Marley Neck Rehabilitation and Wellness Center

Based on interview, review of facility-reported incident investigation and record review, it was determined that the facility failed to thoroughly investigate an incident. This was evident for 1 (Resident #59) of 3 residents reviewed for abuse during the recertification survey. The findings include: A Hoyer lift, also known as a patient lift, is a mechanical device used to safely lift and transfer individuals who are unable to move themselves, often due to mobility limitations. On 6/16/25 at 11:11 AM, in an interview with Resident #59, he/she stated that a Geriatric Nurse Assistant (GNA) was rough when he/she was transferred from wheelchair to bed. He/she added that he/she was supposed to be transferred via Hoyer lift, however, the GNA picked him/her up from my wheelchair and transferred him/her manually to the bed. On 6/27/2025 at 8:09 AM, a review of facility-reported incident MD00211974 revealed that on 11/19/24 at 6:00 PM, Resident #59 was transferred by GNA #10 from the wheelchair to the bed without using a lift. The allegation was confirmed with a statement provided by…

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

Based on record review and interview, it was determined that the facility failed to accurately code the resident's discharge status on the Discharge MDS assessment. This was evident for 1 (Resident #88) of 3 residents reviewed for hospitalization during the recertification survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge assessments include the completion of a select number of MDS items in order to track residents when they enter or leave a facility. A Discharge Assessment-Return Not Anticipated (DCRNA) must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days while a Discharge On 6/20/25 at 7:20 AM, a review of Resident #88'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 reviews and facility staff interviews, it was determined that the facility failed to initiate care plans based on medication use. This was evident for 2 (Residents #4, #32) out of 36 residents reviewed for care plan implementation during a recertification survey process. The findings include: A care plan details the daily support an individual requires to maintain quality of life, including personal care, medication, meals, social interaction, and mobility assistance. It ensures coordinated care across caregivers and service providers. On 6/18/25 at 6:35 AM, a review of Resident #32's medical record revealed a physician order dated 3/21/25 for busPIRone HCl 5 mg oral tablet. The order directs staff to administer 1 tablet by mouth every 8 hours for treatment of anxiety. On 6/18/25 at 12:49 PM, further review of the medical record revealed that the facility failed to initiate a care plan related to antianxiety medication to reflect the plan of care for Resident #32. During an interview with the Director of Nursing (DON) on 6/18/25 at 1:49 PM regarding Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, it was determined that the facility failed to apply a preventative brace ordered for a resident. This was found to be evident for 1 (Resident #1) out of 1 resident reviewed for quality of care. The findings include: Foot drop is an inability to lift the front part of the foot and toes. This can be caused by nerve injuries, muscle disorders, brain or spinal cord disorders (such as stroke). If foot drop persists, the muscles that point the foot downward can become tight and lead to a contracture. A foot drop brace, is designed to support the ankle and foot. The brace extends from the calf, wraps around the ankle, and extends under the foot, often inside the shoe. It provides support and can help lift the foot, preventing it from dropping and allowing for a more normal gait. An Ankle-Foot Orthosis (AFO) is a brace worn on the lower leg to support the ankle and foot. It is commonly used to treat foot drop by holding the foot in a proper position to prevent dragging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to ensure that the medication error rate was not 5% or greater. This was evident for 2 (Resident #74 and #82) out of 6 residents observed for medication administration. 2 errors were discovered out of 38 opportunities. The findings include: According to the Centers for Medicare and Medicaid (CMS) the Medication error rate is determined by calculating the percentage of medication errors observed during a medication administration observation. The numerator in the ratio is the total number of errors that the survey team observes, both significant and non-significant. The denominator consists of the total number of observations or opportunities for errors and includes all the doses the survey team observed being administered plus the doses ordered but not administered. The equation for calculating a medication error rate is as follows: Medication Error Rate = Number of Errors Observed divided by the Opportunities for…

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

Based on observation and interview, it was determined that the facility failed to ensure that the staff followed infection control protocols. This was found to be evident during the review of (1) medication administration and (2) laundry services, it has the ability to affect all residents. The findings include: 1) On 6/18/25 at 9:09 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 administering medications to residents. At that time, it was observed that LPN #1 did not perform hand hygiene before entering the room to administer medication to Resident #82 and Resident #60. On 6/18/25 at 9:43 AM, this surveyor also observed that LPN #1 did not wipe down the blood pressure cuff or the pulse oximeter probe between use on Resident #82 and Resident #60. On 6/18/25 at 9:59 AM, this surveyor conducted an interview with LPN #1 to discuss concerns regarding infection control practices during medication administration. It was explained that the surveyor observed a failure to perform hand hygiene before entering residents' rooms, as well as a failure to disinfect the blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, it was determined the facility failed to ensure that the resident's bathroom call system was functioning properly. This evident for 1 of multiple rooms observed during the recertification survey. The findings include: On 6/24/25 at 1:02 PM, in an interview with Resident #47, he/she stated that she fell in the bathroom on 6/23/25. He/she added that he/she attempted to pull the bathroom call cord to alert the staff, however, he/she was unsuccessful. He/she described the the cord got stuck and was not functioning, so he/she started yelling and maneuvered themselves towards the switch and slid the on/off switch for the call bell to activate. During an observation, the surveyor noted that the bathroom call cord was attached to a switch on the wall; the cord was hanging approximately 2 inches from the floor and the switch was 40 inches from the floor. Also, the surveyor attempted to pull the cord to activate the switch and confirmed that the pull cord was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff interviews it was determined that the facility failed to ensure a Resident was provided scheduled showers. This was found to be evident for 1 (Resident #77) out of 1 Resident reviewed for Activities of Daily Living (ADL) during the re-certification survey. The findings include: According to the National Institute of Health (NIH) Activities of Daily Living (ADL) are basic routine tasks that most healthy individuals can perform without assistance. These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. The inability to perform basic activities of daily living may lead to unsafe conditions and a poor quality of life. The healthcare team should be aware of the importance of assessing activities of daily living in patients to help identify those who require assistance, whether for temporary rehabilitation or long-term 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to 1. provide a Resident with safe transfer from chair to bed and 2. ensure a Resident was free from an accident. This was found to be evident for 2 (Residents #59 and #146) out of 3 Residents reviewed for accidents during the re-certification survey. The findings include: 1. On 6/30/25 at 8:06 AM a review of the Facility Reported Incident (FRI) MD00178278 revealed a report of a fall to the Office of Health Care Quality (OHCQ). The report advised that Resident #146 complained that during incontinent care the Resident fell off the bed. During review of the investigation file conducted on 6/30/25 at 8:17 AM, this surveyor reviewed the statement from Geriatric Nursing Assistant (GNA)#8. In the statement the GNA reported that around 5 am on 5/18/22, while changing Resident #146, the Resident rolled toward me but was sliding off the bed. I quickly grabbed him/her upper body that was leaning toward the floor and guided the Resident 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 record review and interview, it was determined that the facility failed to implement nonpharmacological interventions of pain and ensure that pain medication was given consistent with the professional standards of practice. This was evident for 1 (Resident #59) of 3 residents reviewed for pain management during the recertification survey. The findings include: The medical abbreviation PRN stands for pro re nata, a Latin phrase that translates to as needed or as the situation arises. Nonpharmacological interventions are treatments that manage pain without the use of medication. These interventions may include but are not limited to massage, music therapy, aromatherapy, applying mild heat or cold packs and repositioning. Oxycodone is a strong painkiller from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. Pain parameters are the specific aspects of pain that are evaluated during an interview to understand a person's pain experience. On 6/18/25 at 7:18 AM, a review of Resident #59's active Physician's orders revealed the following: 1.…

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

Based on observations and interviews with facility staff it was determined the facility failed to provide ongoing activities to residents. This deficient practice has the potential to affect all residents. This was found to be evident when multiple observations were made during the survey. The findings include: While conducting the facility's annual survey, multiple observations were made on the nursing unit as follows: On 5/18/22 at 12:14 PM an observation was made and there were no activities taking place. On 5/19/22 at 11:00 AM an observation was made and there were no activities taking place. On 5/24/22 at 1:00 PM an observation was made and there were no activities taking place. An interview was conducted with the Activity Assistant (AA), Staff # 17, on 5/24/22 at 11:48 AM and she was made aware that multiple observations were made and there were no activities taking place. She acknowledged that activities were not ongoing contributing this to being new to the facility. During a subsequent interview at 12:30 PM with Staff #7 provided a copy of the facility's activity calendar…

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

Based on surveyor observation during tour of the facility, it was determined that the facility failed to maintain and enhance the dignity of Resident #70, this occurred in 1 of 37 sampled residents. The findings include: On 5/18/22 at 10:00 am during tour of the facility this surveyor observed Resident #70 lying in bed near the door. The resident was uncovered and exposed. The privacy curtain was partially pulled back, Staff # 22, a GNA, was assisting the resident with morning care. Staff #22 was interviewed about the observation on 5/18/22 at 1:00 pm. She stated, I became busy helping the resident and forgot to pull the curtain around. On 5/19/22 at 9:30 am, surveyor #42782 interviewed Resident #70 was interviewed about the incident. According to the resident, s/he stated, I felt bad. when receiving care while exposed. The Director of Nursing (DON) was made aware of the observation on 5/18/22 at 10:30 am. She stated she would be speaking with Staff #22 regarding the observation.

Based on interviews with residents and staff it was determined the facility failed to: 1). Provide a resident with with the appropriate size adult brief (Resident #50), and 2). Ensure a resident's call bell was in reach when needed (Resident #56). This was found to be evident for 2 of 24 sampled for accommodation during the survey. The findings include: 1). While conducting an interview with Resident #50 on 5/18/22 at 11:38 AM, the resident told the surveyor that his/her adult briefs do not fit. The resident stated that brief size the facility provides does not fully cover him/her and it cannot be closed. The resident showed the package to the surveyor and the size on the package read, Large. The resident stated that s/he thought the brief size was extra-large, which explains why the briefs do not fit. The resident went on to say that the facility does not provide the appropriate size adult briefs and that s/he will have to purchase their own supply. During another interview with Resident #50 on 5/25/22 at 10:00 AM, the resident stated that s/he had to purchase several packs of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to ensure that residents' rooms were maintained in a homelike environment by conducting routine assessments of the resident room and completing repairs when needed. This was found to be evident while touring rooms #43, #45, #47, #48 and for Resident #187's the facility during the facility's annual Medicare/Medicaid survey. The findings include: 1). On 5/18/22 at 12:00 PM during a tour of residents rooms 40-1 through 48-2 were observed. There were multiple rooms noted to have large, spackled areas above the head of the bed in need of repair and paint. On 5/25/22 at 10:37 AM a tour of the unit was done with the Maintenance Director (MD), Staff #6, present. The Maintenance Director observed each of the rooms. room [ROOM NUMBER]-1: had a large, spackled area above the head of the bed. room [ROOM NUMBER]-2: had a large area with a hole in it above the head of the bed. room [ROOM NUMBER]: the was wallpaper was lifted behind…

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

Based on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the residents, the resident's representatives, and the ombudsman along with the reason for transfer. This was found to be evident for 2 out of 5 residents reviewed for a facility-initiated transfer during the investigative of the survey (Residents #67 and #87). The findings include: 1). A review of Resident #67's clinical record revealed on 1/23/21, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the residents, and or the residents' representative. The Administrator was informed of the regulatory concern on 5/25/22 at 10:30 AM, and no evidence of the notification was provided prior to exit. 2). A review of the medical record for Resident #87 on 5/24/22 at 10:00 am revealed Resident #87 was transferred to the hospital on 7/6/21. The continued review of the medical record did not reveal evidence 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 medical record review it was determined the facility failed to notify the resident or resident representative in writing of the facility's bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 1 of 2 residents reviewed during the annual survey (Resident # 87). The findings include: A review of Resident #87's medical record on 5/24/22 at 10:00 am revealed the resident was transferred to the hospital on 7/6/21. A continued review of the medical record did not reveal evidence that the resident or resident's responsible party was notified in writing of the behold policy. During an interview of the Administrator on 5/24/22 1:00 pm he stated the written notification of the bed hold policy could not be located.

Based on medical record review and interviews it was determined the facility failed to: 1). Have a quarterly care plan meeting for Resident #2; 2). Update Resident #2's care plan; and 3). Follow Resident #79's care plan interventions for rendering care when the resident is resistive services. This was evident for 3 of 24 residents sampled during the survey. The findings include: 1). On 05/26/22 at 9:44 am a review of the resident's electronic medical record revealed the last care plan meeting was held on 1/22/22. On 05/26/22 at 10:30 am the surveyor spoke with Staff #2, the Director of Nursing (DON), about the timing of the resident's last documented care plan meeting. On 05/26/22 at 3:11 pm, Staff #2, the DON, provided a list of care plan meetings held for the resident. The dates were documented as 02/18/21, 07/08/21, 10/24/21, and 01/22/22. There was no record of a care plan meeting between February 2021 and July 2021. There was no evidence of a meeting after January 2022. According to the list provided by the DON, the next scheduled care plan meeting for the resident is 06/02/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to follow physician orders for 6 out of 37 residents sampled for record review during the survey (#4, 42, #43, #81, #137, and #187). The findings include: 1). A suprapubic catheter is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow. On 5/24/22 at 10:00 an interview was completed with Resident #4's responsible party (RP). According to the RP, Resident #4 was sent to the emergency room) twice because the resident suprapubic catheter was not flushed. The resident's RP stated, I told the nurse his/her catheter was not being flushed; however, nothing was done. During observation on 5/24/22 at 11:30 am Resident #4 was noted lying in bed with his/her Foley bag covered by a pillowcase hanging on the left side of the bed. On 5/24/22 at 12:00 pm during an interview, Staff #14, a Geriatric Nursing Assistant (GNA), stated the pillowcase…

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

Based on medical record review and interview, the facility failed to provide treatment/services to maintain Resident #11's vision. This is evident for 1 out of 2 residents selected for review during the investigation stage of the survey process. The findings include: During an interview with Resident #11 on 5/19/22 at 10:00 AM, the resident stated he/she is waiting for an appointment with the eye doctor. The resident stated I can't see; my glasses were broken in October 2021, and I need a new pair. On 5/23/22 at 11:30 AM the review of Resident #11's record revealed that the Ophthalmologist saw the resident on 11/1/21 and noted that the current glasses were broken beyond repair and Resident #11 requested replacement. Further review of the medical record did not reveal evidence that the facility placed an order for the resident's glasses. An interview with the Administrator on 5/25/22 at 9:18 AM confirmed Resident #11's glasses were not ordered prior to 05/23/22.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #56). This was evident for 1 out of 19 residents reviewed during an annual survey. The findings include: During an interview with Resident #56 on 5/18/2022 at 8:25 am, the resident reported a fall incident that morning which was witnessed by facility staff. The surveyor reported the fall incident to the Administrator at 5/18/2022 at 10:00 am. An interview was conducted with the Administrator and Director of Nursing (DON) on 5/18/2022 at 12:30 pm. The DON revealed that facility staff reported that Resident #56's fall incident occurred at approximately 5:30 am that morning and there was no mention of injuries or pain when the resident was assessed. The DON interviewed Resident #56, after the surveyor reported the fall incident, and the resident reported having right shoulder pain and no other injuries. The Administrator revealed that the facility would investigate to determine 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 during the initial tour of the facility kitchen it was determined that the facility staff, failed to store, food under sanitary conditions. The findings include: On 5/19/22 10:33 am, during the initial tour and observation of the facility kitchen with the Dietary [NAME] staff #23, it was found that: 1. The dry storage room door was propped open, and two dietary aides', Staff #24 and Staff #25 were in the dry storage room labeling food. A box of relish packets was noted on the floor. 2. The storage room floor was dirty. 3. The storage room walls had chipped paint. 4. Observation was made of the stand-up refrigerator near the kitchen stove. In the refrigerator were an unlabeled 1/2 sandwiches that were in a plastic bag and a drink that was opened and unlabeled. Staff #23 stated the items belonged to a dietary aide who worked on 5/18/21. After surveyor intervention the items were discarded. 5. The 3-compartment sink had no test strips. On Staff #23 stated the Food Service Director, Staff #26 had the additional strips locked up and he would be in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe and sanitary environment for its residents that access entrance units, in the therapy room, and when storing resident's urinals. This deficient practice affects all residents in the facility. The findings include: 1). On 5/18/2022 at 8:10 am, during the initial tour, the surveyor observed dirty floors and debris at the entrance of the unit for the A and B halls. The surveyor also observed a soiled medication cart and a broken bed in the hall of Unit A. The surveyor expressed concerns to the Administrator and Director of Nursing on 5/24/2022 at 1:50 pm. 2). On 5/18/2022 at 8:30 am, during the initial tour, the surveyor observed facility staff member hanging clean urinals on the lip of the trash can in room [ROOM NUMBER]. On 05/18/2022 at 8:31 am, the surveyor interviewed Resident #41 and Resident #45 about the facility staff's storage of clean urinals. Both residents revealed that it was normal for facility staff members to hang clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to 1. ensure that a copy of the resident's Maryland Medical Orders for Life Sustaining Treatment (MOLST) and the medical ineffectiveness forms match. This was found to be evident for 1 out of 42 residents (Resident #32) reviewed for Advance Directives 2. ensure that the residents current code status matched the MOLST and the computer orders and ensure an effective system in place to ensure a resident's code status was communicated to nursing staff providing care. This was evident for 2 of 2 residents reviewed (Resident #23 and #28) in the investigative stage of the survey. The findings include: 1. On [DATE] Resident #32's medical records were reviewed. The review revealed that resident was admitted to the facility in [DATE] for rehabilitation and for long term care and with diagnoses that included Anoxic Brain Damage (injury to the brain due to a lack of oxygen), muscle weakness and stroke. Review of the Physician…

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

Based on medical record review, interview with residents, facility staff and observations, it was determined that the facility failed to keep residents free from abuse related to the fear that a known wandering resident had the potential to inflict abuse (verbal, physical or sexual) secondary to his/her mental status on residents that were dependent on staff for all activities of daily living. This was evident for 1 resident identified during an abuse allegation (Resident #23). The findings include: During the initial screening process Resident #77 was interviewed on 10/11/18 at 9:03 AM. S/he had no concerns with the facility and as the interview was ending s/he stated, the facility does have one problem, it's the wanderers. S/he further stated that, two men come in, they stand by the night stand and one by the door. The resident was asked if s/he has ever been touched and s/he stated no. S/he further stated that during the resident council meeting on 10/9/18, this concern was brought up and the facility put up stop signs at the door, but s/he doesn't feel like that will stop 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 on medical record review, interview and review of recent facility discharge practices, it was determined that the facility failed to provide residents and/or their representative (RP) with the proper paper documentation of the facility's bed-hold policy when a discharge to the hospital occurred, and failed to ensure correct information was shared when contact was made regarding the bed-hold policy. This was evident for 3 of 3 resident records reviewed (Resident #53, #241, #28) regarding planned and unplanned hospitalizations. The findings include: 1. Review on 10/15/18 at 9:51 PM, of the unplanned hospitalization of Resident #53 on: 2/14-2/17, 7/11-7/15 and 7/30-8/11, revealed that the facility failed to provide the resident or RP with a copy of the bed-hold policy upon transfer/admission to the hospital for any of the hospitalizations. 2. Review on 10/12/18 at 9:29 AM of Resident #241's hospitalization on 9/28/18 revealed that the resident and or RP was not given a copy of the facility bed-hold policy. 3. Review of Resident #28's medical record revealed the resident had…

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

Based on medical record review and interviews with staff it was determined that the facility failed to develop comprehensive care plans that describes the resident's 1. psychosocial needs and preference and how the facility will assist in meeting these needs and preferences, 2. wandering tendencies, 3. the use of side rails, 4. a restorative nursing plan including the use of a splint; 5. the treating of diabetes with diet only. This was evident for 4 out of 42 residents (Resident #42, #23, #77, and #28) reviewed during the investigation stage of the long-term care survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. On 10/12/18 Resident #42's medical records and care plans were reviewed. This review revealed that the resident was admitted to the facility in 2014 for long term care and with diagnosis which includes cerebrovascular accident or stroke (the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is…

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

Based on observation it was determined that the facility failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. This was evident during a random observation. The findings include: During tour of the facility on 10/15/18 at 1:08 PM Surveyor observed GNA staff # 13 pulling Resident #67 backwards down the hall. Resident #67 was positioned in a Geri chair (medical clinical style recliner). Staff #13 was observed walking forward with her arm extended backwards pulling the Geri chair down the main hallway and turned onto Hallway A wing. Resident #67 could not be observed from the staff's position and was not checked on by the staff during this observation. Staff #13 was asked by the surveyor if she knew this was a dignity concern and she stated no, but thank you for telling me. The Director of Nursing and the Unit Manger of the A wing were notified at 1:11 PM of the concern and the observation.

Based on interviews with residents and facility staff it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was found to be evident during a resident council meeting that was conducted during the facility's annual survey. The findings include: The survey team conducted a resident council meeting on 10/12/18 at 11:08 AM with the following residents in attendance: Resident #46, Resident #36, Resident #11, Resident #12 and Resident #74. The residents expressed the following concerns: One of the residents reported that a resident who uses a CPAP (Continuous Positive Airway Pressure) machine, requested assistance with putting it on and was told by staff that it is almost morning and that s/he probably did not need to have it on. The CPAP machine is used to help a person with sleep apnea breathe more easily during sleep. The resident said the staff did put the mask on but did not have to make that comment. Another resident stated that recently, s/he put the call light on because they wanted Tylenol and it took 5…

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

Based on observations and interviews with residents it was determined the facility failed to have survey results accessible to residents and a sign posted identifying where the survey results are located. This was found to be evident during a resident council meeting and during an observation of the facility during the facility's annual survey. The findings include: The survey team conducted a resident council meeting on 10/12/18 at 11:08 AM with the following residents in attendance: Resident #46, Resident 36, Resident #11, Resident #12 and Resident #74. The question was asked are the results of the state inspection available to read, and the residents responded by saying, we don't know where we can find the results. During an observation on 10/12/18 at 1:00 PM the state survey book was on the bottom of a table located in the front lobby. There was no sign posted identifying the state survey results location. In a meeting with the Nursing Home Administrator on 10/12/18 at 1:30 PM, s/he acknowledged that there was no sign posted and stated that the facility will post a sign in the…

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

Based on medical records review and staff interview it was determined that the facility staff failed to notify the physician that the resident blood test to measure the effectiveness of medication was hemolyzed. This was true for 1 of 1 residents (Resident #89) reviewed during the investigative stage of the survey. The findings include, On 10/16/18 Resident #89's medical records were reviewed. This review revealed that the resident was admitted to the facility in September for rehabilitation and with diagnosis that includes Venous thrombosis and embolism transient ischemia attack (TIA). A venous thrombus is a blood clot (thrombus) that forms within a vein. An embolism obstruction of an artery, typically by a clot of blood or an air bubble. A TIA is a temporary blockage of blood flow to the brain. Review of the physician orders reveal an order for Coumadin (medication to keep the blood thin). The dose of coumadin is determined by the resident Prothrombin Time and International Normalized Ratio (PT/INR). The goal is to keep the INR greater than 2 and less than 3. The international…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 3 of the 3 residents (Resident #53, #241 and #28) reviewed for hospitalization during the investigative portion of the survey. The finding includes: 1. Interview with Resident #53 on 10/10/18 at 10:09 AM revealed that s/he was hospitalized for approximately a month and a half but not sure how long ago. A review of Resident #53's medical record revealed diagnoses including seizures, chronic kidney disease, legal blindness, cognitive communication deficit and history of falls. Further review of Resident #53's electronic and paper medical record on 10/15/18 at 9:51 AM revealed hospitalizations on: 2/14-2/17, 7/11-7/15 and 7/30-8/11. Review of the medical record failed to reveal any documentation that the resident or the responsible party had been provided with a written notification…

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

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure the Comprehensive Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failing to assess the resident functional status and 2) failing to accurately assess a residents wandering status. This was found to be evident for 2 out of 42 residents (Resident #42 and #23) reviewed during the investigative stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. On 10/12/18 Resident #42's medical records were reviewed. This review revealed that the resident was admitted in August 2014 for long term care and with diagnoses which includes Rheumatoid arthritis, Chronic Obstruction Pulmonary Disease and Renal disease. Review of the Comprehensive assessment…

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

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failure to accurately assess antidepressant use and 2) failure to assess the resident functional status This was evident for 2 out of 46 records (Resident #42 and #32) reviewed during the investigation stage of the survey The Findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Resident #32 quarterly MDS was reviewed on 10/15/2018. This review revealed a quarterly MDS assessment completed on September 1, 2018. Review of section N medication usage revealed that the facility coded antidepressant uses for 0 days indicating the resident did not receive antidepressants. Review of the medication administration…

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

Based on medical record review, interview and observation it was determined that the facility failed to have an effective system in place to ensure restorative nursing services were put in place after the resident was discharged from therapy. This was found to be evident for 2 out of 3 residents (Resident #28 and #65) reviewed for activities of daily living during the investigative portion of the survey. The findings include: 1) On 10/11/18 review of Resident #28's medical record revealed the resident had resided at the facility for several years and whose diagnosis included heart disease, diabetes and dementia. The resident also has left sided hemiparesis (weakness or partial loss of movement). On 10/15/18 review of the medical record revealed an order, dated 8/23/18, for the following: OT (occupational therapy) Clarification: D/C (discharge) from skilled OT with restorative nursing for orthotic management. This physician order had been initiated by Occupational Therapist (OT) #11. Further review of the medical record failed to reveal any documentation regarding the specifics of…

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

Based on medical record review and interview with facility staff it was determined that the facility failed to administer medication as ordered by the physician. This was evident during the review of 1 of 5 (Resident #77) records reviewed for unnecessary medications. The findings include: Review of the medical record on 10/15/18 at 9:30 AM for Resident #77 revealed diagnosis including chronic pain. In addition there was a physician order for morphine sulfate 15 mg twice a day secondary to a compression fracture. Further review of Resident #77's medical record revealed on 10/12 and 10/13/18 at 8:00 PM the scheduled morphine dose was documented as a '9' on the medication administration record (MAR). According to the Assistant Director of Nursing (ADON) when interviewed on 10/15/18 at 5:49 PM the '9' means not given. On 10/12/18 an as needed dose of Oxycodone was administered to Resident #77 at 8 PM and on 10/13/18 an as needed dose of Oxycodone was given at 7:00 PM. Throughout the month of October the Oxycodone was only given in the morning except on 10/12/18 and 10/13/18. No where 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 medical records review and interview with staff it was determined that the facility failed to provide follow-up care for a resident regarding hearing impairments. This was evident for 1 out of 1 residents (Resident #21) reviewed for hearing during the investigation stage of the survey The findings include: On 10/15/18 Resident #21's medical records were reviewed. This review revealed that in March 2018 the resident had an audiology consult. This consult revealed that the resident needed wax removed from both ears. The consult further revealed that the resident should not be scheduled for a follow up appointment until the resident has seen an ears, nose and throat (ENT) specialist and after the ears are clean the resident can reschedule for an evaluation. During an interview with the unit manage on 10/15/18 the surveyor asked what the process after the resident has been seen by the specialist and they make recommendation. She revealed that after the recommendations are made, either she or the unit managers will call the attending physician and arrange a follow-up. The…

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

Based on medical record review, interview and observation it was determined that the facility failed to adequately assess and implement interventions related to a resident with known wandering tendencies. This was evident for 1 of 1 residents (Resident #23) identified for wandering. The findings include: Review of the medical record for Resident #23 on 10/11/18 at 11:00 AM, including nursing notes revealed diagnoses including Parkinson disease and unspecified dementia with behavioral disturbances. Nursing notes throughout the resident's stay documented wandering behavior with intrusion on other residents' rooms from June 2018 to October 2018. Nursing notes also documented attempts at redirecting the resident that were not always effective. Resident #23 was observed on 10/11/18 at 12:12 PM entering another resident's room and being redirected by his/her roommate. There were no staff around at this time during this observation. A review of the resident #23's care plans on 10/15/18 at 11:52 AM revealed a failure to include wandering and possible interventions related to the resident'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 observation, interview and medical record review it was determined that the facility failed to assess and implement bed rails when ordered for a resident with repeated falls. This was evident for 1 of 2 residents (Resident #53) reviewed for bed rails. The findings include: During an interview with Resident #53 on 10/10/18 at 10:10 AM s/he revealed to the surveyor that s/he is always falling and they are getting me a set of 'bars' to put here (pointed to the side of the bed) so I will hit them and know when to stop. I have fallen about 4 times, had a blackened eye, hit my forehead and had a big knot on my head from the bed side table. A review of Resident #53's medical record on 10/15/18 at 8:51 AM revealed diagnoses to include: generalized muscle weakness, seizures, history of traumatic brain injury and legal blindness. Further review of the resident's medical record revealed a fall occurring on 9/22/18 where Resident #53 fell out of bed and hit the bed side table. Another fall on 9/28/18 occurred and resident was found sitting on the floor with no injuries. A physical…

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

Based on medical record review and interview with staff it was determined that the facility failed to ensure pain medication ordered to be given as needed was only administered when indicated. This was found to be evident for 1 out of the 6 residents (Resident #2) reviewed for unnecessary medications during the investigative portion of the survey. The findings include: On 10/12/18 review of Resident #2's medical record revealed the resident had resided at the facility for more than a year and whose diagnosis include: diabetes, high blood pressure and high cholesterol. The resident's current orders for as needed pain medication included the following: Oxycodone 5 mg give one tablet every 6 hours as needed for pain and Tylenol 325 mg give two tablets by mouth every 6 hours for pain. No documentation was found in the orders regarding when the oxycodone was indicated verses when Tylenol was indicated. Oxycodone is an opiate medication used to treat pain. Review of the Medication Administration Record for the as needed pain medications revealed an area for the nurse to document the…

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

Based on medical record review and interview with staff it was determined that the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs as evidenced by: 1) failure to provide adequate indication for the administration of psychotropic medications. This was evident for 1 out of 3 (Resident #32) residents reviewed during the investigation stage of the long-term care survey. The findings include: On 10/15/18 Resident #32's medical records were reviewed. This review revealed that the resident was admitted to the facility in January 2017 for rehabilitation and long-term care and with diagnosis that include Bipolar without psychotic features. Review of the medical records revealed that in January 2017 the resident was started on Seroquel 50 milligram every night. Review of the corresponding note revealed staff reported the resident had been stable will continue the resident on Seroquel 50 milligram. April 2017: the resident's dose of Seroquel was increased to 75 milligram the psychiatry note revealed the following; resident denies feeling depressed,…

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

Based on observations and interviews with facility staff it was determined the facility failed to date medications upon opening them and discard expired medications. This was found to be evident for 2 out of 3 medication carts reviewed during the facility's annual survey. The findings include: An observation was conducted on 10/10/18 at 9:30 AM of three of the facility's medication carts and the following concerns were identified: In medication cart #1, there was a bottle of Systane Balance Lubricant eye drops for Resident #49 that was not dated when opened. There was a bottle of Artificial Tears Solution for Resident #27 with a date on the bottle that read, opened 4/1/18. The medication was to be discarded after 30 days of opening it. The nurse, Staff #16 was interviewed on 10/10/18 at 10:35 AM and stated that the medications were brought over with the resident when s/he was transferred to the unit. There was also a bottle of Xalatan 0.005% eye drops for Resident #17 that was not dated when opened. In medication cart # 3 there was a bottle of Refresh Liquigel Solution 1% that was…

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

Based on medical record review and interview with staff it was determined that the facility failed to maintain medical records in accordance with professional standards as evidenced by failure to ensure primary care physician notes were printed and kept in the medical record for review by other health care providers. This was found to be evident for 1 out of 42 residents (Resident #28) reviewed during the investigative portion of the survey. The findings include: On 10/11/18 review of Resident #28's medical record revealed the resident had resided at the facility for several years and whose diagnoses included heart disease, diabetes and dementia. On 10/15/18 review of Resident #28's medical record, including the electronic health record and the paper chart, failed to reveal any primary care physician notes for 2018. On 10/15/18 at 3:41 PM surveyor informed the Director of Nursing (DON) that no primary care physician notes could be found for this resident. At this time surveyor also addressed a concern regarding diabetes management and blood sugar monitoring that occurred in April…

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

Based on medical record review and interview with staff it was determined that the facility failed to ensure newly admitted residents, with signed consents, received the flu vaccination. This was found to be evident 1 out of 5 residents (Resident #296) reviewed for immunizations during survey. The findings include: On 10/16/18 review of Resident #296's medical record revealed the resident was admitted to the facility in October 2018. The resident's responsible family member signed the Consent for Immunization of Influenza on 10/3/18. Further review of the medical record failed to reveal any documentation that the resident received the flu vaccine since admission to the facility. On 10/16/18 at 1:03 PM the Assistant Director of Nursing #2 reported that the flu vaccine is usually given when the consent is obtained and stated: don't know how (his/hers)got overlooked. She went on to report that they have put in for the resident to receive the immunization today, 10/16/18. The concern regarding the failure to administer the flu vaccine when consent was obtained was reviewed with the…

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