (NHA) on 2/25/25 at 9:04 AM. The NHA said, If residents filled out the forms, it is brought to my attention. I will review them, meet…

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 implement their policy for abuse, neglect and exploitation and their policy for employment background investigations. This was evident for one facility employee (Geriatric Nursing Assistant #64) during the surveyor's review of the following facility reported incidents and complaints: MD#00210602, MD#00210823, MD#00211759, and MD#00210884 during the recertification/complaint survey. The findings include: On 2/19/25 at 1:14PM the surveyor requested the complete investigation files for facility reported incidents, MD#00210823 and MD#00210602 from the facility's Administrator. On 2/19/25 at 8:25AM the surveyor conducted an interview with the facility's Director of Nursing who confirmed with the surveyor that GNA #64 was currently an active employee of the facility. On 2/19/25 at 1:46PM conducted a review of the facility's complete investigation file for MD#00210602 which revealed a copy of the background check which was performed for GNA #64 upon hire, in which their last name was observed to be contained in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to notify the Resident/Resident representative in writing about the bed hold policy when the Resident was transferred/discharged from the facility to an acute care facility. This was evident for one (Resident #64) of two residents reviewed who were transferred to an acute care facility during the recertification/complaint survey. The findings include: Review of the medical record for Resident #64 on 02/24/25 at 08: 40 AM revealed that Resident #64 was admitted to the facility on [DATE] and was sent to an acute care facility on 02/19/25 at 02:35 PM for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the Resident and /or the Resident representative were given written notice of the bed hold policy. The facility's documentation on the change in condition transfer form reveals that the bed hold policy was not given to the Resident and /or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the surveyor's observation, medical record review, and staff interviews, it was determined that the facility failed to have an accurate MDS (minimum data set) assessment regarding the status of dental issues for 1 (Resident # 38) of 80 Residents reviewed during the recertification/complaint survey. The findings include: The facility must comprehensively and accurately assess each Resident's functional capacity. Comprehensive assessment of a Resident's needs, strengths, and goals using the Resident assessment instrument (RAI) specified by the Centers for Medicare and Medicaid Services (CMS). The assessment must also include Dental and nutritional status. The information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. On 02/18/25 at 10 AM, the surveyor observed Resident # 38 missing teeth (both upper and lower jaws) and four front loose teeth (incisors) of the lower jaw. On 02/18/25 at 01:18 PM, a medical record…

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

Based on medical record review and staff interviews, it was determined that the facility failed to ensure that the Level II Preadmission screening and Resident review (PASARR) screen was completed by Adult Evaluation and Review Services (AERS) before the resident's admission. This was evident for 1 (Resident #82 ) of 60 residents reviewed for PASARR compliance. The findings include: Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions, who would then require PASARR Level II evaluation and determination before admission to the facility. The state mental health or intellectual disability authority must conduct a Level II Resident review within 40 calendar days of admission. 1) On 02/18/25 at 12:59 PM, the medical record review of Resident #82 revealed that 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 interviews with residents, review of medical records, and interview with facility staff, it was determined that the facility failed to ensure that residents and/or residents' representatives were provided with summaries of their baseline care plans including a list of their medications and failed to timely complete a baseline care plan. This was evident for 3 (#5, #57, and #145) of 34 residents reviewed for baseline care plans during the recertification/complaint survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. 1) Resident #57…

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, record review, and interviews of the residents and facility staff, it was determined that the facility failed to initiate and develop a comprehensive person-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 3 (Resident #38, #57, and #145) of 34 residents reviewed during the facility's recertification/complaint survey. The findings include: A care plan is an individualized guide that addresses the unique needs of each resident including both medical and non-medical concerns. It describes residents' needs and the interventions to address them and should be updated as changes in the residents' conditions occur. It is used to plan, assess, and evaluate the effectiveness of the resident's care they receive in a facility. Oxygen therapy is a treatment that provides you with supplemental, or extra, oxygen. It is only available through a prescription from your health 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 medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (#4) of 2 residents reviewed for Activities of Daily Living (ADL) care during a recertification/complaint survey. The findings include: In an interview with Resident #4 on 2/18/2025 at 9:30 AM, Resident #4 stated s/he had not been getting showers in the past 2 years and would like to have one. S/he added that they don't understand that taking showers help the body heal. Resident #4 also stated that the staff gave her/him bed baths and s/he would prefer that ADL care be provided after breakfast and not after lunch as was the current practice. On 2/19/2025 at 12:54 PM a review of Resident #4's quarterly MDS (Minimum Data Set) completed on 12/22/2024 revealed that the resident was totally dependent on staff for shower/bathe self, personal hygiene and dressing. The Brief Interview for Mental Status (BIMS) revealed a score of 13…

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 the resident medical records and interviews with facility staff, it was determined that the facility failed to 1) ensure that a resident followed up with a GI (gastrointestinal) specialist and 2) ensure that a physician's order for an anticoagulant lab draw was carried out. This was evident for 2 (Resident #11, and # 437) of 71 residents medical records reviewed during this recertification/complaint survey process. The findings include: Crohn's disease is an inflammatory bowel disease (IBD) that causes the digestive tract to become swollen and irritated. The symptoms are abdominal pain, diarrhea, weight loss, and rectal bleeding. This is a lifelong condition that can't be cured. However, treatments typically help manage your symptoms and allow you to live an active life. 1) During a complaint review on 2/21/25 at 9:24 AM, the surveyor reviewed Resident #437's medical record. The review revealed that the progress note written by the facility's staff on 7/24/24 stated, Resident returned from GI Consult, next follow-up scheduled in 2 months, MD/RP notified. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to monitor a resident's weight who was assessed as underweight and at risk of malnutrition. This was evident for 1 resident (Resident #29) of 5 residents reviewed for nutrition during the recertification/complaint survey. The findings include: Current standards of practice recommend weighing a resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document weight trends. A review was conducted of Resident #29's medical record on 2/21/25 at 8:21 AM and revealed a Nutrition Evaluation dated 12/11/2024. In the Nutrition Assessment section it stated, .Has potential for malnutrition d/t (due to) alcohol abuse, low BW (body weight) and fair appetite. In the Nutrition Goals section it stated, Weight without significant changes and Yes was checked for Proceed to Care Plan. Resident #29's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to 1) administer oxygen as prescribed, 2) label oxygen administration equipment, and 3) develop and implement a care plan that includes appropriate interventions for respiratory/tracheostomy care. This was evident for 2 (#57, and #115) of 4 residents reviewed for respiratory care during a recertification/complaint survey. The findings include: Oxygen flow meters are a relatively simple device that consists of a tube through which gas passes and a small, free-moving indicator such as a ball. When valves are open, the gas moves through the flow meter and causes the ball to float. A numbered scale on the tube along with the indicator allows the healthcare provider to determine the flow rate of oxygen. To ensure the most accurate reading of the flow rate, the flow meter is read at 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 medical record reviews, resident, a complaint review #MD00208110 and interviews, it was determined the facility staff failed to 1) ensure that a resident was given pain medication consistent with professional standards of practice and 2) assess the resident's pain level. This was evident for 3 (#38, #115, #431) of residents reviewed for pain management during a recertification/ complaint survey process. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) During an initial pool screen of Resident #115 on 2/18/2025 at 11:14 AM by a surveyor, the resident complaint of pain around the trachea (windpipe) area and rated the pain at 7/10 (severe pain). The surveyor notified the resident's nurse, Registered Nurse, RN #28. On 2/25/205 at 8:17 AM, a review of physician orders for Resident #115 revealed the following PRN (as needed) pain medication orders: - Oxycodone HCl Oral Tablet 5MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours as needed for Moderate…

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, observation, and resident and staff interviews, it was determined the facility failed to provide culturally competent, trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization for a resident with Post-Traumatic Stress Disorder (PTSD). This was evident for 1 (#145) of 2 residents reviewed for Behavioral-Emotional care during the recertification/complaint survey. The findings include: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. On 2/18/2025 at 11:11 AM,…

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

Based on observation, medical record review, and interview with staff, it was determined that the facility failed to promptly ensure that the Resident received the recommended dental services. This was evident for one Resident # 38 out of five Residents reviewed for dental services during the recertification/complaint survey. The findings include: On 02/18/25 at 10 AM, the surveyor observed Resident # 38 missing teeth (both upper and lower jaws) and four front loose teeth (incisors) of the lower jaw. The Resident's initial admission was on 04/07/2022, and he/she remained at the facility as a long-term care Resident. On 02/18/25 at 01:18 PM, a medical record review revealed that Resident #38 had a Doctor's order dated 07/12/24; dental consult 6-11 bridge failing. Recommendation EXT of the bridge by outside office: 1/10/25 Dietician and Nurses progress notes reveal that the dental procedure was pending. On 02/25/25 at 08:45 AM further medical record review revealed that the nurse's progress notes From 8/6/2024 at 12:43 PM stated the Resident was back to unit from a dentist…

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, interviews, and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (#11, #23) of 5 residents reviewed for dental services during the recertification/complaint survey. 1) On 02/18/25 at 11:35 AM, Resident #11 stated that she/he could not get a dental appointment for his/her top and bottom teeth. The surveyor observed missing teeth and side teeth with visual cavities. On 02/19/2025 at 1:52 PM, a record review revealed that Resident #11's MDS, dated [DATE] and 2/22/25 under Dental/Oral Evaluation, indicated that the resident has obvious or likely cavities or broken natural teeth. The care plan initiated date of 10/21/2024, with a revision date of 02/05/2025, noted that the resident had oral/dental health problems, such as missing and broken teeth. The care plan initiated on 02/06/2025 further indicated…

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 the medical record and staff interview, it was determined that the facility failed to ensure accurately documented resident's health condition. This was found to be evident for 1 (Resident #73) out of 3 residents reviewed for pressure ulcers during this annual survey. The findings include: On 2/22/25 at 8:50 AM, the surveyor reviewed Resident #73's medical records. The review revealed that the resident had sacrum, Right heel, and Left heel wounds upon his/her admission in July 2024. Further review of Resident #73's wound status by weekly skin assessment and wound consultation notes revealed that the Left heel pressure ulcer was resolved on 7/24/24 and re-started on 8/28/24 with worsening status. However, the Treatment Administration Records (TAR) of July and August 2024 documented the order of Left heel: Betadine and leave it open to air. everyday shift for wound treatment from Resident #73's admission till 12/17/24. During a phone interview with a wound consultation doctor (Staff #57) on 2/24/25 at 2:02 PM, he explained that betadine would be used for dried…

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

Based on interviews and an administrative record review, it was determined that the facility failed to have a full-time qualified social worker for the number of licensed beds exceeded 120 in the facility. This facility was licensed for 190 certified beds. This was evident during the recertification/complaint survey and had the potential to affect all residents, as a result an extended survey was conducted. Findings Includes: On 02/19/25 at 12:15 PM, in an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) it was revealed that the facility's licensed social worker comes in once a month. The NHA stated that they have 3 licensed social workers who work on a part-time/as needed basis, and there was full-time social services designee who did not have a qualifying bachelor's degree. On 02/21/25 at 10:17 AM in an interview with the facility social service designee (Staff #2), she revealed that she was not a licensed social worker. She has been working since August 2022 as full-time social service designee . She has a supervisor who is a licensed social…

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 1) ensure the maintenance of the facility's exterior environment and 2) ensure that repairs were made, as needed, in resident areas as identified in 3 resident rooms/bathrooms. This was evident for 2 out of 2 facility buildings observed during the recertification/complaint survey process. The findings include: 1) On 2/18/25 at 7:30AM upon initial surveyor entrance and tour of the facility, surveyors observed various areas of black and green debris/staining present on the outside exterior surface of the facility's main building. On 2/18/25 at 8:15AM the surveyor observed several windows with a white cloudy appearance on the facility's additional building. On 2/27/25 at 11:52 AM the surveyor conducted an additional observation of the exterior condition of the facility's main building and observed the following concerns: various areas of black and green debris/staining on the outside exterior building surfaces, two broken and frayed window…

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

Based on interviews and record review it was determined that the facility failed to complete the annual nurse aide in-service training. This was evident for 1 of 3 (Staff #6 GNA) reviewed during the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for Staff #6, GNA. Staff #41 was asked if they have any additional employee training/ in-services other than what is currently in Staff #6, GNA employee file. Staff #41 said they would check and let the surveyor know tomorrow morning. On 02/24/25 at 2:20 PM the Director of Nursing (DON) was interviewed about employee files missing various training courses and that some staff had no name and no supervisor signature to verify the training. The DON said to check with the Director of Human Resources and that they would look into this issue. On 02/25/25 9:00 AM Additional staff education documentation was received from Staff #41 for Staff #6, GNA. On 02/25/25 9:41 AM Record review of the employee educational files…

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

Based on interviews and record review it was determined that the facility failed to ensure that all staff received behavioral health training. This was evident for 3 of 9 (Staff #10 #43, and #46) reviewed during the Extended Survey investigation portion of the recertification/complaint survey. The findings Include: On 2/24/25 at 12:53 PM the Director of Human Resources (Staff #41) was interviewed about the employee training records for (Staff #10, #43, and #46). Staff #41 was asked if you have any additional employee training/ in-services other than what is currently in their files. Staff #41 said they would check their old education system and let the surveyor know tomorrow morning. On 02/24/25 at 2:20 PM the Director of Nursing (DON) was interviewed about employee files missing various training courses and that some staff had no name and no supervisor signature to verify the training. The DON said to check with the Director of Human Resources and that they would look into this issue. On 02/25/25 9:00 AM Additional staff education documentation was received from Staff #41 for Staff…

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 health records and interviews with facility staff, it was determined that the facility failed to notify Resident #449 or appointed family members after a dietary change. This was evident for one resident (Resident #449) out of seven residents reviewed during the complaint investigation. The findings include: The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment. 1) On 02/18/2025 at 10:49 AM, a review was conducted regarding complaint MD# MD00196883. The complainant stated that since 09/08/2023, Resident #449 had not been receiving the appropriate dietary foods at the nursing facility, despite being on dialysis. On 02/18/2025 at 11:08 AM, a review of records showed that on 08/29/2023 at 10:10 PM, Resident #449 was placed on a renal diet upon admission to the facility. The records also indicated that on 08/30/2023, the resident's BIMS…

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

Based on interview and record review it was determined the facility failed to ensure timely reporting of abuse allegations. This was evident for 1 out of 1 resident (Resident #151) reviewed for allegations of abuse during the surveyor's review of the following facility reported incidents and complaints: MD#00210602, MD#00210823, MD#00211759, and MD#00210884 during the recertification/complaint survey. The findings include: 1.) On 2/18/25 at 9:44AM the surveyor conducted an interview with Resident #151 who reported to the surveyor that they initially reported their sexual abuse concern regarding the facility's GNA to the Kitchen Account Manager #58 in September of 2024, approximately two and a half weeks after the incident occurred, and that they had let the Director of Nursing know they needed to report it. On 2/19/25 at 1:14PM the surveyor requested the complete investigation files for facility reported incidents, MD#00210823 and MD#00210602 from the facility's Administrator. On 2/19/25 at 1:43PM the surveyor reviewed the initial self-report form submitted by the facility 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 review of a facility reported incident it was determined the facility failed to ensure the thorough investigation of an allegation of abuse. This was evident for 1 out of 1 resident (Resident #151) reviewed for allegations of abuse during the surveyor's review of the following facility reported incidents and complaints: MD#00210823, MD#00210602, MD#00211759, and MD#00210884 during the recertification/complaint survey. The findings include: 1.)On 2/19/25 at 1:14PM the surveyor requested the complete investigation files for facility reported incidents, MD#00210823 and MD#00210602 from the facility's Administrator. On 2/19/25 at 1:43PM the surveyor reviewed the initial self-report form submitted by the facility to the Office of Health Care Quality (MD#00210823) which revealed the facility documented the type of allegation being reported was mental/verbal abuse and deprivation of goods and services by staff. The initial self-report form documented two allegations made by Resident #151, one of which involved an allegation received via text message from Resident #151 to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and interviews, it was determined that the facility failed to have documented evidence to support that the facility provided an ongoing program to support residents in their choice of activities. This is evident for 1(Resident #119) of 3 residents reviewed for activities services during the recertification/complaint survey. Findings Include: On 2/18/25 at 2:20 PM, in an interview with Resident #119's healthcare representatives, they revealed concerns that the facility failed to provide any activities to the resident. The healthcare representative stated that the resident was bedbound, alert but non-verbal and the facility never tried to get the resident out of bed to engage in any activities. On 2/25/25 at 10:44 AM, an observation revealed the resident resting in bed, awake, alert, but non-verbal, the TV on was on in the resident's room; however, no other activities observed. On 02/25/25 at 10:50 AM in an interview with licensed Practical Nurse (LPN #16), she stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, reviews of a closed medical record, and staff interview, it was determined that 1) a resident's physician failed to address a resident's total program of care, including treatments at each visit. 2) the facility wound physician failed to place a progress note in the resident medical record after each consultation. This was evident for 2 (Resident #63 and #66) of 70 residents reviewed during a complaint survey. The findings include: 1.) Review of complaint MD00165817 on 07/26/23 revealed an allegation Resident #63 was not assessed and treated timely. A review of Resident #63's closed medical record on 07/26/23 revealed Resident #63 was admitted to the facility on [DATE]. A review of resident #63's weekly nursing skin assessment form, dated 03/24/21, Resident #63 was identified with a Stage II, left buttock pressure ulcer that was shallow with a red, pink wound bed. The 03/24/221 skin assessment indicated that Resident #63's attending physician was made aware of the left buttock wound. 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 and interview, the facility failed to provide a safe and sanitary environment for its residents through failing ensure privacy curtains were clean. This deficient practice affected all 12 rooms on the Shenandoah unit. The findings include: On 3/23/22, the State of Maryland's Office of Health Care Quality received a complaint (MD00178478) alleging the facility failed to maintain the cleanliness of the privacy curtains. On 7/5/22 at 6:45 AM, during the initial tour of the facility, the survey team observed privacy curtains were not clean in Shenandoah Unit room [ROOM NUMBER]. The survey team then made a visual inspection of privacy curtains in Shenandoah Unit Rooms 122, 123, 124, 125, 126, 127, 128, 133, 134, 135, and 136. The survey team observed the privacy curtains were also not clean. On 7/6/23 at 2:00 PM, the survey team interviewed the Environmental Services (EVS) Manager #5 regarding the state of the privacy curtains on the Shenandoah unit. EVS Manager #5 admitted the curtains on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to provide a resident's representative access to a resident's medical records in a timely manner (Resident #25). This was evident for 1 out of 71 residents reviewed during a complaint survey. The findings include: On 3/23/22, the State of Maryland's Office of Health Care Quality received a complaint (MD00178478) alleging the facility failed to provide requested medical records to resident #25's representative. On 8/2/23 at 1:06 PM, interview of the complainant regarding a request for Resident #25's medical records revealed the complainant had requested resident care records starting on 3/10/22 until the resident discharged from the facility on 8/2/22. The complainant also added that the facility requested Power of Attorney (POA) documentation and a signed release of information form to receive the requested medical records. The complainant stated that he/she provided the facility with the POA documentation and the release…

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 a medical record and staff interview, it was determined that the facility staff failed to notify a resident's physician when the finger stick glucose results were outside of the listed parameters. This was evident for 1 (Resident #54) of 71 residents reviewed during a complaint survey. The findings include: Review on 07/11/23 of Resident #54's record revealed Resident #54 was admitted to the facility in May 2022 with diagnoses that included diabetes. Review of Resident #54's July 2023 medication administration record (MAR) revealed a physician order, date 04/21/23 at 1:34 PM, instructing the nursing staff to obtain a finger stick glucose every 12 hours. The physician order also instructed the nursing staff to notify the provider if the result was greater than 250 or less than 70 mg/dl. The following 8 PM finger stick glucose results were documented for Resident #54 in July 2023: 07/01/2023 - 331 mg/dl 07/02/2023 - 321 mg/dl 07/03/2023 - 265 mg/dl 07/04/2023 - 275 mg/dl 07/05/2023 - 310 mg/dl 07/06/2023 - 300 mg/dl 07/07/2023 - 300 mg/dl Further review of Resident…

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

Based on observation and interviews it was determined that the facility failed to maintain a resident's privacy by discussing his/her diagnosis in another resident's room. This was evident using a random tour of the facility. The findings include: On 7/6/23 at 6:46 AM surveyor asked staff GNA #11 why Resident #1 was on enhanced barrier precautions. She stated that she didn't know and they all have signs up. She then stated that the surveyor should ask the unit manager and pointed to Resident #2's room. GNA #11 then proceeded into the room of Resident #2 where Unit Manager #8, was providing services and care to Resident #2. GNA #11 stated over top of Resident #2, What is [Resident #1] on contact for loud enough the surveyor could hear the conversation in the hallway. The UM #8 looked at the surveyor, shook his head and did not answer. GNA #11 walked out of the room and then proceeded to her next resident. When the UM #8 exited resident #2's room he was notified of the privacy concern and failure of GNA #11 to protect sensitive patient health information from being disclosed without…

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, administrative record review, and staff interview, it was determined that the facility failed to protect a cognitively impaired resident (Resident #12) from physical and verbal abuse from a facility staff member. This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include: On 7/12/22, the State of Maryland's Office of Health Care Quality received a facility reported incident (MD00180373) which reported the investigation of an alleged abuse of Resident #12 by GNA #11. The facility investigation was unable to substantiate abuse by GNA #11 toward resident #12. Medical record review on 7/5/23 at 11:27 AM revealed Resident #12 was a long-term care resident admitted to the facility on [DATE] with diagnoses of Dementia and difficulty walking. At the time of the survey, Resident #12 was no longer residing at the facility and unavailable for interview. Administrative record review on 7/5/23 at 11:27 AM revealed Resident Care Assistant (RCS) #9 witnessed…

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 facility reported incident, medical record review, administrative record review and staff interview, it was determined that the facility: 1) failed to notify local law enforcement of an allegation of misappropriation of resident funds. This was evident for 1 of 24 facility reported incidents reviewed during a complaint survey and 2) staff delayed reporting the alleged physical and verbal abuse of a cognitively impaired resident (Resident #12) by a facility staff member. This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include: 1.) Review of facility reported incident MD00182308 on 07/11/23 revealed an allegation Resident #23 had cash stolen on 02/09/22. Review of the facility investigation on 07/11/22 revealed Resident #23 reported an allegation $244.00 was missing from his/her locked box on 02/09/22 at 2:45 PM. On 02/05/22, Resident #23 was sent to the hospital. Upon his/her return on 02/09/22, Resident #23 indicated s/he observed the lock was open.…

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 complaint, reviews of a closed clinical record and a hospital record, and staff interviews, it was determined that the facility failed to permit a resident to return to the facility after a brief hospitalization. This was evident for 1 (Resident #29) of 73 complaints reviewed during a complaint survey. The findings include: Review of complaint MD00161191 on 07/10/23 revealed an allegation that Resident #29 was sent to the emergency room on [DATE] and then not allowed to return to the long-term care facility. In an interview with the complainant on 07/11/23 at 2:50 PM, the complainant stated that Resident #29 was sent to the ER on [DATE]. Resident #29's family was present at the bedside and stated they did not want anymore treatment in the ER for Resident #29. Resident #29's family requested the hospital staff make Resident #29 comfortable and to send Resident #29 back to the long-term care facility. The complainant stated that the hospital staff made transport arrangements and sent Resident #29 back…

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 complaint, reviews of active and closed records, and staff interviews, it was determined that the facility staff failed to: 1) follow a physician order and obtain a resident's weight and as instructed (Resident #63, #30 and #53), and 2) administer an anticoagulant as ordered (Resident #53). This was evident for 4 (Residents #31, #63, #30, #53) of 71 residents reviewed during a complaint survey. The findings include: 1.) Review of complaint MD00189565 on 07/10/23 revealed an allegation Resident #31 did not receive quality care. A review of Resident #31's closed medical record on 07/10/23 revealed that Resident #31 was admitted to the facility on [DATE]. On 02/10/23, Resident #31's physician gave an order to obtain a weekly weight, on Monday, for 2 weeks. The nursing staff documented the following weights for Resident #31: 01/30/23 - 156.6 pounds. 01/31/23 - 156.6 pounds. 02/09/23 - 149.8 pounds. Further review of Resident #31's closed record failed to reveal a documented weight for Monday 02/13/23 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 complaint, reviews of a closed medical record and hospital record, and staff interview, it was determined that the facility staff failed to: 1) take steps to care for a Stage III wound upon admission, and 2) take preventative measures to keep a resident's sacral wound from deterioration from a stage III to a stage IV pressure wound. This was evident for 2 (Residents #63 and #66) of 71 residents reviewed during a complaint survey. The findings include: A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III ( full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer…

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, the facility failed to provide adequate foot care to vulnerable residents, This was evident for 2 out of 71 (Resident #25 and #42) residents reviewed during a complaint survey. Findings include: 1. On 3/23/22, the State of Maryland's Office of Health Care Quality received a complaint (MD00178478) alleging the facility failed to provide essential resident care services including the trimming of Resident #25's fingernails and lack of podiatry care. Review of Resident #25's medical record on 8/1/23 at 7:00 AM revealed the resident was admitted to the facility for rehabilitation after a stroke. Resident #25's stay was from 6/24/21 to 8/2/22. The medical record review also revealed the resident designated his/her representative in March 2022. Additional review of resident #25's medical records on 8/1/23 at 1:40 PM revealed the resident was deemed as being cognitively incapable to make his/her own medical decisions on 7/28/22 and did not have any Podiatry visits until…

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, the facility failed to monitor a resident's weight loss and nutritional status. This was evident for 1 of 71 (Resident #50) residents reviewed during a complaint survey. Findings includes: On 6/10/22, the State of Maryland's Office of Health Care Quality received a complaint which alleged the facility failed to monitor Resident #50's status and well-being during his/her stay in the facility. Review of Resident #50's medical records on 7/13/23 at 1:03 PM revealed the resident was admitted to the facility for rehabilitation after a stroke and Congestive Heart Failure. Resident #50's stay was from 2/28/22 to 7/17/22. The medical record review also revealed the resident was also diagnosed with End Stage Renal Disease which required dialysis three times a week in the facility. Review of care plans revealed the resident regularly refused to complete dialysis treatments completely or refused to go to dialysis which led to the resident being at risk of aggravating symptoms of Congestive Heart Failure. The resident also was at risk of poor…

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 a closed medical record and the hospital record, and staff interviews, it was determined that the nursing staff failed to assess a resident who complained of pain after a fall, and initiate nursing interventions and send the resident to the hospital timely. This was evident for 1 (resident #36) of 71 residents reviewed during a complaint survey. The findings include: Review of complaint MD00160889 on 07/11/23 revealed an allegation that Resident #36 was not sent to the hospital in a timely manner per the complainant's wishes. A review of facility Fall Management policy, dated 2017, on 07/20/23, revealed Practice Guidelines that includes when a fall occurs: 1) the resident is assessed for injury by the nurse. 2) enter the event information into Risk-Console as instructed 3) complete an Incident/accident report. 4) Complete the SBAR (Situation, Background, Assessment, Request) communication Form. 5) add the event to the 24-hour report 6) initiate the interdisciplinary post fall…

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, reviews of a medical record and staff interview, it was determined that the nursing staff failed staff to the Shenandoah Unit with enough nursing assistants to prevent the 2 GNA's from documenting the completion of nursing tasks for other GNA's and before the care had been administered to the resident. This was evident for 1 (Resident #52) of 18 active/current residents reviewed during a complaint survey. The findings include: During an observation of Resident #52 on 07/13/23 at 12:21 PM, Resident #52 was being transferred down the hall to his/her room, in his/her wheelchair, by the facility nursing staff. Staff Member #6 stated that s/he was going to assist Resident #52 with the lunch meal. Staff member #6 handed Resident #52's lunch meal tray ticket to the nurse surveyor. The nurse surveyor observed Staff Member #6 remove Resident #52's lunch meal tray from the facility tray cart located in the hallway. Resident #52 resided on the Shenandoah 100 hall. A review of Resident #52's medical record revealed a July 2023 nursing assistant documentation survey report…

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

Based on review of resident medical records and interview with facility staff, it was determined that facility staff failed to properly process and deliver narcotic medication to the designated nursing unit. This deficient practice impacted one resident (Resident #17) on one nursing unit. The findings include: A Medication Administration Record (MAR) is a document that records when and how much medication a resident is administered. For as-needed pain medication, it also documents what pain score a resident is reporting and whether the pain medication was effective at easing that pain. Failure to maintain an accurate MAR's prevents members of the healthcare team from knowing when and why medication has been given. This can result in medication mistakes, overdose, or denying practitioners information on how much medication a resident receives. On 1/31/21, the state of Maryland's Office of Health Care Quality received a facility reported incident report which reported the Director of Nursing (DON) misplaced narcotic medication ordered for Resident # 17 while he/she was delivering 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 complaint, medical record review, resident and staff interview, it was determined the facility staff failed to: 1) honor a resident's choices to be seen by an outpatient physician consultant (Resident #77) and 2) provide showers as ordered to residents (Resident #16 and #101). This was evident for 3 out of 3 residents selected for review of choices and 3 out of 63 residents reviewed during the annual recertification survey. The findings include: 1. The facility staff failed to honor a resident's choices (Resident #77) to be seen by an outpatient physician consultant. Review of complaint MD00146703 on 12/2/19 at 12:00 PM revealed an allegation Resident #77 was not being sent to physician consultants. The two dates in question were for 6/20/19 and 7/27/19 where Resident #77 failed to be sent to an outpatient appointment. Review of Resident #77's medical record on 12/2/19 at 1:00 PM failed to reveal any consultant notes for the 6/20/19 and 7/27/19 appointments. In an interview with the facility Director of Nursing (DON) on 12/11/19 at 12:40 PM, the DON could only produce a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation it was determined the facility failed to provide a safe, clean, comfortable and homelike environment. This deficiency has the potential to affect multiple residents. The findings include: On 12/2/2019 an initial tour of the facility was conducted. At 9:16 AM interview with Resident #29 revealed their dinner tray from the night before had not been removed from the room. The dinner tray was observed on top of the resident's trash can with a meal ticket dated 12/1/19. At 9:50 AM observation of room [ROOM NUMBER]'s bathroom revealed caulk in disrepair where the sink attached to the wall. On 12/4/2019 at 9:44 AM Resident #381's bed sheets were removed from the mattress revealing multiple crumbs on the mattress under the sheet. These crumbs were not cleaned off before the clean sheets were put back on the resident's mattress. Additionally on 12/11/2019 at 11:00 AM a tour of the west building revealed a soiled wheelchair across from room [ROOM NUMBER] with crumbs and debris on the blue…

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 clinical record review, resident review, and staff interview it was determined the facility staff failed to: 1) ensure residents were receiving ordered medications (Resident#35); 2) provide incontinence briefs that fit (Resident #63) and 3) obtain weekly weights as ordered for a resident (Resident #77). This was evident for 3 out of 63 residents sampled for the survey. The findings include: 1. The facility staff failed to ensure residents were receiving ordered medications (Resident#35). Resident #35 informed a survey team member on 12/6/19 at 9:00 AM that medications were not available on 12/5/19 after 10:00 AM. Resident #35 said the supply of Oxycodone Immediate Release(IR) 10 mg and Xanax .5 mg had been exhausted. Review of Resident #35's clinical record on 12/6/19 at 11:00 AM revealed the Medication Administration Record (MAR) for December 2019 that contained documentation that the last dose of Xanax (an antianxiety medication) was administered on 12/5/19 at 10:00 AM and the last dose of Oxycodone (pain medication) was administered on 12/5/19 at 10:00 AM. 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 record review and staff interview it was determined the facility failed to ensure that residents who require dialysis received services consistent with professional standards of practice. This was evident for 4 of 63 residents (Resident #13, #39, #382, and #383) reviewed during the annual survey process. The findings include: Dialysis is a process in which a machine removes toxins from a person's blood whose kidneys no longer function properly. Dialysis is common in people with kidney problems or kidney failure (end stage renal disease). A Care Plan is a document that outlines specific risks and interventions for a resident and provides information so staff can tailor care to the resident's needs. On 12/3/2019 at 9:57 AM Resident #39's medical record was reviewed and showed an order for Weights Dx (diagnosis) ESRD (end stage renal disease) in the morning every Monday, Wednesday, Friday but no order specifying that the resident should receive dialysis or what days the resident should receive dialysis. Further review of Resident #39's care plan revealed a care plan focus…

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

Based on medical record review and staff interview, it was determined the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention that Resident #22 received medications that had been discontinued. This was evident for 1 of 63 residents selected for review during the annual survey process. The findings include; Medical record review for Resident #22 on 12/11/19 at 10:00 AM revealed that on 6/20/19 the hospice nurse in communication with the facility's Certified Registered Nurse Practitioner (CRNP) ordered to discontinue the following medications: 1. Alendronate: Alendronate is used to treat and prevent osteoporosis (a condition in which the bones become thin and weak and break easily). Alendronate is in a class of medications called bisphosphonates. It works by preventing bone breakdown and increasing bone density (thickness). 2. Cholecalciferol: Vitamin D 3. Donepezil: Donepezil is used to help improve mental function in people with Alzheimer's disease. 4. Memantine: Memantine is used to treat moderate to…

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

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed and equipment was maintained to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 12/2/2019 at 9:00 AM a tour of the [NAME] Building's kitchen was conducted with the Kitchen Manager Staff #30. The hand sink in the dishwasher room was observed without paper towels. Further observation of the kitchen revealed spilled, uncooked macaroni on the floor of the dry goods storage room. An open top Styrofoam cup filled with oatmeal was observed on top of the ice machine and was discarded by the Kitchen Manager during the tour. On 12/11/2019 at 11:10 AM a tour of the East Building's kitchen was conducted with the Kitchen Manager Staff #30 present. Upon entering the kitchen, a large puddle of water was observed under the door. Interview with the Kitchen Manager confirmed the puddle was caused by a leak in the juice machine adjacent to the door. Any meal tray…

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

Based on observation, resident and staff interview it was determined that the facility failed to maintain resident equipment in safe operating condition. This was evident for 1 resident of 63 residents (Resident #115) reviewed during the investigative portion of the survey. The findings include: On 12/2/2019 at 9:46 AM interview with Resident #115 revealed that their Rollator wheeled walker's brakes were not functioning and could not stop the walker when used. When asked how the resident stopped they replied that they would wedge the walker against the wall. Further inspection of the walker revealed that the rear wheels were splitting in half from the center. Maintenance staff were made aware of these findings immediately and the brakes were serviced to be adequate for the resident. The Administrator and Director of Nursing were made aware of these findings on 12/11/2019 during the exit conference.

Based on observation and interview, it was determined the facility staff failed to provide a resident with the most dignified existence related to meals. This was evident for 1 of 1 resident (Resident #23) reviewed for dignity during the survey process and 1 of 63 residents selected for review during the annual survey. The findings include: Dining observation on 12/2/19 at 12:00 PM of the first-floor dining room revealed that Resident #23 had a lunch tray sitting on the table in front of the resident. There were two other residents present at the table. Resident #23 was watching the other two residents eating and finishing their lunches. Further observation revealed Resident #23 did not receive assisted with eating until 12:20 PM. The Director of Nursing was interviewed on 12/04/19 at 1:23 PM and confirmed the facility staff failed to provide Resident #23 with the most dignified existence with dining.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon staff interview and medical record review it was determined the facility staff failed to take immediate steps to have documentation in place to carry out the family's wishes for a Maryland Order of Life Sustaining Treatment (MOLST), that Resident #332 was to have an order for Do Not Resuscitate (DNR) and failed to get a translator for the spouse who was the surrogate decision maker. This was evident for 1 of 63 residents (Resident #332) reviewed during a complaint survey. The findings include: On [DATE] and [DATE], the surveyor reviewed Resident #332's medical record which revealed that the resident was admitted to the facility from the hospital on [DATE], with a diagnosis of, but not limited to, sepsis secondary to pneumonia and Myxedema coma. Sepsis is a potentially life-threatening condition caused by the body's response to an infection. Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple…

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 a medical records, and interview with staff it was determined the facility failed to provide a resident and the resident's responsible party with a written notice and reason for the room change before the resident was actually moved. This was evident for 2 of 63 residents (Residents #17 and #231) observed during the annual recertification survey. The findings include: 1. In an interview with Resident #17's responsible party on 12/3/19 at 12:35 PM, it was revealed that Resident #17 was moved to a different room the responsible party's knowledge on 11/20/19. Resident #17's responsible party also stated that the family did not receive any written notification nor a reason for the move on 11/20/19. In an interview with the facility Social Worker #9 on 12/3/19 at 2:17 PM, Social Worker #9 stated Resident #17 was moved to another room due to an altercation with another resident. Social worker #9 stated Resident #17's responsible party was notified of the room change. When asked, Social…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to void an older Medical Orders for Life-Sustaining Treatment (MOLST) form located in a resident's active medical record for Resident (#129) and the facility staff failed to ensure the criteria of a resident's advance directive was met prior to changing the code status of Resident (#131). This was evident for 2 of 6 residents reviewed for Advance Directives during the annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it.…

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 staff failed to ensure resident's medical records were maintained securely. This was evident for 1 out of 63 residents (Resident #26) reviewed as part of the survey. The findings include: While a surveyor was walking from the building housing the Shenadoah, Potomac, and [NAME] units towards the main building via the parking lot on 12/6/19 at 10:12 AM, a piece of paper was observed on the blacktop near the second parking spot of the center set of parking spaces near the main entrance. The piece of paper was a medication order summary for Resident #26. The medication order summary is a document that is sent and/or shared with the pharmacy. The summary included the following medication order for the resident: Remeron [an antidepressant] 15 mg. Give 7.5 mg by mouth at bedtime for appetite. The Director of Nursing was interviewed on 12/6/19 at 11:00 AM. She was shown the document and the concern for keeping resident information secure was reviewed.

Based on a resident complaint, reviews of administrative documents and staff interview, it was determined the facility failed to notify local law enforcement of an allegation of alleged physical abuse. This was evident for 1 of 5 residents (Resident #77) reviewed for abuse during the annual recertification survey. The findings include: During an interview with Resident #77 on 12/2/19 at 8:46 AM, Resident #77 alleged that a staff member hit Resident #77. Resident #77 stated this incident was reported to the facility staff. A review of the facility investigation on 12/5/19 at 8:48 AM, revealed that during the investigation the staff asked Resident #77 if they wanted the local police called and the facility investigation indicated Resident #77 stated no. In an interview with the facility Director of Nursing (DON) on 12/9/19 at 8:59 AM, the facility DON stated that the facility does call the police when there are allegations of abuse, but that sometimes the facility staff ask the resident if they want the local police called and the residents refuse. The facility staff must take steps…

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

Based on record review and staff interview it was determined the facility staff failed to report an allegation of abuse of a resident to the Office of Health Care Quality(OHCQ) in a timely manner for Residents (#282). This was evident for 1 of 5 residents selected for review of abuse during the annual survey and 1 of 63 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence being investigated by the facility be reported to the appropriate agency within 24 hours and the conclusion of the investigation to be reported in 5 days to the appropriate agency (OHCQ) and the Office of Aging (Ombudsman). Surveyor review of Facility Reported Incident (FRI) MD00123820 on 12/3/19 at 12:00 PM revealed the allegation of a facility staff Resident Care Specialist (RCS) yelling at a resident and leaving the resident in stool. Further review of the FRI revealed the allegation of abuse…

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 clinical record review and staff interview it was determined the facility staff failed to ensure the Ombudsman was notified when a resident was sent to the hospital. This was evident for 1 out of 25 residents (Resident #67) sent to the hospital. The findings include: A review of Resident #67's clinical record on 12/3/19 at 9:55 AM revealed the resident was sent to the hospital on [DATE] and on 10/20/19. The facility only notified the ombudsman of the 10/3/19 visit to the hospital. The Director of Nursing was interviewed on 12/5/19 at 1:18 PM and agreed the second hospitalization was not on the list of Ombudsman notifications. No evidence of notification was presented prior to the survey team exiting the facility on 12/11/19.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the quarterly care plan meetings. This was true for 1 out of 63 residents (Resident #76) reviewed during the survey process. The findings include: Care plan meetings are held on a quarterly basis to develop a person-centered comprehensive care plan and to revise already developed care plans as necessary for the residents. The care plan meetings are attended by the interdisciplinary team (IDT) composed of individuals who have knowledge of the resident. The team should include the primary physician, a nurse, a nurse aide, a dietary staff member, the resident and/or responsible party (if practicable), and any other necessary staff. A review of Resident #76's clinical record on 12/4/19 at 9:12 AM revealed that the resident had care plan meetings on 7/30/19, 9/10/19 and 11/26/19. The Interdisciplinary Care Plan attendance sheet showed that only the social worker, a nurse 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 clinical record review, resident interview, and staff interview it was determined the facility staff failed to: 1) ensure a resident had an audiology appointment (Resident #128) and 2) ensure residents had a vision appointment (Resident #128 and #131). This was evident for 2 out 5 residents selected for review for vision and 2 out of 63 residents in the survey sample. The evidence is as follows: 1. Interview of Resident #128 on 12/2/19 at 10:01 AM revealed that the resident had not been seen for either an audiology exam or a vision exam since admission. A review of Resident #128's clinical record on 12/2/19 at 1:30 PM revealed that neither an audiological nor a vision exam had been done for the resident since admission in December 2015. The Director of Nursing (DON) was interviewed on 12/6/19 at 9:55 AM and the resident's wishes were shared with her. The DON was interviewed on 12/9/19 at 2:10 PM and indicated the appointments had been made for Resident #128. 2. The facility failed to obtain an ophthalmology consultation as ordered by the physician for Resident #131. Medical…

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, the facility staff failed to provide treatment/services to prevent pressure ulcer to (Resident #101). This is evident for 1 of 7 residents selected for review of pressure ulcers during the annual survey process and 1 of 63 residents selected for review during the annual survey. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Medical record review on 12/5/19 at 12:30 PM revealed that on 2/16/19 the physician ordered: Float both heels while in bed and on 12/25/18 ordered heel protectors every shift while in bed. Heels are particularly vulnerable to skin breakdown since the posterior (back) heel is covered only by a thin layer of skin and fat. When residents lie supine (on the back), all the pressure of their lower legs and feet rest on the heels, which have relatively poor skin perfusion and a paucity (a small quantity) of muscle tissue to absorb stress. Pillows can be used for offloading heel…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to apply a palm guard as ordered for a resident. This was evident for 1 of 2 residents (Resident #16) selected for review of range of motion during the annual survey process and 1 of 63 residents selected for review during the annual survey. The findings include: Medical record review for Resident #16 on 12/6/19 at 7:39 AM revealed that on 5/10/18 and 11/12/19 the physician ordered: resident to wear right hand palm protector always except for hygiene + exercise. A palm guard is used as a barrier between fingers and palm skin to prevent injury to the palm from severe finger flexion contracture. A contracture is the shortening or stiffening of muscles, skin, or connective tissues that results in decreased movement and range of motion. Observation of Resident #17 on 12/3/19 at 9:00 AM and 12/6/19 at 9:40 AM and 12:40 PM revealed the resident in bed; however, the facility staff failed to apply the palm protector as ordered. Interview with Staff #33 and #34 on 12/6/19 at 1:00 PM…

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

Based on medical record review and staff interview it was determined the facility staff failed to document the percentage of intake for Resident #14 as ordered and failed to obtain a dietary consultation for Resident #14. This was evident for 1 of 8 residents reviewed for nutrition during the annual survey. 1A. Medical record review on 12/4/19 at 10:00 AM for Resident #14 revealed on 10/3/19 the dietician in collaboration with the physician ordered: 4 oz med pass 3 times a day at 10:00 AM, 2:00 PM and at hour of sleep and document percentage consumed. Med Pass Fortified Nutritional Shakes provides a convenient way to supplement calories and protein. Designed to be used as a medication pass drink, Med Pass products deliver more nutrition than water, juice or milk. This additional intake can mean weight maintenance or weight gain. On 11/7/19 the dietician in collaboration with the physician ordered: fortified foods with all meals and document percentage consumed. Fortified foods are foods to which extra nutrients have been added. Examples of these nutrients include vitamin A, B…

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 Certified Registered Nurse Practitioner (CRNP) failed to ensure the criteria of a resident's advance directive was met prior to changing the code status of Resident #131. This was evident 1 of 5 residents selected for review of advance directives and 1 of 63 residents selected for review during the annual survey process. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. A living will usually provides specific directives about the course of treatment healthcare providers and caregivers are to follow. In some cases, a living will may forbid the use of various kinds of burdensome medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. The living will may be used only if the individual has become unable to give informed consent…

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

Based on medical record review, observation and interview, it was determining the facility staff failed to: 1.) ensure the pharmacy provided the facility with the accurate dose of medication for administration for Resident #117. This was evident for 2 out of 26 opportunities for error and 1 out of 4 residents observed for medication pass and 2.) ensure the accurate completion of the Controlled Drugs Count Records for residents. This was evident for 2 of 5 Controlled Drug Count records reviewed during the survey process. The findings include: 1. Medical record review for Resident #117 on 12/4/19 at 9:30 AM revealed that on 9/30/19 the physician ordered: Risperdal .5 milligrams, give .25 milligrams in morning for dementia. Risperdal is used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder). This medication can help the resident to think clearly and take part in everyday life. Risperdal belongs to a class of drugs called atypical antipsychotics. It works by helping to restore the balance of certain natural…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Resident #22 was free from unnecessary medication. This was evident for 1 of 6 residents selected for review of unnecessary medication and 1 of 63 residents selected for review during the annual survey process. The findings include; Medical record review for Resident #22 on 12/11/19 at 10:00 AM revealed that on 6/20/19 the hospice nurse in communication with the facility's Certified Registered Nurse Practitioner (CRNP) ordered to discontinue the following medications: 1. Alendronate: Alendronate is used to treat and prevent osteoporosis (a condition in which the bones become thin and weak and break easily). Alendronate is in a class of medications called bisphosphonates. It works by preventing bone breakdown and increasing bone density (thickness). 2. Cholecalciferol: Vitamin D 3. Donepezil: Donepezil is used to help improve mental function in people with Alzheimer's disease. 4. Memantine: Memantine is used to treat moderate to severe confusion (dementia) related to Alzheimer's…

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

Based on medical record review, observation and interview, it was determined that the facility staff failed to obtain a medication error rate less than 5% for residents. This was evident for 2 out of 26 opportunities for error and 2 out of 4 residents (Resident #12 and #117) observed for medication pass. The findings include: 1. The facility staff failed to administer medications to Resident #12 as ordered. Medical record review for Resident #12 on 12/4/19 at 9:00 AM revealed that on 9/23/19 the physician ordered: Norvasc 2.5 milligrams by mouth every day, hold for systolic blood pressure (top number) less than 110 or heart rate less than 60. Norvasc is a calcium channel blocker that dilates (widens) blood vessels and improves blood flow. Surveyor observation of medication pass on 12/4/19 at 8:16 AM revealed facility Staff #23 administered the Norvasc prior to obtaining the blood pressure and heart rate. After Resident #12 took the medication, Staff #23 obtained the blood pressure and heart rate. The blood pressure was noted to be acceptable at 153/107; however, the residents heart…

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 and staff interview it was determined that the facility staff failed to: 1.) ensure proper temperature storage of medications to preserve medication integrity, 2.) properly label multi-dose medications and 3). properly secure controlled substance medications. This was true for 1 of 3 medication storage rooms and 3 of 5 medication carts reviewed during the annual survey. The findings include: 1. On [DATE] at 10:52 AM, a medication storage observation was conducted on the Chesapeake Unit accompanied by Nurse #37. Observation of the medication cart #2 revealed an unopened box of eye drops. Review of the medication label revealed that the eye drops must be refrigerated until opened. Further review of the cart revealed an undated and opened insulin pen. Nurse #37 acknowledged surveyors' findings and alerted the Unit Manager(UM) #28. The UM retrieved and discarded the eye drops and the insulin pen. 2. Insulin expires 28 days after opening. The standard of practice requires that, when opened, 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 medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimens on Resident #281 as ordered by the physician. This was evident for 1 of 1 resident selected for review of infection and 1 of 63 resident selected for review during the annual survey process. The findings include: 1A. The facility staff failed to obtain a laboratory blood test on Resident #281 as ordered. Medical record review for Resident #281 on 12/11/19 at 12:38 PM revealed that on 11/30/19 the physician ordered: blood cultures x 2. A blood culture is a test that checks for foreign invaders like bacteria, yeast, and other microorganisms in the blood. Having these pathogens in the bloodstream can be a sign of a blood infection, a condition known as bacteremia. A positive blood culture means that you have bacteria in the blood. It is the standard of practice to obtain blood cultures from 2 different sites. Further record review revealed the facility staff failed to obtain the blood cultures as ordered by the physician. 1B. The facility staff failed to obtain…

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 clinical record review, resident interview, and staff interview it was determined that the facility staff failed to obtain a dental consult for the residents. This was evident for 2 out 5 residents (Resident #128 and #131) selected for review of dental services and 2 of 63 residents in the survey sample. The findings include: 1. Resident #128 was interviewed on 12/2/19 at 9:48 AM and stated that a dental consult had never been obtained since admission in 2015. A review of Resident #128's clinical record on 12/6/19 revealed that a dental consult had not been obtained. The Director of Nursing was interviewed on 12/9/19 at 2:10 PM. She said an appointment had already been made but could not answer as to why the resident had not had a dental consult in the last several years. 2. The facility staff failed to take steps to ensure Resident #131 received dental services as ordered by the physician. Medical record review on 12/5/19 at 10:00 AM for Resident #131 revealed that on 6/26/19 the physician ordered: in-house dental consultation. Further record review revealed the facility…

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

Based on clinical record review, resident interview, and staff interview it was determined the facility staff failed to ensure residents received sufficient food amounts and respected resident choice. This was evident for 1 out 7 residents (Resident #35) selected for investigation of food quality. The findings are: Resident #35 was interviewed on 12/2/19 at 10:40 AM and stated that they often go to bed hungry because of insufficient portions and sometimes is served a disliked item. Observation of lunch on 12/6/19 at 12:48 PM revealed that Resident #35 had fish and it was one piece of fish with what might have been part of a second piece of fish. The spinach serving was about 1/4 cup instead of the menu listed 1 cup serving. The rice pilaf was about 1 cup as well. Upon interview, the resident stated that spinach was on a list of dislikes. The resident said the list of his/her vegetable likes included corn, broccoli, and cauliflower only. The resident said they told the facility dining staff that rice was also a disliked item. Staff #18 was interviewed on 12/10/19 at 8:17 AM 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 interview and observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents. The findings include: On 12/6/2019 at 10:30 surveyors met with the Resident Council who expressed concern about the coffee and tea temperatures during lunch time. On 12/11/2019 at 11:46 AM the hot water for making tea in the [NAME] building dining room was tested and found to be 115 degrees Fahrenheit directly out of the container. Interview with a resident family member present in the dining room confirmed that the water was no longer hot by the time lunch was served and that this was a common problem. The family member also stated that the facility removed a microwave that had previously been used to reheat liquids. Lunch carts had not arrived on the unit at this time. The Administrator, Director of Nursing and Kitchen Manager were made aware of these findings on 12/11/2019 during the exit conference.

Based on medical record review, observation and interview, it was determined the facility staff failed to assure the food is prepared and appropriate to meet resident's needs and according to their assessment. This was evident for 1 of 8 residents (Resident #28) selected for review of nutrition and 1 of 63 residents selected for review during the survey process. The findings include: On 12/2/19 at 12:20 PM, Resident #28 was observed eating chicken noodle casserole with chunks of chicken in the casserole. Review of the meal ticket which accompanied the meals revealed the resident was ordered chicken noodle casserole with ground chicken. Medical record review for Resident #28 on 12/3/19 at 1:15 PM, revealed the physician ordered Dysphagia Ground texture, Regular consistency diet for Resident #28. Dysphagia is a disorder which can range from minor difficulties with managing food and drink, to severe problems with swallowing. The Unit Manger was made aware and the food was removed from the resident, and the correct diet was given to Resident #28. Interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that facility staff failed to maintain a medical record in the most accurate form for Resident #115. This was evident for 1 of 63 residents reviewed during the survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. Records must be complete, accurately documented, readily accessible and systematically organized. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. On [DATE] Resident #115's medical chart was reviewed…

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 1.) read the purified protein derivative (PPD) skin test of Resident #281 per standard of practice. This was evident for 2 of 63 residents selected for review of infection control during the annual survey process and 2.) provide a safe, sanitary environment to prevent the development and transmission of disease and infection (Resident #331). This was evident during the initial tour on 12/02/19 of the nursing units. The findings include: 1. A purified protein derivative (PPD) skin test is a test that determines if the resident has or has been exposed to tuberculosis (TB). TB is a serious infection, usually of the lungs, caused by the bacteria Mycobacterium tuberculosis. A measured amount of PPD in a shot is put under the top layer of skin on your forearm. This is a good test for finding a TB infection. After 48 to 72 hours, the area will be checked to see if you have had a strong reaction to the test. Medical record review of Resident #281 on 12/11/19 at 11:30 AM revealed the facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with staff, it was determined that the facility failed to provide a sanitary environment for a resident by failing to clean and prevent lingering odors in the resident's room. This was evident for 1 of 63 residents (Resident #79) reviewed during an annual recertification survey. The findings include: On 12/2/19 at 11:07 AM the surveyor toured the third floor nursing unit and observed room [ROOM NUMBER] to have a strong odor of urine emitting throughout the room. A second observation of room [ROOM NUMBER] on 12/05/19 at 8:30 AM revealed the same strong odor of urine emitting throughout the room. In an interview with LPN#20 on 12/5/19 at 8:38 AM, LPN #20 stated Resident #79 had a history of refusing to allow staff to enter the room. LPN #20 stated that the facility environmental staff were going to deep clean room [ROOM NUMBER].

Based on record review and interviews with facility staff it was determined the facility failed to 1. provide a physician ordered back brace for a resident #47, and 2. provide residents opportunities to participate in an activity of their choice. This was evident for 2 of 4 residents (#47 and #53) reviewed for choices. The findings include: 1. Resident #47 was admitted to the facility with the following but not limited to diagnosis: Low Back Pain, and Age-related Osteoporosis (a condition in which the bones become less dense and more likely to fracture). An interview was conducted with the resident on 6/8/18 at 12:00 PM and the resident stated that s/he had back pain and needed to have his/her back brace. The resident further stated that the facility was aware because s/he went to appointment and that the report in his/her chart. Review of the consultation report dated 2/21/18 revealed Resident #47 was ordered a lumbar support brace and no further follow-up was required. During an an interview with the Acting Director of Nursing (ADON ) on 6/8/18 at 12:00 PM s/he reviewed 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 upon interviews of residents and staff, and review of resident council minutes it was determined that the facility staff failed to put a system in place to ensure that resident council concerns were acknowledged, addressed as soon as possible, and outcomes were communicated back to residents. This failure had the potential to affect all residents. The findings include: A resident council is an independent, organized group of persons living in a nursing facility who meet on a regular basis to discuss concerns, develop suggestions, and plan activities. On 06/07/18 at 08:53 AM an interview with the facility's resident council was conducted. During the meeting it was disclosed that the facility was not consistent with providing updates on various concerns and suggestions brought up during the meetings. A review of the Resident Council meeting minutes from June 2017 to May 2018 was conducted on 06/08/18 at 11:15 AM. Review of the August September, October and December 2017 minutes revealed that members of the council expressed there were not enough staff on the unit which resulted…

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 resident interview it was determined that the facility failed to provide a list of names, mailing and email addresses, and telephone numbers of the State Long-Term Care Ombudsman program advocacy groups for residents. This was true in 1 (West Building) of 2 buildings reviewed during the survey. The findings include: On 06/07/18 at 08:53 AM an interview with the facility's resident council was conducted. During the meeting it was disclosed that the residents in the [NAME] Building were unaware as to how to contact the State Ombudsman advocacy group. Observation of the [NAME] Building in the facility on 06/07/18 at 09:10 AM revealed that the wall posting for the State Ombudsman program failed to identify the State Ombudsman advocate or provide any contact information for the office or their designated representatives. The Administrator was made aware of surveyor's findings at 09:30 AM. As of the end of the morning on 06/14/18 the posting had not been updated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to 1) to ensure the physician was made aware of consultant recommendations in regard to the restarting of an anticoagulant medication (#37), and 2) notify the responsible party of a change in the resident's condition and was transferred to the hospital (#242), 3) notify the responsible party that the resident had a fall (#15). This was found to be evident for 3 out of 3 residents (Residents #37, #242, #15) reviewed for changes in condition. The findings include: 1) On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, Atrial fibrillation [Afib], pressure ulcers, high blood pressure and a leg fracture. The leg fracture was diagnosed on [DATE]. Atrial fibrillation is an irregular heart beat which puts the resident at risk for developing blood clots. Review of the practitioner's progress notes for March revealed that the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to have an effective system in place to ensure areas in need of cleaning and repairs were identified and addressed, as evidenced by: 1) staff failure to dispose of used pressure ulcer dressing material, 2) failure to ensure areas around water pipes under resident sinks were sealed and that baseboards in vending area were intact, 3) failure to ensure exhaust fans in resident bathrooms were in good working order, and 4) failure to ensure issues with the elevator were reported and addressed. This was found to be evident on one out of the five units but had the potential to affect all residents. The findings include: 1) Review of Resident #96's medical record revealed orders for daily dressing change to an ulcer on the residents heel. On 6/6/18 at 11:18 AM surveyor observed an approximately 12 inch by 2 inch white gauze with two areas of dark red splotches of about an inch by two inches hanging from tubing of an air mattress at the foot of…

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

Based on medical record review and interviews it was determined that the facility failed to 1. develop a care plan addressing a resident's care needs after the diagnosis of a leg fracture (#37), 2. update a resident's care plan after a fall and (#106) follow a care plan in regard to g-tube site care, 3. develop care plans triggered by the care area assessment (#247). This was found to be evident for 3 out of 8 residents reviewed for accidents during the investigative portion 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. A care plan is completed from the resident assessment. 1) On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis including but limited to renal disease with dependence on dialysis and a leg fracture. On 6/8/18 review of the medical record revealed that on 3/12/18 the resident sustained a witnessed fall. The nursing note revealed the following: Patient's was attempting to transfer 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 interviews with facility staff, it was determined the facility failed to 1. update a resident's care plan for use of a slider board for self transfers (#12), 2. have a care plan meeting following MDS assessment (#106), 3. ensure that residents' comprehensive care plans are reviewed and revised timely and not conducting a quarterly care plan for a resident (#53) and 5). not revising a resident's care plan after return from an extended hospital stay (#91). The findings include: 1. Review of Resident #12's careplan on 6/6/18 revealed that the resident would safely transfer to and from bed to chair (or wheelchair) using sliding board independently, with an initiation date of 5/29/18. During an interview conducted with Staff #1, s/he stated that on 6/1/18 a foley catheter and wound vac was placed on Resident #12. During an interview with the Director of Nursing (DON) on 6/11/18 at 10:55 AM, s/he confirmed that the resident's careplan was not updated to reflect changes in the resident status and that the resident currently had a foley catheter and 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 medical record review and interview it was determined that the facility failed to 1) ensure a resident at risk of blood clots based on diagnosis of atrial fibrillation and a recent leg fracture received an anticoagulant medication (#37). This failure represents a multisystem failure as evidenced by a) the health care providers erroneously documenting the continued use of the anticoagulant, b) the pharmacy reviews not identifying the problem, c) the nursing staff not informing the physician of the cardiologist recommendation to re-start the anticoagulant for more than a week, and d) the order inaccurately being entered into the electronic health record which resulted in the resident receiving one dose per day as opposed to the two doses per day as ordered. Additionally, the facility failed to 2) provide medications as ordered (#119), 3) identify and provide needed care and services regarding the use of a hearing aid, timely assistance with meals, and cause and treatment of an injury of an unknown origin (#39). This was found to be evident for 3 out of 38 residents (Resident…

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

Based on medical record review and interview it was determined that the facility failed to 1) complete incident reports and investigations into falls (#37), 2) prevent a fall while resident was receiving care (#37), 3) implement interventions post fall (#106), 4) keep a resident safe and free from accidents and hazards by not properly assessing a resident to use a slider board for self transfers (#52) and 5) provide a resident with a safe environment and enough supervision to prevent a resident from falling out of the bed onto the floor (#15). This was found to be evident for 4 of the 8 residents reviewed for accidents during the investigative portion of the survey. The findings include: 1) On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, high blood pressure, and pressure ulcers. On 6/8/18 review of the medical record revealed that on 3/12/18 the resident sustained a witnessed fall. The nursing note revealed the following: Patient's was attempting to transfer to the wheelchair and [his/her]…

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 employee files and interview with staff it was determined that the facility failed to ensure recently hired nurses demonstrated competency in skills required to provide care. This was found to be evident for two out of two (Nurse #23 and #28) recently hired nurses reviewed for staffing during the investigative portion of the survey. The findings include: 1. Review of nurse #23's employee file revealed the nurse was hired in April 2018. Review of the Skills Validation Checklist revealed the section for Arteriouvenous (AV) Shunt Care was marked NA [not applicable]. The section for Accessing Vascular Ports, care of Central Lines, PICC Lines, etc was blank. Further review of the Skills Validation Checklist for nurse #23 revealed several areas without a date of validation but rather a notation of Experience hand written in. Some of the areas without documentation of validation but marked as experience included but not limited to: oral and trache suctioning, tracheosotomy care, nasogastric tube care, entral tube feeding/pumps, indwelling catheter insertion and catheter…

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

Based on review of medical records and facility policy and interview with staff it was determined that the facility failed to 1. have an effective system in place to ensure pharmacist recommendations resulting from identified irregularities during the monthly pharmacy review were addressed by the physician, include timeframe's for the different steps in the drug regimen review process (#22), and 2. ensure that the pharmacist notify the facility that staff administered the incorrect dose of Clonazepam and failed to clarify a recommendation from the pharmacist to the physician (#96). This was found to be evident for 2 of 7 residents reviewed for unnecessary medications during the investigative portion of the survey. The findings include: 1) On 6/14/18 review of Resident #22's medical record revealed diagnosis which included, but not limited to, dementia and generalized anxiety disorder. Review of the current medication orders revealed the following, current orders: Voltaren Gel 1% Apply 1 application transdermally [to the skin] every 6 hours as needed for pain; and Xanax 0.25 mg give…

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 records review and interview with staff it was determined that the facility failed to consistently monitor a resident blood pressure before administering a medication known to affect blood pressures. This was true for 1 out of 7 (#96) resident reviewed for unnecessary medications. The findings include: On 6/14/18 Resident #96's medical records were reviewed. This review revealed that the resident was admitted to the facility in August 2015 for long term care and with diagnosis which included essential hypertension (high blood pressure). Review of the March physician orders revealed an order for Amlodipine Besylate tablet 5 mg (milligram) give 1 tablet by mouth in the morning related to essential hypertension; Hold for systolic blood pressure less than 110. Amlodipine is a calcium-channel blocker that is used to lower high blood pressure. Review of the resident's medication administration records failed to reveal blood pressure monitoring prior to the administration of Amlodipine for April, May and part of June. and part of May. During an interview with staff #12 on…

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

Based on medical record review and interview with staff it was determined that the facility failed to 1. ensure that a prn [as needed] order for an anti-anxiety medication was limited to 14 days or provide a rationale for the continuation of the order (#22), and 2. implement a gradual dose reduction of an antipsychotic as recommended by psychiatry and evaluate and document the continued need for a PRN (as needed) medication (#96). This was found to be evident for 2 of 7 residents reviewed for unnecessary medications during the investigative portion of the survey. The findings include: 1. On 6/14/18 review of Resident #22's medical record revealed diagnosis which included, but not limited to, dementia and generalized anxiety disorder. Review of the current medication orders revealed the following, in effect since 3/2/17: Xanax 0.25 mg give 1 tablet by mouth every 24 hours as needed for agitation/anxiety. Review of the Medication Administration Record (MAR) for September thru June revealed documentation that the resident received the prn Xanax on 9/16/17, 12/11/17, 12/31/17 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 with staff it was determined that the facility failed to: 1) administer the correct dose of medication, 2) consistently administer the ordered insulin dose, 3) administer the correct dose of short acting insulin according to the resident's blood sugar, 4) discontinue the correct medications per order and 5) administer the correct pain medication according to the pain scale. This was evident for 2 of 7 residents (#96 and #293) reviewed during unnecessary medication review. The findings include: 1) On 6/14/18 Resident # 96's medical records were reviewed. This review revealed that the resident was admitted to the facility in August 2015 for long term care and with diagnosis which included insulin dependent diabetes, dementia and anxiety. Review of the 12/5/17 physician orders revealed an order to discontinue the Clonazepam 0.5 milligram and start Clonazepam tablet 0.5 milligram, give 0.25 milligram by mouth in the morning for Anxiety; Behavior. Review of the Medication Administration Record (MAR) for 12/5/17 thru 3/7/18 revealed the 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 medical record review and interview with staff it was determined that the facility failed to 1) have a system in place to ensure staff documented care provided on days that the electronic health record (computer) system was not functioning as evidenced by failure to have printed Treatment Administration Records for use by staff (#37 and #106), 2) ensure documented authors of nursing notes were the actual nurse who wrote the note (#106), 3) ensure staff only documented tasks that they actually performed as evidenced by documentation of the changing of a foley bag for a resident who did not have a foley (#106), and 4) maintain complete documentation as evidenced by inaccurate documentation on the pharmacy consultation report form (#96). This was found to be evident for 3 of 38 residents (Resident #37, #106, #96) reviewed during the investigative portion of the survey, all of whom where located on the same nursing unit. The findings include: 1) On 6/11/18 the survey team had been informed by facility staff that the internet in the facility was not working. The facility's…

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

Based on observations and interview with the facility staff it was determined that the facility staff failed to follow infection control practices and guidelines as staff failed to follow a physician order for Contact Precautions. This was evident for 1 of 38 residents (#60) observed during the investigative stage of the survey. The findings include: On 6/14/18 Resident #60 medical records was reviewed, this review revealed that the resident was admitted to the facility in October 2016 for long term care and with diagnosis which included stroke, high blood pressure and diabetes. Review of Resident #60's physician orders revealed an order written on 6/13/17 for Contact Precautions (procedures that reduce the risk of spread of infections through direct or indirect contact. Transmission occurs with physical contact of the infected patient or handling of a contaminated object in the infected patient's room. Masks, gowns, and gloves as well as standard precautions must be used by health care providers when in the infected patient's room). Observation of the resident's room on 6/14/18…

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 surveyor observation and interview with staff it was determined that the facility failed to keep dietary instructions from therapy private or protected so that others could not see identifying information about the resident. This was true for 1 of 7 resident (#247) reviewed for dignity. The findings include: On 6/6/18 at 2:25 PM during the initial tour of Resident #247's, room the surveyor observed a large sign posted on the resident's bulletin board. The bulletin board was located on the wall at the end of the resident's bed. The sign had instructions for the resident posted by the therapy department. The following information was posted on the board: Have the resident sit in an upright position for all meals, encouraged the resident to chew multiple times and encourage swallowing in between bites, encouraged the resident to take small sips of liquids. During an interview with the Rehabilitation manager on 6/6/18 at 3:30 PM she acknowledged that the information about the resident should not have been posted. She further revealed that the therapist was new and probably 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 review of medical records and other pertinent documentation and interviews it was determined that the facility failed to have an effective system in place to ensure complaints were addressed and followed up on as evidenced by the failure to respond to a family's request for information about a fall. This was found to be evident for one out of eight residents (Resident #106) reviewed for accidents during the investigative portion of the survey. The findings include: On 6/11/18 review of Resident #106's medical record revealed the resident had resided at the facility for several years and had multiple diagnosis which included heart disease, diabetes, communication deficits and dependence on a G-tube for nutrition. Review of the 11/24/17 Minimum Data Set [MDS an assessment form used to help plan for the resident's care] assessment revealed the resident required extensive assistance of two persons for bed mobility and had total dependence on staff for bathing with two person physical assist. Review of nursing notes revealed an SBAR Summary note, dated 2/3/18 at 7:10 AM 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 administrative record review and interviews with facility staff it was determined the facility failed to keep residents safe and free of abuse. This was evident for 2 of 3 residents (#52 and #125) reviewed for abuse during the facility's annual Medicare/Medicaid survey. The findings include: During the facility's survey, concerns were brought to the survey team that involved Resident #52 and Resident #125. The Director of Nursing (DON) submitted a copy of the facility's investigation for Resident #52 to the survey team on 6/12/18 at 4:00 PM. According to the facility's investigation, a face to face meeting was held on 2/8/18 with the DON and Resident #52's family member. The resident's family reported multiple concerns, one in which staff made fun of the way the resident genetalia looked and would pick it up and show it to others. The resident identified the GNA as Staff #14. Customer service education was completed with Staff #14, according to the facility's investigation. An interview was conducted with the DON, Corporate Nurse(CN) #1 and CN #2 on 6/13/18 at 2:25 PM 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 administrative record review and interviews with facility staff it was determined the facility failed to report allegations of abuse to the appropriate agencies agency. This was evident for 2 of 3 residents (#125 and #89) investigated for abuse during the facility's annual Medicare/Medicaid survey. The findings include: 1. Review of the facility's investigation for Resident #125 revealed that on 5/14/18 the resident completed a concern form concerning Staff #14 indicating that the staff was nasty and rude to him/her. According to the investigation, staff #14 entered the resident room, aggressively got up in the resident face and confronted him/her, with other staff present. An interview was conducted with CN #1 on 6/14/18 at 11:00 AM and s/he stated that the facility was able to substantiate Resident #125 concerns and that Staff #14 was terminated as a result. The CN was asked if the facility reported this incident to the board of nursing and s/he stated, no. On 6/15/18 at 11:00 AM during a brief interview with CN #1, s/he submitted documentation of transmittals that the…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to complete a thorough investigation for allegations of abuse. This was evident for 2 of 3 residents (#52 and # 125) investigated for abuse during the facility's annual Medicare/Medicaid survey. The findings include: 1. During the facility's survey, concerns were brought to the survey team that involved Resident #52 and Resident #125. The Director of Nursing (DON) submitted a copy of the facility's investigation for Resident #52 to the survey team on 6/12/18 at 4:00 PM. According to the facility's investigation Staff #14 laughed at the size of Resident #52's genetalia. Staff #14 lured others to come over to see the resident's genetalia. The administrative staff submitted an investigation that was done by the facility after it was reported that Staff #14 aggressively confronted resident #125 for submitting a grievance concern. Review of the facility's investigations revealed that no other residents were interviewed during the facility's investigation. The Nursing Home…

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

Based on medical record review and interviews it was determined that the facility failed to have a system in place to ensure that the residents and the resident's representatives were provided written notification of and reason for the transfer to the hospital. This was found to be evident for 3 out of 6 residents (#106, #91 and #39) reviewed for hospitalization during the investigative portion of the survey. The findings include: 1. On 6/11/18 review of Resident #106's medical record revealed the resident had an unplanned discharge to an acute care hospital in February 2018. Further review of the medical record failed to reveal any documentation to indicate the resident or the resident's family had been notified in writing of the transfer and the reason for the transfer. On 6/11/18 at approximately 1:30 PM the Director of Nursing confirmed that there was no process at present for providing information in writing to the family regarding hospital transfer. 2. Review of Resident #91's medical record on 06/06/18 at 4:41 PM revealed the resident had an unplanned discharge to an acute…

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 that residents or resident representatives were given written notification of the facility bed hold policy when they were being transferred out of the facility to a hospital. This was found to be evident for 1 (#91) of 6 residents reviewed for hospitalization during the investigative section of the survey. The findings include: On 06/06/18 at 4:41 PM, review of Resident #91's medical record revealed the resident had an unplanned discharge to an acute care hospital in April 2018. Further review of the medical record failed to reveal any documentation to show that the resident or the resident's representative were given written notification of the facility's bed-hold and reserve bed payment policy before and upon the transfer. On 06/15/18 at 09:08 AM, Corporate Nurse #12 confirmed that there was no documentation to support that the resident or their representative had received information in writing regarding the facility's bed hold policy.

Based on medical record review and staff interview it was determined that the facility staff failed to correctly provide an accurate assessment of Resident #39's hearing status. This was true in 1 of 38 residents (#39) reviewed for assessments during the investigative portion of the survey. The findings include: The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Its designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. Review of the medical record for Resident #39 was conducted on 06/13/18 at 10:27 AM. Resident's diagnosis included but was not limited to dementia and two-sided sensorineural hearing loss. A review of the resident's MDS assessment conducted on June 2018 revealed in section B (Hearing and Vision assessment) that the resident was coded as having moderate difficulty in their ability for hearing and did not have a hearing aid. Review of the resident's April 2018 MDS assessment under section B…

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 the medical record and interview with facility staff it was determined that the facility failed to have a system in place to complete an interim care plan and to provide a written summary of the interim plan of care to the resident or responsible party. This was found to be evident for 1 of 38 residents (Resident #113) reviewed for care planning in the investigative section of the survey process. 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 6/14/18 Resident #113's medical records were reviewed. This review reveal that the resident was admitted to the facility in May 2018 for rehabilitation and with diagnosis which included End Stage Renal Disease- getting hemodialysis. Further review of the medical records and care plans failed to reveal a 5-day interim care plan for dialysis or nutrition. During an interview with the Administrator in Training (AIT) on 6/15/18, the AIT acknowledged that there are no interim care plans for 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 medical record review and interview with staff it was determined that the facility failed to prevent the development of two pressure ulcers and failed to ensure coordination of care between the outside wound clinic and the in house wound care physician resulting in multiple trips to an outside wound clinic. This was found to be evident for one out of four residents (Resident #37) reviewed for pressure ulcers during the investigative portion of the survey. The findings include: On 6/8/18 review of Resident #37's medical record revealed current diagnosis of renal disease with dependence on dialysis, diabetes, Atrial fibrillation [Afib], pressure ulcers, high blood pressure and a leg fracture. The resident was originally admitted in December 2017 for the treatment of an abdominal wound, review of initial nursing assessments failed to reveal any pressure ulcers upon admission to the facility. The resident had been wheelchair bound for several years prior to admission. Review of the Skin - Weekly Pressure Ulcer Records revealed that a pressure ulcer was identified on the…

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

Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure communication of assessment information was conveyed between the nursing facility and the offsite dialysis center and failed to ensure newly hired nurses demonstrated competency in post dialysis assessment. This was found to be evident for one out of two residents (Resident #37) reviewed for dialysis and was the only resident reviewed who received dialysis at a secondary location. The findings include: 1. On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, Atrial fibrillation [Afib], pressure ulcers, high blood pressure and a leg fracture. Further review of the medical record revealed the resident had been attending dialysis at an offsite dialysis center three days a week since April 2018. On 6/15/18 at 7:59 AM the nurse #27 reported prior to sending a resident out for dialysis they take vital signs and complete the top portion of the form [Dialysis…

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

Based on interviews with resident family member, review of staffing schedule and assignment sheet for the [NAME] Unit and review of the facility assessment, it was determined that the facility failed to provide the residents with sufficient nursing staff. The findings include: An interview was conducted with a family member on 6/12/18 at 2:00 PM and s/he stated that the unit needed more staff particularly on the weekends. The family member stated that they were very concerned because there had been a couple of overnight shifts where there was only 1 aid working on the unit and had to care for all of the residents. Review of the staff assignment sheets for the [NAME] Unit on Saturday May 5, 2018 11 PM-7:00 AM shift, revealed a total of 28 residents and the staff to residents ratio was: GNA-1:28 and Nurse-1:28. On Friday May 25, 2018 11 PM- 7:00 AM shift revealed a total of 29 residents and the staff to residents ratio was: GNA-1:29 and Nurse-1:29. The facility assessment tool was reviewed on 6/13/18 at 10:30 AM. According to the staffing plan, the unit had 1 nurse on all three…

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 Assignment Sheets and interview with staff it was determined that the facility failed to retain posted daily nurse staffing information for the required 18 months for each unit in the facility, and failed to include the total number and actual hours worked by nursing staff on the posted staffing sheets. This was found to be evident for all five of the units. The findings include: Review of the Unit Assignment Sheets used by the facility failed to reveal any documentation regarding the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The Assignment Sheets provide information regarding which staff was assigned to care for residents according to room numbers. On 6/13/18 during the investigation of an incident occurring in February 2018 surveyor requested the assignment sheets for the week of 2/2/18. Review of the Unit Assignment Sheets provided failed to reveal any sheets for the third floor nursing unit for the time period requested. On 6/13/18 at 5:21 PM the Administrator in Training…

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 ensure that antianxiety medication that was removed from the resident's supply was actually administered to the resident. This was found to be evident for one out of the seven residents (Resident #22) reviewed for unnecessary medications during the investigative portion of the survey. The findings include On 6/14/18 review of Resident #22's medical record revealed diagnosis which included, but not limited to, dementia and generalized anxiety disorder. Review of the current medication orders revealed the following, in effect since 3/2/17: Xanax 0.25 mg give 1 tablet by mouth every 24 hours as needed [prn] for agitation/anxiety. Review of the Medication Administration Record (MAR) for September thru June revealed documentation that the resident received the as needed Xanax on 9/16/17, 12/11/17, 12/31/17 and 3/30/18. Review of the Controlled Medication Utilization Record revealed a supply of nine 0.25 mg Xanax tablets was received at the facility on 8/5/17. In addition to the doses…

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

Based on medical record review and interview it was determined the facility failed to ensure that physician ordered lab tests were completed as ordered. This was found for 1 of 38 residents (Resident #37) reviewed during the survey. The findings include: On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, high blood pressure, pressure ulcers, and a leg fracture. On 6/8/18 further review of the electronic health record revealed an order, dated 5/11/18 for a CBC [complete blood count] and CMP [complete metabolic panel] to be obtained on 5/14/18. Review of the medical record failed to reveal any results for these labs which had been due on 5/14/18. On 6/8/18 at 11:27 AM the unit clerk #17 reported that labs should be in the lab section of the chart. Surveyor informed the unit clerk unable to locate the labs that were due on 5/14/18. Further review of the medical record revealed that the most recent lab work found on the chart was dated as reported on 3/8/18, this was confirmed by the unit nurse…

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

Based on medical record review and interview it was determined that the facility failed to ensure lab results were available for all practitioners caring for the resident to review. This was found to be evident for 1 of 38 residents (Resident #37) reviewed during the investigative portion of the survey. The findings include: On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, high blood pressure, pressure ulcers, and a leg fracture. On 6/8/18 at 11:27 AM the unit clerk #17 reported that labs should be in the lab section of the chart. Further review of the medical record revealed an order, dated 4/26/18 for a CBC and BMP in the AM [morning]. The most recent lab work found on the chart was dated 3/8/18, this was confirmed by the unit nurse manager #1. On 6/8/18 at 3:02 the unit nurse manager provided a copy of lab results, dated 4/27/18, for a BMP [basic metabolic panel] and a CBC with platelets. The unit manager confirmed that these results had not been on the resident's chart and that all 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 interviews it was determined that the facility failed to have an effective system for ensuring required follow up appointments with outside providers were scheduled and appropriate transportation was arranged when appointments were scheduled as evidenced by 1) failure to ensure a resident with a fractured leg was seen for follow-up by the orthopedic surgeon as ordered by the primary care physician, 2) failure to ensure resident was sent to the appropriate location of appointment and failure to re-schedule a missed visit by a specialist and 3) failure to coordinate between resident, specialty providers, nursing and support staff responsible for scheduling appointments to ensure residents were seen by specialty providers as needed. This was found to be evident for 3 of 38 residents (#37, #106 and #119) reviewed during the investigative portion of the survey. The findings include: 1) On 6/8/18 review of Resident #37's medical record revealed the resident had diagnosis of renal disease with dependence on dialysis, diabetes, high blood pressure,…

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: 1) failed to develop policies and procedures that ensure that each resident or responsible party (RP) received education regarding benefits and risk and 2) document that the residents, or the responsible party, was provided education regarding the benefits and potential side effects of the influenza immunization prior to administration for five residents. This was evident for 5 of 5 residents (#43, #40, #4, #66, and #38) reviewed for immunization status. The findings include: 1) On 6/15/18 the facility resident immunization policy was reviewed. This review revealed the following: Fact Sheet Influenza, Precautions and Special Considerations. It also reveals what to do for pandemic flu. No other policy on influenza immunization was provided to include benefits and potential side effects. During an interview with staff #12 on 6/15/18, no other policy was given to the survey team to address additional information for the resident or RP. 2) On 6/15/18 review of Residents #43, #40, #4, #66 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 observation and interview with staff it was determined that the facility failed to maintain the walk in freezer in good operating manner as evidenced by a build up of ice in the facility's one walk in freezer. This deficient practice has the potential to affect any resident who consumes food provided from the kitchen. The findings include: On 6/5/18 at 3:17 PM, with the Food Service Director (FSD), surveyor observed an approximately 10 inch x 8 inch area of ice on the floor located below the condenser fan in the walk-in freezer. The FSD reported this was from condensation and that maintenance was aware of the ice. On 6/13/18 at 1:28 PM, with the FSD, surveyor observed ice on the floor of the walk in freezer near the entrance door. The FSD reported that she thought air was getting in at the door way and that she had informed maintenance about this about two weeks prior. Also during this observation a frozen puddle of water, similar to that observed on 6/5/18, was noted below the condenser. On 6/15/18 at 10:50 AM surveyor reviewed the concern with the Administrator regarding…

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.