Goodwill Mennonite Home, Inc.

Based on observation, record review, and interviews, it was determined that the facility failed to implement a resident-centered care plan, as evidenced by the failure to implement interventions to prevent skin injury. This was evident for 1 (#67) of 33 residents reviewed during the survey. The findings include: A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. In an observation on 4/2/25 at 12:10 PM, Resident #67 was noted with a wound dressing to his/her right elbow. The resident's representative was present and stated, Sometimes she gets skin tears from falls. A review later that day of Resident #67's treatment orders included an attending provider's order dated 10/22/2023 for Resident #67 to get Geri Gloves applied to [bilateral] arms to prevent injury, on [in the morning] [and off in the evening] every day and evening shift. A continued review of Resident #67's care plan revealed the potential for alterations in skin integrity as one of the problems. The care plan documented as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it was determined that the facility failed to 1) ensure that a resident received the correct cream/protectant ordered by a physician, and 2) protect residents from injury. This was evident for 2 (Resident # 5 and #160) out of 5 residents reviewed for non-pressure skin conditions. The findings include: 1) On 4/2/25 at 10:16 AM an interview was conducted with Resident #5, a long-term resident residing in the dementia care unit. During the interview s/he complained that s/he had an itchy back which was being treated with a cream kept by her/his bedside. On 4/2/25 at 10:17 AM a tube of Dimethicone skin protectant was observed next to the Resident #5. On 4/9/25 a review of Resident #5 physician orders failed to reveal an order for Dimethicone skin protectant. On 4/9/25 4:41 PM during an interview with the Assistant Director of Nursing (Staff #8) she confirmed that Resident #5 did not have an order for the Dimethicone skin protectant. Staff #8 reported that Resident #5…

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

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 assess the risk of entrapment from side rails and failed to re-evaluate the need for side rails. This was found to be evident for two (Resident #29 and #26) out of two residents reviewed for side rail use. The findings include: 1) On 4/2/25 at 12:56 PM, during an observation, the surveyor noted that Resident #29 had a one-half side rail on their bed. On 4/3/25 at 2:42 PM, the surveyor observed Resident #29 in bed with the side rail raised. A noticeable gap was observed between the mattress and the side rail. Review of Resident #29's Bed Rail Assessments, completed on 4/4/24, 7/3/24, 10/01/24, 12/19/24, 1/25/25, and 4/4/25, revealed that the facility did not include assessing the risk of side rail placement for entrapment. On 4/3/25, at 2:47 PM, the surveyor spoke with the Director of Nursing (DON) and asked whether side rail assessments are completed for residents. DON stated that assessments are conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that an accurate inventory of controlled medications was maintained. This was evident for one medication cart (on Memory Lane) of three medication carts observed. The findings include: During an observation on the Memory Lane unit on 4/02/25 at 1:04 PM, the facility pharmacy service delivered medication to the nurses station, and the Licensed Practical Nurse (LPN #11) was observed to sign for the delivery. The surveyor then asked LPN #11 to show the surveyor where medications were stored. During the observation of the medication storage room on Memory Lane Unit on 4/02/25 at 1:06 PM with LPN #11, the medication cart and controlled substance storage was also reviewed. During this observation, it was revealed that LPN #11 had presigned and dated the controlled substance log count for the 3 PM - 11 PM shift for 4/02/25 as being a completed count off. LPN #11 told the surveyor that they had gotten ahead of themselves. The deficiency was confirmed with the Director of Nursing (DON)…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident received their medications according to the attending physician's orders. This was evident for 1 (#4) out of 6 residents reviewed for unnecessary medications. The findings include: A pulse is the heart rate. It's the number of times the heart beats in one minute. A normal resting heart rate for most adults is between 60 and 100 beats per minute. A record review on 4/7/25 at 4:22 PM showed that Resident #4's diagnoses included high blood pressure and received antihypertensive medicine twice daily per the attending provider's orders. The order also stated to hold (not give) the medication for a Pulse less than 70. A subsequent review of Resident #4's medication administration records (MARs) from March 1- April 10, 2025, showed that the resident received the antihypertensive medicine on 3/16/25 for a pulse of 63, 3/24/25 for a pulse of 66, 3/31/25 for a pulse of 64, 4/5/25 for a pulse of 66 and 4/10/25 for a pulse of 64. In an interview on 4/8/25 at 2:00 PM, staff #8, an…

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

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: An observation of the facility's walk-in refrigerator #1 on 4/2/25 at 9:36 AM with staff #29, dietary services director present, showed an opened container of coleslaw dressing not labeled with an open date or use-by date. Staff stated that all opened food items were to be labeled with the opening date. A subsequent observation of the Memory care unit snack refrigerator on 4/2/25 at 11:32 AM, with staff #30, a Geriatric nurse aide present, showed an opened carton of Thickened lemon-flavored water with an open date of 4/17/24. The best by date on the carton was July 2024. Staff #30 confirmed that it had expired. An interview with Staff #10, the Unit manager for the Memory care unit, confirmed that the Thickened lemon-flavored water had expired. In an interview on 4/3/25 at 3:07 PM, the director of nursing (DON) indicated that her night nurses cleaned out the…

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

Based on observation and interview, it was determined that that facility failed to protect resident data. This was evident on one out of three nursing units. The findings include: On 4/03/25 at 1:29 PM, the surveyor observed an unattended medication cart to the left of the nurse's station on the south wing with an unlocked computer on top. The computer screen displayed visible resident information, including a photo and personal data. Two individuals were seen walking past the unattended cart during this time. The surveyor then witnessed the Infection Control Nurse (Staff #3) notice the unlocked computer and proceed to lock the screen. When speaking to the surveyor, she acknowledged that the computer had been left unattended with resident data displayed. When the surveyor asked which resident's data had been visible, she responded that she was unsure, as she had closed the screen too quickly to identify the resident.

Based on interviews and reviews of facility documentation, it was determined that the facility failed to inspect beds and identify risks for entrapment. This was evident in two out of two Residents (#29 and #26) reviewed for bed safety. The findings include: 1) On 4/2/25 at 12:56 PM, during an observation, the surveyor noted that Resident #29 had a one-half side rail on their bed. Review of Resident #29's care plan revealed that the resident was dependent on staff for bed mobility. A review of Resident #29 ' s Bed Rail Assessments, conducted on 4/4/24, 7/3/24, 10/01/24, 12/19/24, 1/25/25, and 4/4/25, revealed that the facility did not include an inspection of the bed or an assessment of entrapment risks during these evaluations. 2) Resident # 26's care plan revealed that the resident was dependent on staff for bed mobility. Review of Resident #26's Bed Rail Assessments completed on 3/23/24, 6/16/24, 9/3/24, 12/19/24, and 3/14/25, revealed that the facility did not include an inspection of the bed or an assessment of entrapment risks during these evaluations. On 4/3/25 at 2:47 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 observations, record review, and staff interviews, it was determined that facility staff failed to develop and implement a resident-centered care plan for a resident with behaviors. This was evident for 1 (#98) of 36 residents reviewed for 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. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) An observation of Resident #98 on 3/3/20 at 9:41 AM and on 3/5/20 at 8:58 AM revealed the resident had facial hair and his/her hair was disheveled. A record review for Resident #98 on 3/5/20 at 2:20 PM, revealed that the facility staff failed to have a care plan in place for resistance to care and implemented interventions to assists staff when they attempt to give care. During an interview…

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

Based on surveyor observation and interview with staff, it was determined the facility staff failed to properly store medications by failing to ensure schedule III - V medications were stored in separately locked, permanently affixed compartments. This was evident in 1 of 5 facility medication carts observed during medication storage review. Per the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970: Controlled substances are generally defined as medications that are considered easily abusable. Under the Controlled Substances Act, these medications are categorized into 5 schedules. Schedule I medications have the highest abuse potential, while medications in Schedule V have a low abuse potential. The findings include: On 3/5/20 at 9:22 AM, the surveyor observed the Memory Care medication cart. The cart contained a separately locked drawer containing Fentanyl Patches and liquid Morphine. Both were schedule II medications. A storage drawer located above the locked drawer contained the following medications: 17 tablets of Lorazepam 0.5 mg (milligrams) and 16 tablets 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 resident interview, record review and staff interviews, it was determined that the facility failed to ensure that residents were included in their plan of care. This was evident for 1 (#39) of resident of 2 residents reviewed for care plans during investigation phase. 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. During an interview with Resident #39 on 3/3/20 at 9:30 AM, the resident reported that he/she had not been invited to their care plan meetings. A record review on 3/6/20 at 8:18 AM, revealed care plan evaluation notes, dated 4/24/19, 10/15/19, and 1/14/20, that did not mention Resident #39 being present or declining to be at the care plan meeting. A care plan evaluation note, dated 7/17/19, stated that resident declined to attend the meeting. An interview with MDS Coordinators #10 and #11 on 3/6/20 at 8:56 AM, revealed that they go to the resident and invite them to the care plan meeting verbally and have them sign an Invitation Form.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to void an older MOLST form located in a resident's active medical record. This was evident for 1 (Residents #97) of 2 residents reviewed for Advance Directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, it was determined that staff failed to ensure that activities were provided to residents meet their individual needs and preferences. This was evident for 2 (#16 and #23) of 2 residents reviewed for activities. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) A record review for Resident #16 on 3/5/20 at 12:00 PM, revealed that resident was admitted to the facility 2 years ago. The medical record indicated the resident had a diagnosis of dementia. Review of the MDS with an Assessment Reference Date (ARD) of 12/16/19, revealed in Section C Cognitive Patterns that the resident was rarely understood and was unable to be interviewed to determine a level of cognitive impairment. Section F Preferences for Customary Routine and Activities documented resident enjoys listening to music, doing things…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reviews of a medical record and staff interview, it was determined that the facility staff failed to assess a resident's bruising timely. This was evident for 1 (Resident #82) of 2 residents reviewed for non-pressure related skin conditions during an annual recertification survey. The findings include: Review of Resident #82's medical record on 03/03/2020 at 1:00 PM revealed Resident #82 was admitted to the facility 2 years ago and resided on the memory care unit. Resident #82's medical record indicated that Resident #82 suffered from dementia with behaviors that include hitting and kicking. During the initial tour of the facility on 03/03/2020 at 1:00 PM, the surveyor observed discoloration and/or bruising to Resident #82's left hand and wrist. There was no bleeding observed. Resident #82 did not look to be in pain while sitting in a lounge chair on the unit. Review of Resident #82's medical record, on 03/03/2020 at 1:00 PM, failed to reveal any assessment nor documentation of Resident #82's left hand bruising. In an interview on 03/04/2020 at 2:26 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 staff interview and surveyor observation, it was determined the facility failed to provide food in a safe manner. This was evident for 1 (Resident #59) of 37 residents reviewed during an annual recertification survey. The findings include: Resident #59 has resided in the facility for 7 years and is totally dependent upon the facility staff for all aspects of his/her care including being fed all meals. On 03/03/2020 at 12:35 PM, Resident #59 was observed being fed by staff member #6. Observed on Resident #59's lunch meal tray were large chunks of what appeared to be fruit pushed to one side of the plate. In an interview with staff member #6 at this time, staff member #6 stated that Resident #59 was on a pureed diet but the peaches that came with Resident #59's lunch meal tray were not entirely pureed. Staff member #6 pointed out the 2 large chunks that had not been totally pureed on Resident #57's lunch meal plate, and that she had moved the non- pureed peaches to the side of the plate. In an interview on 03/03/2020 at 12:41 PM, the facility administrator was made aware 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 observation and interview with facility staff, it was determined that the facility failed to maintain a clean and homelike environment for residents. This was evidenced by 1.) unpainted sections of wall spackling in residents' living quarters; 2.) missing or broken molding in residents' living quarters; 3.) broken tile in the bathroom and 4.) a dirty grate next to the clothing washing machine. This was true for 7 of 32 rooms (rms 266, 268, 270, 272, 275, 269, 271). The evidence includes: During observations made during the initial tour of the facility that took place on 9/4/18 between 9:17 AM and 2:41 PM, the following findings were identified: 1) Unpainted spackling present next to the shower in room [ROOM NUMBER]'s bathroom in an area measuring 15 x 4; 2) Molding missing next to the shower wall in room [ROOM NUMBER]'s bathroom in an area measuring 4 x 4; 3) 12 missing section of molding in room [ROOM NUMBER]'s bathroom; 4) Unpainted, unsanded spackling in a 2' x 1' area behind the resident's reclining…

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

Based on medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 1 (#41) of 4 residents reviewed for hospitalization, 1 (#87) of 4 residents reviewed for accidents and 1 (#71) of 5 residents reviewed for unnecessary medications. The findings include: 1) Review of the medical record for Resident #41 on 9/5/18 revealed that the resident was sent to an acute care facility on 7/11/18 with a complaint of chest pain. The resident was admitted to the hospital and returned to the facility on 7/15/18. The 7/15/18 at 22:09 nursing note documented while in hospital complained of dysuria and diagnosed with (urinary tract infection) UTI. A 7/31/18 at 21:53 concurrent review stated that the resident was lethargic, twitching and blood glucose level was elevated, therefore, resident was sent to acute care facility. A 7/31/18 at 23:55 note stated, resident was admitted to [hospital name] for UTI. The resident returned from the hospital on 8/3/18. An 8/4/18 at…

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

Based on observation and interview with staff, it was determined that the facility staff failed to date and label food items and failed to discard damaged food items. This was evident during the initial tour of the kitchen. The findings include: On 9/4/18 at 11:10 AM, a tour of the kitchen was conducted along with the Dietary Manager (Staff #4). Observation was made of the stand-up refrigerator. In the refrigerator were 2 racks of 1/2 sandwiches that were in wax paper sandwich bags on trays which were not dated or labeled. The freezer below the refrigerator, the second rack, had rust on the front of the rack. Observation was made in the dry storage room of (1) 6 lb. 10 oz. can of salsa with the top dented, (1) 6 lb. 10 oz. can of sliced peaches with the side dented and (1) 6 lb. 10 oz. can of sliced peaches with the top edge dented. Staff #4 acknowledged the areas of concern.

Based on observation, medical record review, and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (#86) of 1 residents reviewed for Hospice and 1 (#9) of 2 residents reviewed for activities of daily living. The findings include: 1) Observation was made of Resident #86, on 9/4/18 at 12:32 PM, lying very still in bed with sunken features around the mouth. At 12:34 PM, the surveyor asked Staff #9 how the resident was doing, as the resident appeared to be hardly breathing. Staff #9 advised the surveyor that the Hospice nurse was in earlier in the day that the resident had a noticeable change, had rattles and was end stage. Resident #86's medical record was reviewed on 9/4/18 at 12:34 PM and the last Hospice note found in the paper medical record was dated 7/26/18. There was no documentation related to the resident's noticeable change in either the paper medical record or the electronic record. On 9/5/18 at 8:30 AM, the surveyor walked to Resident #86's room on the North hall and the resident's bed was not…

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

Based on review of facility records and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 1 (#99) of 3 residents, reviewed for Beneficiary Protection Notification. The findings include: The SNFABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to an expedited review of a services termination. The NOMNC only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must issue the SNFABN to address liability for payment. A review was conducted on 9/5/18 at 2:10 PM of the beneficiary notification for Resident #99 was conducted on 9/5/18 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 medical record review and staff interview, it was determined that the facility staff failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed, encoded and electronically transmitted to the CMS System. This was evident for 1 (#2) of 2 residents reviewed for resident assessments for a discharge during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process which ensures that each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the medical record for Resident #2 on 9/5/18 revealed that the resident was admitted to the facility on [DATE], and passed away at the facility on 7/30/18. The only MDS documentation in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and signed by a registered nurse. This was evident for 1 (#2) of 2 residents reviewed for resident assessments for a discharge during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the medical record for Resident #2 on 9/5/18 revealed that the resident was admitted to the facility on [DATE] and passed away at the facility on 7/30/18. The only MDS documentation in the system was an entry on 7/24/18.…

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

Based on medical record review and staff interview, it was determined that the facility failed to revise resident care plans. This was evident for 1 (#41) of 4 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #41 on 9/5/18 revealed a nursing note, dated 6/19/18 at 17:31, which stated that the resident was a new admission to the facility and was wearing a heart monitor due to recent hospitalization for unresponsiveness. On 7/11/18 at 21:51, a concurrent review revealed that the resident was complaining of chest pain and was sent to an acute care facility. The resident returned to the facility on 7/15/18 with an order for Nitroglycerin tablets. Nitroglycerin tablets are taken sublingually (under the tongue) and used to treat episodes of angina (chest pain) in people who have coronary artery disease (narrowing of the blood vessels that supply blood to the heart). A 9/2/18 at 00:11 nursing note revealed, resident c/o c/p (chest pain) and heaviness. Having SOB (shortness of breath). B/P 144/77 Rates pain an 8. Nitro given. A…

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