Autumn Lake Healthcare At Glen Burnie

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, it was determined that the facility failed to:1.Maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (#186) of 9 residents reviewed for baseline care plans during this annual survey.2(a-c).Accurately document the baseline care plan. This was found to be evident for 8 (#193, #192, #44, #55, #78, #96, #118, #181) of 19 residents reviewed for smoking ,and 1 (#10) of 2 residents' Kardex reviewed.The findings include: 1. A tracheostomy is a hole that surgeons create in the front of the neck, into the windpipe (trachea). Surgeons place a tracheostomy tube into the hole to keep it open for breathing. The term for the surgical procedure to create this opening is tracheotomy. On 5/7/26 at 3:35 PM, the GNA (GNA #22) that had provided care to Resident #186 on the day in question was interviewed by the surveyor about what had happened. GNA 22 stated that she and the nurse had just provided tracheostomy…

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

Based on record reviews and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive. This was evident for 1 (#55) out of 9 residents reviewed for Advanced Directives during the annual recertification survey.The findings include: On 5/4/26 at 12:28 PM, the surveyor conducted a resident record review. During the resident record review, the surveyor could not locate resident #55's advance directive, nor could the surveyor locate documentation indicating that Resident #55 declined the opportunity to complete an advance directive when the facility offered the resident an opportunity to complete one. On 5/7/26 at 10:07 AM, the surveyor interviewed the Nursing Home Administrator (NHA) #1. During the interview, the NHA #1 mentioned that Resident #55 does not have an advance directive in place. The surveyor asked the NHA #1 if the facility has documentation indicating that resident #55 declined to complete an advance directive when the facility offered Resident #55 an opportunity to complete one. The NHA #1 indicated that…

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

Based on record reviews and interviews with staff, it was determined that the facility failed to ensure residents' rights to personal privacy. This was found to be evident for 3 (#60, #122, #141) of 4 residents residing together in a room on the Shenandoah Unit.The findings include:On 5/6/2026 at 12:20PM, the Surveyor confirmed the use of a private video monitoring device for Resident #6, installed at the request of their resident representative. Resident #6 resides in a room with Resident #60, #122, and #141. During a tour of the unit, a Surveyor observed that signage of video monitoring in the shared residents' room was not present. According to the facility's Audio/Visual Recording in Resident Rooms policy revealed that, If the resident is in a shared room, recording may not occur without written consent of the roommate and A sign will be placed on the door stating, 'Electric monitoring in progress'.On 5/7/2026 at 9:54AM, the Surveyor interviewed the Nursing Home Administrator (NHA #1) and requested documentation to verify Resident #60, #122, #141 provided written consent for the…

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

Based on review of Facility Reported Incident (FRI) investigative file and interviews, it was determined that the facility failed to report a misappropriation of resident property to the Office of Health Care Quality (OHCQ) within the required 24 hours after the allegation was made. This was found to be evident for 1 FRI (#3004409) out 7 FRIs reviewed during the annual recertification survey.The findings include:On 5/4/2026 at 9:47AM, during an interview with Resident #158's resident representative (RP), the Surveyor was informed that the resident's rings were stolen by a facility staff member. The RP stated that he/she called the police and informed the Nursing Home Administrator (NHA #1), who is currently investigating the allegation.On 5/6/2026 at 12:00PM, a review of Resident #158's FRI #3004409 revealed that the night supervisor was made aware of the allegation on 4/26/2026 at about 8:00AM and the NHA #1 was made aware of the allegation on 4/26/2026 at about 9:00AM. Further review revealed that the facility submitted the initial report to OHCQ on 4/28/2026 at 9:48AM.On 5/8/2026…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, it was determined that the facility failed to provide written notification of transfer and bed hold policy. This was evident in 2 (#6, #19) of 3 resident records reviewed for discharge processes. The findings include: 1. On 5/11/26 at 6:37 AM, Resident #6's medical record was reviewed. The record review revealed that according to Resident #6's AUTM Change in Condition/Concurrent Review 2.0 – V 13 form, dated 1/21/26, Resident #6 was hospitalized for complaints of chest pain on 1/21/26. It is also documented that Resident #6's responsible party was onsite at the facility and aware of the resident being transferred to the hospital. On 5/11/26 at 6:59 AM, Resident #6's medical record was reviewed. The record review revealed that the facility listed Resident #6's name on the bed hold policy for when Resident #6 was being transferred to the hospital on 1/21/26; however, the facility did not have Resident #6's responsible party sign the bed hold policy, although 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 record review and interview with staff, it was determined that the facility failed to ensure a resident's Minimum Data Set (MDS) assessments were completed and submitted in a timely manner. This was found to be evident for 1(#19) of 8 residents reviewed for accidents during the annual recertification survey.The findings include:The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. MDS assessments in Maryland should be signed and completed by the Registered Nurse (RN) Assessment Coordinator no later than 14 calendar days after the Assessment Reference Date (ARD). The signature certifies that the assessment is complete, accurate, and reflects the resident's status within the look-back period.On 5/8/2026 at 9:42AM, a review of Resident #19's Annual MDS assessment, with an ARD of 1/26/2026, revealed that the RN Assessment Coordinator signed 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 interviews with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 5 (#12, #51, #55, #85, #139) of 19 residents reviewed for smoking and 1 (#195) of 3 residents reviewed for respiratory care during the annual recertification survey.The findings include:1.On 5/6/2026 at 8:20AM, a review of the facility's Smokers List as of 5/6/2026 included Resident #12, #51, #55, #85, and #139 identified as current smokers.On 5/6/2026 at 10:25AM, a review of the electronic medical records for these residents, who were identified as current smokers at the time of the Annual MDS assessment revealed the following concerns with Section J 1300 Current Tobacco Use:-Resident #12- Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #51- Annual MDS assessment dated [DATE] indicated No for tobacco use-Resident #55-Annual MDS assessment dated [DATE] 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 record review and interview with staff, it was determined that Preadmission Screening and Resident Review (PASARR) was not re-evaluated and updated to reflect a resident's current diagnosis of serious mental illness. This was found to be evident for 1 (#19) of 2 residents reviewed for PASARR during the annual recertification survey.The findings include:Preadmission Screening and Resident Review (PASARR) is a federal program that screens individuals applying to or residing in Medicaid-certified nursing facilities for serious mental illness (SMI) or intellectual disability (ID). The purpose is to ensure these individuals receive the most appropriate and least restrictive care setting and services.On 5/7/2026 at 11:40AM, a review of Resident #19's most recent PASARR dated 8/14/2024 showed no diagnosis of serious mental illness. However, a review of the resident's electric medical record at 12:00PM revealed the resident had been diagnosed with major depressive disorder on 12/16/2025.On 5/7/2026 at 12:55PM, during an interview with Social Worker (SW #9) and 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 review of complaint #s 2723504 and 2788226, resident records, and staff interviews, it was determined that the facility failed to adhere to professional standards of practice when administering medications to residents. This was found to be evident for 1 (Resident #6) out of 1 resident reviewed for medications during the annual recertification survey.The findings include:On 5/5/26 at 2:07 PM, the surveyor reviewed complaint #s 2723504 and 2788226. Complaint #s 2723504 and 2788226 indicated that Resident #6's medication was not administered timely.On 5/7/26 at 2:36 PM, the surveyor reviewed Resident #6's medical records. Resident #6's Medication Admin Audit Report indicated that Resident #6 received the following medications late on 1/28/26:-Miconazole Nitrate External Cream 2 % (Miconazole Nitrate [Topical]) for rash, was scheduled for 3:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26, and documented at 12:47 AM on 1/29/26.-Icosapent Ethyl Oral Capsule 1 GM (Icosapent Ethyl) for hyperlipidemia, was scheduled for 5:00 PM on 1/28/26, administered at 12:47 AM on 1/29/26,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure a follow up medical appointment recommendation was followed and timely scheduled. This was evident for 1 (#27) out of 4 Residents reviewed for care planning during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 5/4/26 at 9:16AM Resident #27 expressed to the surveyor that they were concerned regarding their medical care which included an enlarged area present on their body and they did not know what the plan was for the medical care of it.Review of Resident #27's medical record by the surveyor on 5/8/26 at 1:06PM revealed diagnoses and medical history which included liver cell carcinoma, malignant ascites, and included documentation of an area having been identified on 3/17/26 as an aggressive osseous lesion on the Resident's hospital Discharge summary dated [DATE], prior to the Resident's admission to the facility on 3/25/26. Further review by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview with staff, it was determined that the facility failed to ensure a resident was properly assessed for the safe use of side rails and develop and implement a person-centered care plan. This was found to be evident for 1 (Resident #194) out of 2 resident reviewed for side rails during the annual recertification survey.The findings include:Bed rails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks.On 5/4/2026 at 9:10AM, during an initial tour of the Gateway Unit, Resident #194 was observed sitting up in bed with the head of the bed elevated about 75 degrees and 1/4 size side rails raised on both sides of the bed.On 5/6/2026 at…

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

Based on record review and interview it was determined the facility failed to ensure yearly performance evaluations of geriatric nursing assistants. This was evident for 72 out of 75 geriatric nursing assistants during the surveyor's review of the staffing task during the facility's recertification survey.The findings include:On 5/4/26 at 11:20AM the surveyor conducted an interview of the facility's Director of Nursing (DON) who reported to the survey team that they had been in their role for seven months and each nursing unit has a unit manager who performs the performance evaluations every year of nursing assistants. During the interview, the DON stated to surveyors that they review the evaluations with the unit managers.On 5/5/26 at 10:17AM the surveyor requested complete employee personnel files for Geriatric Nursing Assistants (GNA) #22, #23, and #24 from the facility Administrator.On 5/5/26 at 11:22 AM the surveyor conducted a review of the complete employee personnel files for GNA #22, #23, and #24 which revealed inconsistent documentation for yearly performance reviews.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 observation and interview it was determined that the facility failed to ensure daily staffing information was current and displayed in a prominent location. This was evident for 1 out of 1 staffing sheet observed to be present during the surveyor's initial tour of the facility.The findings include:On 5/4/26 at 8:19AM surveyors observed the front desk of the facility's main building at which time a plastic container was observed prominently displayed with staffing information which was dated 5/1/26. Upon further tour of the main areas of the facility's main building, no other posting with all required staffing information was observed to be present.On 5/4/26 at 8:48AM the surveyor shared the concern with Front Desk Staff #4 who observed and acknowledged the concern and reported to the surveyor that the displayed staffing information was supposed to be over on a table in a side hallway and not at the front desk. Updated staffing information was then observed displayed on a side hallway table with the date of 5/4/26 present, and the front desk staffing information was removed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an interview and record review conducted during the annual survey, it was determined that the facility staff failed to promptly provide or obtain routine dental care and treatment. This was found to be evident for 1 (# 8) out of 8 residents reviewed for dental services during an annual survey.The findings include:During an initial screening conducted on 05/04/26 at 11:37 AM, Resident #8 reported experiencing aching in their back teeth. This resident also expressed uncertainty regarding their dental history at this facility and whether they have previously seen a dentist here. Resident #8 was able to answer questions appropriately and made his/her needs known.A record review conducted on 05/08/26 regarding Resident #8 revealed that the resident was admitted to this facility on 08/21/25 with diagnoses of left stroke resulting in hemiplegia, dysarthria, and type 2 diabetes.The admission orders signed by Physician #28 on 08/21/25 specify that a dental consultation should be conducted annually and as necessary. Additionally, the functional status assessment indicates that…

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

Based on observations, medical record reviews, and interviews, it has been determined that the facility failed to honor resident preferences and provide consistent meal selections. This was evident for 1 (#8) of 8 residents reviewed for food preferences during an annual survey.The findings include:On 05/04/26 at 12:30 PM, Resident #8 pointed out that they were served fish. A review of the meal tray and ticket confirmed the fish entree was served and listed, and the resident noted receiving fish or pork multiple times previously.On 05/06/26 at 12:45 PM, an observed revealed that the resident's lunch meal ticket indicated a restriction for No Pork only. Additionally, floor staff stated that this resident would not eat fish.A record review conducted on 05/08/26 regarding Resident #8 revealed that the resident was admitted to this facility on 08/21/25 with diagnoses of left stroke resulting in hemiplegia, dysarthria, and type 2 diabetes. Physician #28's order dated 08/21/25 indicated regular diet. Notes from Dietitian #30 dated 02/11/26 showed that this resident consumed 50% or less for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with a resident and staff, it was determined that the facility failed to ensure a resident had the opportunity to communicate food preferences upon admission. This was evident for 1 (Resident #192) out of 3 residents reviewed for food concerns during the annual recertification survey.The findings include:On 5/5/2026 at 8:40AM, during an interview with Resident #192, the Surveyor was informed that he/she did not get any meat on their tray for breakfast. The Surveyor observed eggs, a piece of coffee cake, a bowl of hot cereal, milk, and juice. The resident appeared frustrated.On 5/6/2026 at 12:55PM, Resident #192 was observed eating lunch. The resident informed the Surveyor that he/she did not receive enough food for breakfast. The resident stated, They gave me 2 small pancakes, as he/she demonstrated the size of the pancakes with his/her hands. The resident appeared frustrated.On 5/7/2026 at 12:28PM, during a follow-up interview, the resident expressed the concern that he/she…

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

Based on interviews and medical record reviews, it was determined that the facility failed to 1) use an interdisciplinary team to revise care plans in order to meet the residents' need and 2) ensure that a resident's representative was offered an opportunity to participate in a quarterly care plan review assessment. This was evident for 5 (#23, #2, #64, #73 and #119) of 34 residents reviewed during the recertification/complaint survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) An interview was conducted on 02/18/25 at 11:59 AM with 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 observations, interviews with facility staff, and review of the facility's documentation, it was determined that the facility failed to accurately provide a meal based on the facility's established menu and respect residents' right to make choices about their diet. This was evident for 10 of 64 residents (Resident #147, #169, #524, #523, #149, #525, #450, #451, #452, #453) reviewed for accuracy of meals during a recertification/complaint survey. The findings include: The Certified Dietary Manager (CDM #62) was interviewed during an observation in the kitchen on 2/24/25 at 12:07PM. When asked how residents choose meals, he stated they have a menu with the 4 week cycle of meals and a copy of the menu is also provided by the activities staff. Residents can call or put in a ticket during certain times if they want to make any changes and so a resident will receive the listed menu items [referred to as the Regular meal] unless they request something different. The Regular meal being served for lunch was Dijon Pork Loin, Capri Vegetable Blend, and [NAME] Pilaf as observed by the…

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

Based on observation and interview it was determined the facility failed to: 1.) ensure the plate warming device was in operating condition, 2.) ensure foods were labeled, 3.) ensure accuracy of food discard dates, 4.) ensure food was not adulterated, 5.) ensure stored food was covered/protected, 6.) ensure kitchen surfaces were free from dust/debris, 7.) ensure food preparation surfaces were free from personal belongings, 8.) ensure the ceiling was free from chipping paint, and 9.) ensure kitchen equipment was clean and in good repair. This was evident during the surveyor's initial tour of the facility's kitchens during the facility's recertification/complaint survey. The findings include: During the surveyor's initial tour of the facility's main kitchen on 2/18/25 at 7:59AM the surveyor observed the exterior metal surface of the dishwasher and noted areas of peeling plastic were present and black debris was present. On 2/18/25 at 8:01AM the surveyor observed orange colored splattering on the wall and flooring next to the juice/drink machine in the main kitchen. On 2/18/25 at…

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

Based on review of facility records and interviews with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assurance (QAPI) meetings. The findings include: On 2/27/25 at 9:42 AM review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan policy revealed, The QAPI Committee members consist at minimum of: Administrator, Director of Nursing (DON), Quality Assurance (QA) Coordinator, Infection Preventionist (IP), Staff Development, Department Heads, Vendors (including pharmacy), and a GNA (Geriatric Nursing Assistant). Review of the facility's QAPI monthly attendance records for 1/2024 to 12/2024 revealed the following: 1. A Geriatric Nursing Assistant failed to attend 4 of 12 meetings (February 2024, October 2024, November 2024, December 2024). 2. The Medical Director failed to attend 1 of 12 meetings (February 2024). 3. The Director of Nursing failed to attend 1 of 12 meetings (April 2024). On 2/27/25 at 10:52 AM in an interview with the DON and Administrator attendance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to implement an effective infection control program by 1) failed to change oxygen tubing as per the facility protocol. This was evident for one Resident (Resident #38) out of 34 Residents reviewed for infection control, and 2) ensure that they implemented and maintained an effective infection control program related to transmission-based precaution and enhanced barrier precaution protocols: including isolation precaution posted signs on rooms. This was evident by 3 (Resident # 73, # 100 and #119) of 34 residents and 3 residents' rooms reviewed during the recertification/complaint survey. The findings included: 1) On 02/18/25 at 01:23 PM, the surveyor observed Resident #38 receiving continuous oxygen via nasal cannula, and oxygen tubing was labeled with a date of 02/02/25. On 02/18/25 at 2 PM, an Interview with a Licensed Practical Nurse (LPN) validated that the date on the tubing was 16 days old and clarified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff received training in effective communication. This was evident for 9 of 9 (Staff #6, #7, #10, #42, #43, #44, #45, #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 #6, # 7, #10, #42, #43, #44, #45, #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 called Care fed, 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 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 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.

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 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.

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.

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 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].