Largo Nursing And Rehabiliation Center

Based on record reviews and facility staff interviews, it was determined that the facility failed to ensure a resident received a beneficiary notification. This was found to be evident for 1 (Resident #16) of 3 residents reviewed for Beneficiary Notifications during the recertification survey.The findings include: The Advance Beneficiary Notice (ABN) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The Notice of Medicare Non-Coverage (NOMNC) informs the beneficiary of his or her right to file an appeal of the decision for non-covered services and their right to an expedited review of Medicare non-coverage of services. On 11/25/2025 at 08:30 AM, record review of resident # 16, confirmed that the facility had stopped billing for Medicare part A on 05/27/2025. On 11/25/2025 at 9:30 AM, information and copies for the Advanced beneficiary notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms were requested for 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.

cite Based on record reviews and staff interviews, it was determined that the facility failed to ensure adequate monitoring for residents receiving antipsychotic medications. This was evident for 3 (Residents #14, #5 #1) out of 3 residents reviewed for Unnecessary Medications during the annual survey.The findings include:1) During the medical record review on 11/20/2025 at 6:44 AM for Resident #14, it was noted that the resident had a physician's order for busPIRone HCl 5 mg oral tablet, to give 1 tablet by mouth once daily for anxiety.2) On 11/20/25 at 10:30 AM review of Resident #5's medical record revealed a physician's order for bupropion HCl ER (XL) 300 mg oral tablet, to be administered by mouth once daily for depression.3) On 11/20/25 at 10:40 AM review of Resident #1's medical record revealed a physician's order for ARIPiprazole Oral Tablet 10 MG (Aripiprazole) Give 1 tablet via PEG-Tube one time a day for BIPOLAR DISORDER. 2) TraZODone HCl Tablet 100 MG Give 1 tablet via PEG-Tube at bedtime for DEPRESSION.Further review of the medical records on 11/20/25 at 11:00 AM 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 record review and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This deficient practice was identified for 1 out of 1 facility-reported incidents reviewed during the annual survey.The findings include:On 11/19/2025 at 2:59 PM, this surveyor reviewed the facility-reported incident investigation regarding an allegation of sexual abuse involving Resident #101 and housekeeping staff member #19. The resident reported that the staff member had touched him/her inappropriately. Review of the file showed that during the investigation only residents on the Arcadia Unit were interviewed, and only female residents were included. There was no documentation that male residents or residents on other units were interviewed or observed for potential signs of abuse.On 11/20/2025 at 10:25 AM, this surveyor interviewed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the scope of the investigation. During the interview, it was confirmed that the Licensed Practical Nurse (LPN) #17 who conducted 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, staff interviews, and review of the facility's discharge practices, it was determined that the facility failed to: 1) provide the resident and/or resident representative with written notification of the bed-hold policy, and 2) notify the Ombudsman of the resident's transfer. This was evident for 1 (Resident #120) of 2 residents reviewed for hospitalization during the annual survey.The findings include:Review of the medical record for Resident #120 on 11/24/25 at 9:57 AM revealed that on 9/24/25, the resident was transferred from a nephrology appointment to the emergency room (ER) due to a change in condition. On 11/24/25 at 10:15 AM further review of the medical record revealed that on 9/24/25 at 11:59 PM, the nurse's notes documented that a call was placed to the hospital and confirmation was received that Resident #120 had been admitted with fluid overload related to congestive heart failure (CHF). No documentation was found in either the paper or electronic record to indicate that the resident or resident representative had been provided with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and staff interviews, it was determined that facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This was evident for 1 of 3 residents reviewed for unnecessary medications (Resident #14) during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. An active diagnosis documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. A record review was completed for Resident #14 on 11/20/25 at 6:44 AM for an Unnecessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, it was determined that the facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs) received scheduled showers. This was evident for 1 (Resident #6) out of 1 resident reviewed for ADLs during the annual survey. The findings include: On 11/17/25 at 2:33 PM an interview with the resident's Responsible Party (RP) revealed that the resident has been in the facility since 8/4/25 and has not received a shower, only bed baths. The RP also stated that he is aware the facility has a chair that could be used to transport the resident to the shower room.Record review on 11/18/25 at 1:17 PM showed that Resident #6 had been in the facility since August 4, 2025. The Plan of Care indicated that the resident was to receive showers on Mondays and Thursdays, totaling eight showers per month, with staff assistance required. On 11/18/25 at 1:30 PM a review of GNA shower documentation for Resident #6 from 11/1/25 to 11/19/25 revealed that no showers were provided on 11/3, 11/6, and 11/13. On 11/17, the resident was…

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

Based on interviews, observations, and record reviews, it was determined that the facility failed to offer comprehensive activities in accordance with resident interests, physical, mental, and psychosocial well-being. This was evident for 3 (Resident #61, Resident #9, Resident # 10) of 24 residents reviewed for activities. The findings include: 1) On 11/17/2025 at 11:08 AM, resident #61 stated there are no activities for blind people, only bingo. Resident # 61 reports facility staff have never offered or brought activities in their room. Resident #61 was observed lying in bed with the TV on with no activity supplies in their room. On 11/20/2025 1:20 PM, review of resident #61 activity care plan, attends some activities daily and also pursue independent activities and watching television in his/her room. with the interventions Assist in planning/Encourage to plan own leisure-time activities; Encourage participation in group activities of interest; Provide assistant to accommodate participation in activities of choice; Provide daily Activity Flyer; Provide supplies/materials 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 interview and observation, it was determined that the facility failed to provide quality of care to residents. This was evident for 1 (Resident #56) out of 1 resident reviewed during the annual survey.The findings include:On 11/17/2025 at 2:19 PM, this surveyor conducted an interview with Resident #56. The Resident reported he/she had pressed the call bell at approximately 11:30 AM because he/she needed assistance with being changed and cleaned. The Resident reported he/she had not yet received assistance. Resident #56 pressed the call bell again while this surveyor was present in the room.On 11/17/2025 at 2:33 PM, this surveyor was in the hallway and observed that Resident #56's call bell light remained illuminated outside the room and was visible on the nurse's station display.On 11/17/2025 at 2:34 PM, this surveyor observed Certified Nursing Assistant (CNA) #6 walking down the hallway and noted that Resident #56's call bell light was now turned off. CNA #6 then proceeded onto the elevator. Before the elevator doors closed, this surveyor asked CNA #6 if she had checked 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 observations, medical record reviews, and staff interviews, it was determined that the facility failed to implement measures to prevent pressure ulcers. This was evident for 1 (Resident #6) of 1 resident reviewed for pressure ulcers during the annual survey. The findings include: An in-house acquired pressure ulcer is a pressure injury (also called a bedsore or decubitus ulcer) that develops or worsens while a resident is receiving care in a healthcare facility, such as a hospital, nursing home, or long-term care facility. These ulcers were not present on admission but occur due to factors such as immobility, pressure, friction, shear, or inadequate preventive care during the resident's stay.On 11/17/25 at 2:57 PM Resident #6's Responsible Party reported that the resident had no pressure ulcers upon admission to the facility but has since developed a pressure ulcer in the sacral area.During unit rounds on the first floor on 11/18/25 at 9:50 AM Resident #6 was observed lying on his/her back at 10:00 AM and remained on his/her back at 12:00 PM. On 11/19/25, the resident was…

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

cited:Based on interview and record review, it was determined that the facility failed to provide sufficient pain management. This was found to be evident for 1 (Resident #75) out of 1 resident reviewed for pain management during the annual survey. The findings include:The 0-10 pain scale is a standardized numeric rating tool used to assess a resident's level of pain. Residents are asked to rate their pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. This scale helps staff measure the resident's subjective pain experience, monitor changes over time, and evaluate the effectiveness of pain interventions. PRN pain medication refers to analgesic medication that is ordered to be administered as needed based on the resident's reported pain level or clinical presentation. PRN pain medications must be given in accordance with the prescriber's parameters-such as pain score, frequency limits, and specific indications-and require staff to assess, document, and monitor the resident's response to ensure effective and safe pain management.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 of medication administration, review of medical records, and interviews with facility staff, it was determined that the facility failed to ensure a medication error rate of less than 5%. This was evident for 2 medication administration errors out of 25 medication administration opportunities observed which resulted in a medication error rate of 8% during the recertification survey . The findings include: During a medication administration observation conducted on 11/18/25 at 8:10 AM, Licensed Practical Nurse (LPN) #3 prepared and administered Resident #29's morning medications. The LPN administered the following medications: Breo; cholecalciferol 1000 units; losartan potassium 100 MG ; mirabegron 25 MG; acetaminophen 500 MG ; aspirin 81 MG; gabapentin 200 MG ;ipratropium bromide and albuterol sulfate 0.5mg/1mg On 11/18/2025 at 12:18 PM, a review of Resident #29 Medication Administration Record (MAR) revealed that 2 of the 8 medications were given at an incorrect time interval. Gabapentin and acetaminophen were ordered to be administered at 10:00 AM and were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to (1) store food under sanitary conditions and (2) ensure food items in the nourishment refrigerators were properly labeled and dated. This was found evident during the kitchen review conducted as part of the annual survey and has the potential to affect most residents.The findings include:(1)On 11/17/2025 at 8:21 AM, this surveyor observed the kitchen freezer. There were two fans, the right freezer fan was not operating, and icicle formation was noted beneath the fan. Icicles had formed to the point of dripping onto an open box of packaged ice creams. An opened package of frozen breaded [NAME] was stored with loose pieces of fish outside of the box and exposed. Another box of frozen fish also contained loose, exposed pieces. Photographs were taken of these observations.On 11/17/2025 at 8:32 AM, this surveyor conducted a concurrent interview and observation with Head [NAME] #13. When asked about the fan, Head [NAME] #13 reported 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 interview and record review, it was determined that the facility failed to accurately document resident records. This was evident for 1 (Resident #75) of 1 resident reviewed for pain management during the annual survey.The findings include:The 0-10 pain scale is a standardized numeric rating tool used to assess a resident's level of pain. Residents are asked to rate their pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. This scale helps staff measure the resident's subjective pain experience, monitor changes over time, and evaluate the effectiveness of pain interventions. On 11/18/2025 at 11:21 AM, this surveyor interviewed Resident #75, who reported having recently fallen out of bed. The resident stated he/she had pain in the left shoulder, where he/she landed on the floor during the fall. On 11/25/2025 at 10:06 AM, record review of the resident's progress notes showed the fall occurred on 11/16/2025 at 5:00 PM. A progress note dated 11/17/2025 by Licensed Practical Nurse (LPN) #20 stated that the resident verbalized…

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

Based on observation, interview and record review, it was determined that the facility failed to maintain proper infection prevention and control practices by (1) failing to maintain sanitary and safe practices related to the resident care environment and supplies, and (2) failing to ensure staff were wearing required personal protective equipment (PPE). This was found evident during the Infection Control review conducted during the annual survey and has the potential to affect most residents.The findings include: (1) On 11/21/2025 at 8:33 AM, this surveyor observed visibly soiled linens placed on the floor of Resident #15's room. Resident #15 was observed lying on the bed without sheets, directly on a bare mattress. Photographs of these observations were taken at this time.At approximately 8:34 AM, an interview was conducted with Resident #15 in his/her room. The Resident reported that a staff member had cleaned him/her, removed the soiled linens, placed them on the floor, and left the Resident lying on the uncovered mattress without clean sheets.On 11/25/2025 at 12:30 PM, this…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that allegations of abuse were immediately reported. This was found to be evident for 1 resident (# 1) of 44 residents reviewed during a complaint survey. Findings include,Complaint 2611778 was reviewed on 10/29/25 at 10:00AM for multiple concerns including an allegation of abuse regarding Resident # 1. According to the report, Resident # 1 reported that a male nurse who applied cream molested him/her.Further review of the facility's investigation and a corrective action form for Licensed Practical Nurse (LPN # 11) dated 9/9/25 revealed the following comments: Resident # 1 reported to the nurse (#11) on 9/7/25 that a Geriatric Nurse Assistant touched him/her inappropriately on 9/5/25 while providing care and changing the resident brief pad. The resident stated that the night nurse was made aware of this on 9/5/25. The Nurse (#11) failed to report the alleged abuse to the supervisor timely.Further review of a statement by LPN (staff # 1) dated 9/8/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, it was determined that the facility failed to ensure the proper process of discharge for the resident. This was evident for 1 (#3) resident out of 1 resident investigated during the facility's complaint survey.Findings include:On [DATE] at 9:00 AM during review of complaint #297110, it revealed the following The assigned social worker (Social Services Coordinator #21) repeatedly failed to return calls or follow through on discharge planning. After months of dishonesty and lack of communication, I confronted [them] in frustration. Since then, [they] have refused to speak with me and directed me to the administrator, leaving my [family member name] without proper social work advocacy.On [DATE] at 1:36 PM during initial call with complainant, this Surveyor was informed that the resident was ready to be discharged around [DATE] but unable to get a Registered Nurse (RN) assessment needed to set-up home care; this was due to the Social Worker being out on leave.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrative documents, and interviews of residents and staff, it was determined that the facility failed to ensure that grievances and concerns from the resident group were documented, reviewed, and responses provided to the group in writing. This was evident in review of 7 of 7 resident council meeting minutes. The findings include: An introduction interview was held with the resident council president (resident #272) on 1/18/24 at 1:00 PM. They revealed that they had lived at the facility for 14 years and had been the president of the resident council for a long time. A follow up interview was held with the resident council president on 1/25/24 at 8:55 AM. She/he was asked for permission by the survey team to review the resident council minutes. She/he granted permission and indicated that the Director of Activities would have the meeting minutes. On 1/25/24 at 9:16 AM, an interview was conducted with the Director of Activities (staff #18). She was informed that the resident council president granted permission for the survey team to review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident for 3 of 3 nursing units on both floors of the facility. The findings include: An interview was conducted with the maintenance director (staff #10) on 1/18/24 at 11:25 AM. He revealed that he had been the maintenance director for 3 months beginning mid-October 2023. The maintenance department was comprised of the maintenance director and two assistants. He indicated that a renovation/remodel of the first floor was initiated the first week of his hiring. The mass project was to include all the floors, new lights, painting the hallways and the resident bedrooms, nurse station rehab gym, and lobby areas. Per signage in the lobby, the renovation was expected to be completed by early spring. The renovation was being performed by contractors. On 2/2/24 at 11:05 AM, the maintenance director and surveyor began a tour in the 2nd floor hallway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: An interview was conducted with the Food Service Manager (staff #3) on 1/8/24 at 8:41 AM. She revealed that she has has been the facility's Food Service Manager for a few years. The Food service manager was hired in March of 2021. She was asked if she was a certified dietary manager (CDM) and she replied that she was not. On 1/8/24 at approximately 9:30 AM, the Food service manager was provided a Nutritional Department Information Request List that included a request for the Food service manager's credentials and copies of the facility's certified dietary manager's credentials. Additional information was received on 1/10/24. The food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews it was determined that facility failed to assess a resident's needs and preferences and respond to resident that expressed dissatisfaction with the food provided by the facility and was eating food provided by family members. This was evident for 1 (Resident #109 ) of 10 residents that were reviewed with expressed concerns with the food provided by the facility. The findings include. Resident #109 was admitted to the facility on [DATE]. Resident #109 was interviewed on 1/8/24 at 12:02 PM. The resident was questioned if the food looked and tasted good, and resident #109 indicated that he/she does not eat the facility's food and his/her family brings food into the facility. The resident was asked if he/she has met with the dietitian to review his/her food preferences and the resident indicated he/she had not met with the dietitian. Resident #109's medical record was reviewed on 1/19/24 at 2:12 PM. The dietitian's (staff #6) nutrition assessment 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 interview, observation and record review, it was determined that the facility administration failed to provide effective oversight for the facility to ensure that resident needs were met as evidenced by failing to: 1) ensure that the facility had sufficient nursing staff, 2) ensure that the facility was kept clean and in good repair, 3) ensure residents were protected from potential hazards in the environment, 4) employ qualified kitchen and Dietitian staff, 5) ensure residents' social services needs were met, and 6) ensure an effective Quality Assurance and Performance Improvement (QAPI) program. This was evident during the survey and had the potential to affect all residents. The findings include: Quality Assurance and Performance Improvement (QAPI): Nursing home QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to have an effective Quality assurance and performance improvement (QAPI) program. This was evident during the QAPI facility task investigation during the recertification survey and had the potential to affect all residents, families, and visitors. The findings include: On 2/05/24 at 1:30 PM the Administrator was asked about the facility's QAPI program and who was responsible for it. He stated that he was the person responsible for the QAPI program at the facility. The surveyor asked the Administrator to meet to discuss the QAPI program and invited the Administrator to bring the QAPI binder and any other information regarding the facility's QAPI activities. On 2/05/24 at 2:08 PM an interview with the Administrator was conducted. The Administrator brought a 3-ring binder which contained QAPI information and sign in sheets for the 2023 monthly QAPI meetings. When asked about the QAPI process he said each department head was responsible for identifying and bringing issues to the monthly QAPI meetings. He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview it was determined the facility failed to: 1) keep the kitchen walk-in freezer in safe operating condition. This was evident during the initial tour of the kitchen and during 2 subsequent visits; and 2) ensure two assistive shower chairs and one sitting chair in a resident room were in safe condition for use evident in one of one seated style shower chair and one of one adjustable shower chair and one of two sitting chairs located in room [ROOM NUMBER] on the [NAME] Wing. The findings include: 1. On 1/8/24 at 8:41 AM an initial tour of the facility's kitchen was performed with the food service manager (staff #3). When the door was opened to the walk-in freezer it was like walking into a cloud and the visibility of items in the freezer was very difficult to see. On 1/18/24 at 11:50 AM, the 2nd observation of the walk-in freezer was easier to see than the first day. There were small mounds of ice covering the entire ceiling of the freezer. There was a built-up ice clump…

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

Based on observation, resident and staff interviews, and medical record reviews, it was determined that the facility failed to treat residents with dignity and respect as evidenced by: 1) not removing a staff member from resident's assignment after the resident requested it, and 2) failure to ensure timely emptying of a resident's urinal. This was evident for 2 (#72, #11) of 7 residents reviewed for dignity. Additionally, the facility failed to 3) properly transport a resident in the hallway, evident for 1 resident (Resident #114) during a random observation on the facility nursing units. The findings Include: 1) On 1/8/24 at 10:05 AM during an interview, Resident #72 was asked if he/she was treated with dignity and respect by staff. Resident #72 told the surveyor that they did not get along with Staff #49, a Geriatric Nursing Assistant (GNA). Furthermore, Staff #49 would not assist them with turning and repositioning or rolling during the provision of activities of Daily living (ADL) and was nasty to him/her. The resident stated that they reported this issue to the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of facility reported incident investigations and policy, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, misappropriation of resident property, and injuries of an unknown source, and failed to ensure measures were taken to prevent further abuse of the Resident #87 while the investigation was in progress. This was evident for 7 residents (Resident #87, #319, #369, #39, #470, #418, #419) of 28 residents reviewed for abuse. The findings include: 1.) On [DATE] at 9:37AM Resident #87 reported to the surveyor the following allegation of abuse: I was pushed to the bed by a head nurse, my knees hit the metal (of the bed,) and I fell to the floor. The nurse left when I hit the floor. Resident #87 further reported that the floor manager reported to their supervisor and x-rays were ordered and had been performed. On [DATE] at 11:46AM, the surveyor requested the facility's complete investigation file for Resident #87's allegation of abuse from 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 medical record review and interviews with staff and a resident, it was determined that the facility failed to ensure that an interdisciplinary team, which included the resident and or the resident's representatives, contributed to the resident's comprehensive care plan as evidenced by the failure to conduct a care plan meeting for residents at quarterly intervals. Additionally, facility staff failed to document and evaluate each care plan to ensure the interventions continued to be appropriate for the resident's condition. This was evident for 5 residents (Resident #5, #75, #17, #39, #96) reviewed for care planning. 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 1/9/24 at 10:07 AM in an interview, Resident #5 was asked if they go to care plan meetings or was invited. Resident told the surveyor that they had not had a care plan meeting for a while and thought it 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 interviews with residents and staff interview, and a review of the facility's documentation, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 3 of 23 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency and 7 (Resident #3, #18, #39, #67, #72, #109, and #272) of 10 interviewable residents, and 3 out of 5 staff interviews. The findings include: 1) Three of twenty-three complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this complaint survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents who resided at the facility. The surveyor reviewed these complaints on 1/24/24. a) A portion of a complaint revealed that Resident #2 was left in the room for more than 2 hours wet with urine. b) A complaint reported in August 2022 stated that Resident #318 did not receive medication timely. A family member witnessed it and verified that there was only one nurse was available 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 observation, record review, and interview it was determined the facility failed to act upon multiple pharmacy drug problems that were identified. This was evident for 1 of 5 residents (#1) reviewed for unnecessary medications. The findings include: On 1/19/24 at 10:36AM the surveyor reviewed the medical record for Resident #1 which revealed on 12/12/23 and 1/11/24 the pharmacy medication regimen reviews noted to refer to a report for irregularities and/or recommendations. On 1/22/24 at 11:29AM the surveyor requested copies of the last three months of medication regimen reviews and pharmacy recommendations for Resident #1 from the Director of Nursing (DON.) On 1/25/24 at 11:58AM the surveyor noted the documentation received was not as requested; the surveyor was only given documentation for the months of September, November, and December 2023, which reflected the resident had no recommendations made during those months. The surveyor inquired to the DON and Staff #48, Regional Nurse as to why the documentation given to the surveyor was different from what was requested. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to: 1) ensure a resident was free from unnecessary medications. This was evident for 1 (Resident #1) of 5 residents reviewed for unnecessary medications; and 2) reconcile and transcribe medication orders accurately to the medication administration record as evidenced by transcribing a medication twice. By failing to reconcile and transcribe orders accurately the resident received up to twice the amount of medication ordered. This was identified for 1 (#12) of 66 residents; and 3) ensure physicians orders for pain medication clearly identified when staff were to give each of 2 medications as needed for pain, and administered as needed pain medications when the resident indicated their pain level was low or absent. This was evident for 1 (#18) of 1 resident's reviewed for Psychiatric/Opioid Side Effects during a recertification survey. The findings include: 1) On 1/19/24 at 10:13AM the surveyor conducted a review of the medical record…

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

Based on medical record review, interviews, and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident: 1) for 1 (#18) of 3 residents reviewed for Hospitalization, 2) for 1 out of 9 residents (#30) reviewed for wounds, 3) for 1 (Resident #323) out of 3 residents reviewed for hospital visits, and 4) 1 (MD00145026) of 23 facility reported incidents reviewed during the survey. The findings include: 1) Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed Resident #18's diagnoses included but were not limited to Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. Resident #18's census record revealed the resident was discharged to the hospital on 6/22/23. A progress note dated 6/22/23 at 15:38 (3:23 PM) by Staff #59 a Licensed Practical Nurse (LPN) indicated ER (Emergency Room) Transfer. Around 2:05 pm, Three sheriffs arrived the facility with court order to transfer resident to ER/psych (psychiatric) unit. (Staff #58,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to maintain an effective infection control program by failure to: 1) place an order for isolation precautions for those diagnosed with C-diff, which was evident for 1 (Resident #23) of 4 residents reviewed for transmission-based precautions; 2) perform hand hygiene while conducting wound dressing, which was evident for 2 (Resident #103 and #175) of 9 residents' reviews for wound dressing; 3) keep linens from contamination, which was evident for 1 (Arcadia unit) of 1 linen closet and laundry room observation; 4) conduct an annual review of infection control policies; and 5) ensure consistent infection prevention monitoring of waterborne infection, which was evident by incomplete water temperature monitoring logs reviewed during the survey. The findings include: Clostridioides difficile (also known as C-diff), is a germ that causes diarrhea and colitis, an inflammation of the colon, transmitted from person to person, via the fecal-oral route. Centers for Disease Control recommended contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of the facility records and residents' medical records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by 1) the indications for antibiotic use were not documented for their orders, and 2) the facility's antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true for 2 (Resident #3 and #53) of 3 residents reviewed for antibiotic use, and a review of the facility's antibiotic stewardship program during the annual survey. The findings include: 1) On 1/19/24 at 10:00 AM, the surveyor reviewed three resident records with antibiotic orders. For 2 of the 3 resident records, the facility failed to include the diagnoses in the orders of the residents' antibiotics. This was evidenced by: 1a) Resident # 53 had an order dated 11/15/2023 for Clindamycin HCl 300 MG Capsule by mouth three times a day for seven (7) days. There was no diagnosis listed in the order. 1b) Resident #3 had an order dated 12/10/23 for Ceftriaxone Sodium Solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview with staff it was determined the facility failed to provide a behavioral health training program for all staff which included but was not limited to providing care for residents diagnosed with mental, psychosocial, or other behavioral health condition and Individualized non-pharmacological approaches to care. This was evident for 1 (#18) of 4 residents reviewed for Behavioral-Emotional. The findings include: Facility Reported Incident MD00198994 was reviewed on 1/25/24 at 11:00 AM. The report revealed an incident on 10/28/23, witnessed by another staff member in which Staff #29 allegedly struck Resident #18 with a telephone during a physical struggle. The employee file for Staff #29 was reviewed on 1/29/24 at 12:53 PM. Staff #29 was hired on 7/30/19 as a Geriatric Nursing Assistant (GNA) and began working as a full-time receptionist at the facility in November 2021. Staff #29's record of training since hire was requested and reviewed. The record revealed she received ½ hour of RELIAS (an electronic training software) training on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive. This was evident for 1 (#82) of 4 sampled residents for advance directives during an annual 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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to ensure that allegations of abuse and injuries of unknown origin were reported to the state agency within required timeframes. This was evident for 3 (#87, #7, #18) of 28 residents reviewed for abuse during the facility's Recertification survey. The findings include: 1) On 1/9/24 at 9:37AM, Resident #87 reported to the surveyor the following allegation of abuse: I was pushed to the bed by a head nurse, my knees hit the metal (of the bed,) and I fell to the floor. The nurse left when I hit the floor. Resident #87 further reported that the floor manager reported to their supervisor and x-rays were ordered and had been performed. On 2/1/24 at 10:27AM, the surveyor reviewed the medical record for Resident #87 which revealed a health status note (designated as a late entry) with an effective date of 5/4/23 written by Staff #8, Unit Manager, 2nd Floor, Licensed Practical Nurse, which documented the following information : Upon schedule rounds, resident reported to writer stating three weeks ago I 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 the facility staff failed to permit each resident to remain in the facility unless the transfer/discharge was necessary for the resident's welfare and the residents need could not be met in the facility, failed to ensure appropriate information was communicated to the receiving health care institution and failed to ensure that a resident was sent home with appropriate discharge instruction paperwork. This was evident for 2 (#18, #322) of 4 residents reviewed for hospitalization and discharge The findings include: Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed Resident 18's diagnoses included, but were not limited to, Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. Resident #18's census record revealed the resident was discharged to the hospital on 6/22/23. A Change in Condition progress note, dated 6/22/23 by Staff #26 a Licensed Practical Nurse (LPN), reflected: Resident allege of being hit by another resident. his/her mental status evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the required notice of discharge/transfer when a resident was transferred to a hospital. The was evident for 1 resident (Resident #13) of 26 residents reviewed for facility reported incidents. The findings include: On 2/02/24 at 1:01 PM, a review of the facility reported incident for Resident #13 was conducted. On 1/05/24, Resident #13 was found with swelling and limited mobility in his right arm and an x-ray revealed a shoulder fracture. The resident was seen by the Nurse Practitioner who ordered a transfer to hospital and on 1/05/24, the resident was transferred. A review of the medical record revealed no evidence that a transfer notice was provided to the resident or the resident's representative. On 2/02/24 at 1:10 PM, an interview with the Corporate Registered Nurse (RN#48) was conducted and she stated that the notice of transfer/discharge was normally provided by the unit nurse, but if the unit nurse was unable to do so, then social services would provide it, and it would ultimately be…

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

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to sufficiently prepare and orient residents for their transfer to the hospital. This was evident for 1 (#18) of 3 residents reviewed for hospitalization. The findings include: Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. Resident #18's census record revealed the resident was discharged to the hospital on 6/22/23. A progress note, dated 6/22/23 15:23 (3:53 PM), by Staff #59 a Licensed Practical Nurse (LPN) Note Text: ER (Emergency Room) Transfer. Around 2:05 pm, Three sheriffs arrived the facility with court order to transfer resident to ER/psych (psychiatric) unit. (Staff #58, the Physician), present at the facility when they arrived. Paramedics later came with the stretcher to transfer. Sheriffs/Paramedics transferred resident on the stretcher to (the hospital) around 2:30 PM. There was no documentation to indicate that staff informed the resident where he/she was going and took steps to minimize his/her anxiety. In an interview on 1/25/24 at 10:54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, it was determined that the facility failed to offer a bed-hold notice to the resident or resident's representative before the facility transferred a resident to the hospital. This was evident for 2 (Residents #173 and #169) of 3 resident records reviewed for hospitalization, and for 1 resident (Resident #13) of 26 residents reviewed for facility reported incidents. The findings include: Bed hold notice includes providing written information to the resident; and bed charges, including the duration, during which the resident is permitted to return and resume residence in the nursing facility. 1) On 01/12/24 at 09:15 AM, the surveyor's record review revealed that Resident (#173) was transferred to hospital on [DATE]. However, there was no evidence that the resident received a bedhold policy at that time. On 01/12/24 at 9:35 AM, the surveyor's record review revealed that Resident (#173) was transferred to the hospital on [DATE]. However, the resident received an incomplete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately code significant weight loss of a resident on the Minimum Data Set (MDS) assessment. This was evident for 1 of 7 (#30) residents reviewed for nutrition during the facility's recertification survey. The findings include: On 1/8/24 at 1:52PM, the surveyor reviewed the medical record of Resident #30 which revealed documentation that on 7/4/23, the resident weighed 191.6 lbs (pounds), and on 7/26/23 they were weighed twice, and weighed 168.6 lbs on both occasions, indicating they had sustained significant weight loss of greater than 10% during the month of July 2023. Upon further review of the medical record on 1/11/24 at 12:25PM, the surveyor observed a documented medical order beginning on 7/28/23 which prescribed a medication for the resident that indicated the medication was being used for the purpose of appetite stimulation. Continued surveyor review of the medical record on 1/11/24 at 1:00PM revealed Staff #6, Registered Dietician's progress note on 7/27/23 which documented the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff, it was determined that the facility staff failed to accurately complete assessments and refer residents for Preadmission Screening and Resident Review (PASRR) level II determination. This was evident for 1 (#18) of 4 residents reviewed for Behavioral-Emotional. The findings include: Per https://health.maryland.gov/mmcp/longtermcare/Pages/Pasrr: Preadmission Screening and Resident Review (PASRR) process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness (SMI) or Intellectual Disability. This is called a Level I Screen. Those individuals who screen positive at Level I are referred to the local health department (LDH), where they receive an in-depth Level II PASRR evaluation. The LHD forwards the results of this evaluation to the Developmental Disabilities Administration or the Behavioral Health Administration as appropriate. The State…

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

Based on resident interview, review of medical records, and staff interviews, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of a resident 's admission. This was evident for 3 (Resident #50, #96 and #173) of 48 residents reviewed for baseline care plans. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 01/09/24 at 9:05 AM, Resident #173 was interviewed. During the interview, the resident was asked if they had ever received a copy of his/her baseline care plan. The resident stated, no, they never received a copy of the care plan. On 01/11/24 at 10:48 AM, Resident #173's medical record was reviewed. The review…

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

Based on observation, medical record review, and interview, it was determined the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 1 (#18) of 4 residents reviewed for Behavioral-Emotional health needs, and 2 (#75, #23) of 48 residents reviewed for comprehensive care plans. 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) Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed Resident 18's diagnoses included, but were not limited to, Paranoid Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. Review of the medical record on 1/29/24 at 10:50 AM revealed that a plan of care was developed on 10/24/23 and revised on 11/7/23 for Resident #18 with the focus: The resident has behaviors - being disruptive, belligerent, tobacco product-seeking, using profanity, refusing weights, refusing wound care, urinating in (his/her)…

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

Based on observation, record review, and interview, it was determined the facility failed to meet professional standards of practice by failing to ensure staff followed physician orders for administration of medications and documentation. This was evident for 1 (Resident #12) of 4 residents observed for medication administration during a recertification survey. The findings include: On 1/25/2024 at 10:05am, surveyor met the nurse, Licensed Practical Nurse, LPN #28, at a medication cart on the 2nd floor Independence Unit. LPN #28 reported she was preparing medications for Resident #12. LPN #28 was observed removing some medications from the medication cart including 2 tablets of Acetaminophen 325 mg. LPN #28 then signed the medications prior to giving them to Resident #12. A review of the medical record revealed that Acetaminophen was ordered to be given three times a day for pain and was scheduled to be given at 6:00 AM, 1200 noon, and 8:00 PM. However, LPN #28 had removed 2 tablets of Acetaminophen from the medication cart at 10:05 AM and gave them to the resident with the other…

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

Based on observation, medical record review and interview, it was determined that the facility failed to provide activity services to meet the needs of the resident. This was found to be evident for 1 (Resident #39) of four residents reviewed for activities during the investigative portion of the survey. The findings include: On 1/9/24 at 1:06 PM, Resident #39 was asked about his/her activity participation here at the facility. The resident indicated that there were not enough staff to transport the resident to and from activities. Resident #39's medical record was reviewed on 1/31/24 at 12:20 PM. Review of Activity Notes revealed that the last activity note was documented on 11/2/2022. The 11/2/22 note was written by the Director of Activities (Staff #18) with indication that resident #39 preferred to engage in independent activities within the comforts of his/her room . the resident enjoys listening to music, emailing, listening to audio books, and news updates on his iPad. The note further indicated the resident exercises every morning, enjoys socializing with staff, refuses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, reviews of medical records, and interviews, it was determined that the facility failed to: 1) ensure right orders for treatment were put in and documented on, and 2) identify and implement interventions for a resident with significant weight loss. This was evident for 2 (#55, #324) of 66 residents reviewed during a recertification/complaint survey. The findings include: 1) On 1/19/24 at 9:15 AM, a review of a complaint intake MD00175326 revealed allegations concerning Resident #324's appearance and weight loss. On 1/19/24 at 9:43 AM- a review of the weight log from admission to discharge showed a weight loss of over 20lbs. Resident #324 had a weight of 172 lb. on admission [DATE]) and on discharge (12/3/21), his weight was 150.4 lb. Further review showed that the significant weight loss was not reported to the doctor or the dietitian, nor was the issue addressed by the facility staff. On 1/29/24 at 10:05 AM review of the Skilled evaluation form under Nutrition evaluation' from 12/3/21 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined the facility failed to: 1) implement preventative measures to prevent the development of pressure ulcers. This was evident for 3 (Resident #169 and #370, #30) out of 9 residents reviewed for pressure ulcers during the survey; and 2) ensure the Hoyer lift sling was removed from under a resident (Resident #31) when the Hoyer lift was used to assist the resident's transfer between surfaces. This was evident for 1 of 23 complaints investigated during the survey. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and observation, it was determined that the facility failed to provide appropriate treatment and services upon admission for the care of a resident with an indwelling catheter. This was evident for 1 (Resident #57) of 4 residents reviewed for Foley catheter during the survey. The findings include: A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Always place the drainage bag below the level of the bladder and off the floor to prevent infections. (Foley catheter definition on www.merriam-webster.com) A review of Resident #169's medical record on 1/17/24 at 11:51 AM revealed that the resident was re-admitted to the facility on [DATE] from an acute care facility with a Foley catheter. A review of the resident's discharge summary from the hospital, dated 1/05/24, indicated that the resident's urine culture grew Proteus Mirabilis (a common pathogen responsible for complicated Urinary Tract Infections). Further review of Resident #169's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, it was determined that the facility failed to recognize, evaluate, and manage residents' pain. This was evident for 1 Resident (#50) reviewed for pain during the survey. The findings include: On 1/08/24 at approximately 10:00 AM, Resident #50 was observed moaning and yelling out, with a facial grimace, and although the resident opened their eyes they did not respond in any other way. Staff were observed nearby in the hallway, but did not enter the room. On 1/08/24 at 2:00 PM, Resident #50 was observed in their room and their moaning could be heard in the hallway. Licensed Practical Nurse (LPN#5) was in the hallway and was asked if she knew about the resident's moaning. She replied that the resident had a pressure ulcer and was probably in pain. On 1/09/24 at 10:30 AM, another observation outside Resident #50's room was made. The door was closed, and the resident could be heard moaning. Staff entered the resident's room and closed the door. 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 medical record review and interview with staff, it was determined the facility staff failed to ensure that the care of each resident was supervised by a physician. This was evident for 1 (#18) of 3 residents reviewed for hospitalization, and for 1 (#96) of 7 residents reviewed for nutrition during the survey. The findings include: 1) Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed the residents diagnoses included but were not limited to Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. A progress note, written 6/22/23 at 15:23 (3:23 PM) by Staff #59 a Licensed Practical Nurse (LPN), indicated ER Transfer. Around 2:05 pm, Three sheriffs arrived the facility with court order to transfer resident to ER/psych unit. (Staff #58, the Physician), present at the facility when they arrived. Paramedics later came with the stretcher to transfer. Sheriffs/Paramedics transferred resident on the stretcher to (the hospital) around 2:30 PM. The record failed to reveal documentation by a physician regarding resident #18's condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician evaluation of a resident's current medication regimen. This was evident for 1 out of 7 (Resident #1) residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: On 1/19/24 at 2:33PM, the surveyor conducted a review of the medical record which revealed documentation by Staff #43, Physician, for Resident #1's visit note, dated 12/21/23, for a chief complaint of Diabetes Mellitus. The surveyor noted the provider's documented current medication list on their visit note did not match the active medical orders for medications for the resident. Upon further review, the visit note was found to document discussion of the treatment plan with the resident, which included the following: DM (Diabetes Mellitus) well controlled, continue with diabetic diet, continue with Lantus (Insulin medication) and Metformin (medication.) However, upon surveyor review of the resident's medication orders, they were no longer taking these medications. On 1/30/24…

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

Based on a review of employee files and interviews, it was determined that the facility failed to put a system in place to ensure Licensed Practical Nurses (LPNs) and Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 3 (one LPN and two GNAs) out of 5 employee files reviewed for competencies and skill sets. The findings include: On 1/30/24 at 9:04 AM, a review of employee files was conducted for GNAs #40 and #42, LPN #5, #41, and #53. The review of employee files reveals that they did not have documentation to support that they completed their competency skills and techniques to provide safe care to the residents. a. GNA #42 was hired in October 2021. However, there was no competency skills and techniques evaluation in his/her employee file. b. GNA #40 was hired in July 2019. No competency skills and techniques evaluation were in his/her file. c. LPN #41 was hired in April 2020. LPN #41 had competency skills evaluation records for some areas. However, there was no supportive evidence to prove 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 a review of Geriatric Nursing Assistant (GNA) employee records and staff interviews, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was evident for 2 (GNA # 40 and #42) out of 2 GNAs records reviewed during this survey. The findings include: On 1/30/24 at 9:04 AM, in an interview with the Director of Nursing (DON) and Human Resources (Staff #47), the surveyor requested employee files for two randomly selected facility GNAs. A review of these records revealed that: GNA #40 was hired in July 2019. There was only one performance evaluation in 2019, and no further evaluations were documented. GNA #42 was hired in October 2021. There was one performance evaluation in January 2024 and no additional evaluation since his/her hire. On 1/30/24 at 3:10 AM, in an interview with Staff #23 (educator), she stated that the educator did GNA's performance review yearly, and the records were filed in the employees' chart. During an interview with the Director of Nursing (DON) on 1/30/24 at 4:14 PM, the DON confirmed that nurse aides'…

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

Based on review of the medical record and interview with staff, it was determined the facility staff failed to identify and provide appropriate treatment and services to assist residents in attaining their highest practicable mental health. This was evident for 1 (#18) of 4 residents reviewed for Behavioral-Emotional. The findings include: Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed Resident 18's diagnoses included, but were not limited to, Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. A nursing progress note, dated 6/20/23 20:07 (8:07pm), indicated that Resident #18 was sitting in a wheelchair in the hallway, stood up and exposed his/her buttocks to other residents and started cursing at staff and making finger sign. Patient made aware behavior unacceptable, keeps on saying I need my cigarettes, per Aide, patient doesn't have a cigarettes in the cart. A nursing progress note on 6/20/23 at 21:15 (9:15pm) indicated the resident inquired about a 2 liter soda when restaurant food was delivered. When staff informed…

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

Based on review of the medical record and interview with staff, it was determined the facility failed to ensure it had sufficient staff members who possess the basic competencies and skills sets to meet the behavioral health needs of residents by failing to implement person-centered care approaches and non-pharmacological interventions designed to meet the individual behavioral health goals and needs of each resident. This was evident during review of 1 (#18) of 28 residents reviewed for Abuse. The findings include: During an interview on 1/09/24 at 11:04 AM, Resident #18 indicated when asked, that he/she was hit by a receptionist with a phone and had to go to the hospital to get stitches in his/her head. Resident #18's medical record was reviewed on 1/12/24 at 12:28 PM. The record revealed Resident #18's diagnoses included, but were not limited to, Paranoid Schizophrenia, Major Depressive Disorder and Anxiety Disorder. Review of facility investigation documentation on 1/25/24 at 11:00 AM revealed that on 10/28/23 at approximately 5:00 PM, Resident #18 was in the first-floor dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, it was determined that the facility failed to provided Medically related Social Services This was evident for 1 complaint (MD00175251) of 23 complaints investigated during the annual survey. The findings include: On 1/10/24 at 11:42 AM, a review of complaint MD00175251 was conducted and revealed an allegation that a request had been made for Resident #17's to transfer to another nursing facility closer to their home. Although steps were taken, no beds were available and no further follow up was provided. On 1/12/24 at 9:38 AM an interview with Social Worker (SW#1) was conducted. SW#1 stated that a few months ago she assisted Resident #17's family with their wish to transfer the resident to another facility. She called the facility, sent documentation, called the family, but did not reach them. The desired facility did not have a bed available, and SW#1 said she notified the resident's family by voice mail message and has not heard back from them. When asked if SW#1 had reached out again to the family, SW#1 said no. On 2/02/24 at 11:26 AM an…

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

Based on observation, interview, and medical record review, it was determined the facility failed to ensure that its medication error rates are not 5 percent or greater. This was found to be evident based on errors identified during medication administration for one (Resident #12) out of four residents observed. The observations were made on one of two nursing units and involved one of two different nurses. The findings include: On 1/25/2024 at 10:05 AM, surveyor met the nurse, Licensed Practical Nurse, LPN #28, at a medication cart on the 2nd floor Independence Unit. LPN #28 reported she was preparing medications for Resident #12. LPN #28 was observed removing the following medications from the medication cart: 2 Acetaminophen 325 mg 1 Duloxetine 20 mg 1 Tramadol 50 mg 1 Ferrous Sulfate 325 mg 1 Hydrochlorothiazide 25 mg 1 Losartan Potassium 50 mg Brimonidine Tartrate Ophthalmic Solution 0.2 % (eye drops) Cosopt PF Ophthalmic Solution 2- 0.5% (Dorzolamide HCL-Timolol Maleate) (eye drops), and Dorzolamide HCL-Timolol Mal Solution 22.3- 6.8 mg/ml (eye drops). LPN #28 then 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.

Based on observations and interviews it was determined that the facility failed to properly store medications. Medications were stored in an area where residents and unauthorized staff could access them. This was evident on 2 of 3 nursing units. The findings include: On 1/12/24 at 9:53 AM Staff #8, Unit Manager, 2nd floor, Licensed Practical Nurse, showed the surveyor to a room labeled the Central Supply Room located on floor 2, on the Independence hallway and proceeded to push the door open and enter the room without use of the keycode pad located on the front of the door. Staff #8 verbalized to the surveyor that this room was the medication room. On 1/12/24 at 9:53 AM the surveyor observed various medications and supplies in the room labeled the central supply room located on floor 2, on the Independence hallway; including but not limited to: aspirin, acetaminophen, naproxen, guaifenesin oral solution, vitamin C, vitamin B, vitamin D, vitamin E, milk of magnesia, Dakin's solution, calcium tablets, povidone iodine 10% solution, multivitamins, multivitamins with iron, Claritin,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and medical record review, it was determined that the facility failed to ensure that residents who required dental services on a routine or emergent basis received necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #96) of 4 residents reviewed for dental service, and 1 complaint of 23 complaints investigated during the annual survey. The findings include: 1) On 1/08/24 at 10:39 AM, an interview was conducted with Resident #96. The resident stated that he/she had jaw pain and needed to follow up with the dentist. A review of Resident #96' s medical records on 1/22/24 at 11:12 AM revealed that the resident was diagnosed with mouth cancer in July 2023 while he/she resided in this facility. An oncologist for chemotherapy and radiology therapy has followed up with the resident. Further review revealed that the resident had a dental referral to an oral surgeon on 10/30/23 for evaluation and treatment. Oral exam and extraction. On 1/24/24 at 2:10 PM, 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, record review, and interview it was determined the facility failed to have an effective process in place for the kitchen to accurately serve according to medical orders and effectively institute dietary changes when they are made, and provide documentation in the medical record for rationale of nutritional changes. This was evident for 3 out of 10 residents (#87, #11, #30) reviewed for food concerns during the facility's recertification survey. The findings include: 1.) On 1/23/24 at 11:01AM the surveyor reviewed the medical record for Resident #87 which revealed a nutrition progress note dated 9/18/23 which documented the resident's past medical history of: unspecified severe pcm (protein calorie malnutrition) and further documented the following recommendation: house supplement 4oz BID (2 times per day.) On 1/23/24 at 11:29AM the surveyor conducted an interview with Staff #3, Food Service Manager, and requested a copy of the snack and supplements list. Staff #3 provided this list and confirmed with the surveyor that the list accurately reflected the days 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 surveyor interview and observation, it was determined that the facility failed to have adequate and functional mechanically operated exhaust ventilation, as necessary to control moisture and odors to ensure good air circulation to keep all parts of the facility odor free. This was evident during the initial tour of the facility. The findings include: On 5/2/2024 at 9:30 AM the Surveyors entered and began the initial tour of the facility. Immediately upon entering the second floor, a distinct ligneous malodorous smell was persistent throughout the second floor of the facility. On 5/3, 5/7 and 5/8/24, the malodorous smell was persistent to all Surveyors. On 5/7/24 at 9:23 AM, a tour with the Maintenance Director revealed that all 10 intakes located on the second-floor nursing unit were not functional. On 5/7/24 at 11:18 AM an interview with the Maintenance Director Revealed that all intakes are vented to the outside using 2.5-inch PVC pipe and the intakes are not built to use a motor. The Maintenance Director confirms the malodorous smell which he states may be coming from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and interview, it was determined the facility failed to ensure nurse aides receive the required training, including dementia care and abuse prevention, no less than 12 hours per year. This was evident for 3 Geriatric Nursing Assistants (GNAs) (#29, #40, and #42) of 3 GNA training records reviewed. The findings include: GNA's personnel files were reviewed on 1/30/24 at 9:04 AM. 1. A review of GNA #29's personnel file revealed GNA #29 was hired in July 2019. The employee file showed that GNA #29 completed online training for abuse and neglect in December 2020, May 2022, and October 2023. However, there were no required training records (abuse, neglect, and dementia care) upon hire and in the year 2021. 2. A review of GNA #40's personnel file revealed GNA #40 was hired in July 2019. The record listed GNA #40's abuse training in November 2020, November 2021, and November 2023. However, there were no records of abuse and dementia training upon hire in 2022. 3. A review of GNA #42's personnel file revealed GNA #42 was hired in October 2021. The online…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise and update the comprehensive care plan that addressed the resident's change in condition. This was evident 1 out of 36 residents reviewed, involving Resident #89, during the survey process. The 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. The findings include: On 2/22/19 at 10:51 AM medical record review revealed that Resident #89 was admitted to the facility with diagnoses which included but was not limited to cerebral infarction (occurs when blood stops flowing to the brain) for rehabilitation therapy and other chronic health conditions which require ongoing treatment. Continued record review revealed that on 10/28/18 Resident #89 was reported to have fallen out of bed by staff who documented and assessed Resident #89. The post fall assessment was dated 10/29/18. Medical record review revealed that a fall care plan was initiated on 08/11/18 which included goals 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 hospital records and hospital complainant interview, the facility staff failed to ensure that Resident #217's oral care was being done. This was evident for 1 out of 36 residents investigated during the survey process. The findings include: On 1/9/19 Resident #217 was sent out to the hospital for abnormal labs. The hospital issued a complaint regarding the resident's oral hygiene on arrival. On 2/21/19 during the investigation of that complaint, the surveyor spoke to the hospital Complainant. Per the hospital staff complainant, the resident arrived with a mouth full of debris that took some time to clean out of the resident's mouth. On 03/08/19 around 03:15 PM during a review of the hospital medical records, nursing documented in the emergency room report documented, spent considerable amount of time performing oral hygiene on this patient. It is obvious that it has been a long time since oral hygiene has been performed, as the patient's dentures were caked in old stuff and his tongue was black with film. Used foam swabs, toothpaste and lots of suctioning. The amount 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 complaint and hospital records, the facility staff failed to provide appropriate oral care for Resident #217 according to professional standards of practice. This is evident for 1 out of 33 residents investigated during the survey process. The findings include: On 1/9/19 Resident #217 was sent out to the hospital for abnormal labs. Per hospital records the resident's mouth was full of debris that needed cleaning out in the emergency room. On 03/08/19 around 03:15 PM during a review of the hospital medical records, nursing documented in the emergency room report; spent considerable amount of time performing oral hygiene on this patient. It is obvious that it has been a long time since oral hygiene has been performed, as the patient's dentures were caked in old stuff and his tongue was black with film. Used foam swabs, toothpaste and lots of suctioning. The amount of debris that was removed from all the mouth, was approximately a measuring cup full. Patient is at risk for aspiration, with all that was removed from his mouth (end nursing report). It is the facility staffs'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview, it was determined that the facility staff failed to have a plan in place to manage Resident # 93's pain related to a fall and hospital visit. The was evident for 1 out of 33 residents investigated during the survey process. The findings include: On 2/18/19 staff was called out of Resident #93's room and was notified by a Geriatric Nursing Assistant (GNA) that the resident was noted on the floor at the nursing station with blood oozing out of the head. The resident was noted to have a laceration to the back of the head measuring approximately 1.5 x 0.3 centimeters. The medical doctor gave an order to send the resident out via 911. On 2/19/19 while interviewing the resident's daughter, it was noted that the back of the resident's head was swollen and there were sutures present. As the resident was leaving to go to physical therapy the Resident could be heard saying his/her back was hurting. On 2/26/19 upon seeing Resident #93 again the surveyor asked the resident about any pain. The resident stated that there was pain in the lower back…

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

Based on observation, the facility failed to complete the refrigerator temperature log sheets for the month of January 2019. This was evident for 1 out of 3 months observed. The findings include: During the medication observation of the medication storage room on 2/25/19, it was noted that the staff for the 2 floor medication room did not fill out the medication refrigerator temperature logs from 1/15/19 through 1/31/19, on the evening shift. The temperature log states to record the time, temperature and initials two times per day in the A.M. and P.M. The Director od Nursing (DON), Administrator and the Corporate Nurse were made aware of this deficient practice.

Based on review of resident records and staff interviews, the facility failed to document the use of a low bed and continue to document the neurological assessment for Resident #264 after 8:30 AM on 10/18/18. This was evident for 1 out 1 resident reviewed. The findings include: Resident 264 was admitted to the facility in October 2018 following surgery on he/his back and neck. She/he was at the facility for rehabilitation. When the resident entered the facility, her/his daughter was with him/her. The resident's daughter was concerned because the resident had a history of falling and wanted him/her to remain safe. The daughter requested bed rails, but the facility denied the request. The facility informed the resident's family that they do no not use bed rails here. According to the corporate nurse, residents who need fall precautions are placed in a low bed. On 2/22/19 at 11:01 AM record review revealed that at 4 AM (morning) of 10/18/18, the resident got out of bed and walked into the hallway where he/she was found on the floor. At that time the resident was assessed, and neuro…

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