Complete Care At Hagerstown

Based on record review, interview and review of facility policy, it was determined that the facility failed to ensure the safety of all residents by sending an employee home or away from patient care immediately when there was an allegation/concern of abuse. This was evidenced by the review of 1 of 10 facility reported incidents. The findings include:1. Review of the facility reported incident # 2686981 occurring on 12/6/25 revealed an allegation of intimidation acted out by the facility contracted Respiratory therapist. He was witnessed by multiple staff stating towards the resident I tell you like I tell all my patients, if you hit me, I hit back.Interview with Staff GNA # 9 on 1/16/26 at 9:25 AM revealed that she was present on 12/6/25 with Resident #1 and RT #8. She stated that Resident #1 was agitated and was putting his/her hands up but more blocking RT#8 not swinging at or attempting to hit RT#8. She further verbalized to this surveyor that the incident really upset her, and the RT was loud and agitated that entire day, so she was glad he didn't come back. She was asked why…

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

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to report a medication error when they became aware, putting the resident at risk of discomfort and even death. This was evident during the review of 1 of 3 residents (R#16) reviewed during a complaint survey. The findings include:During the medical record review of Resident #16 on 1/21/26 at 12:37 PM a medication error was identified while specifically reviewing the residents Medication Administration record (MAR). This error was immediately reported to the facility DON. Resident #16 was ordered a double dose of Oxybutynin Chloride extended release, 20mg, instead of 10mg, of which the resident was receiving from 1/9/26 until the date of this review.According to the National Institute of Health, Oxybutynin is an anticholinergic medication used to treat overactive bladders, dosing starts at 5mg with a max of 30mg a day. Symptoms of oxybutynin overdose may include central nervous system overactivity (which includes Rapid heartbeat, high blood pressure, anxiety,…

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

Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing residents and complete a total review of the residents' plan of care and appropriately implement said plans and treatment. This was evident for 2 of 2 (R#16, R#15) residents reviewed and 4 of 4 physicians reviewed during a complaint survey.The findings include:1a. Medical record review on 1/21/26 at 12:37 PM the medical record of Resident #16 revealed admission to the facility after a fall with subsequent rib fractures, for monitoring and routine healing. On 1/22/26 this surveyor continued the review of Resident #16's medical record and noted that a nephrology consultation was completed on 1/13/26 at the facility by NP staff #13, however, that note was not available and uploaded to the system for staff access until 1/15/26.Interview with a facility unit manager, staff #28 on 1/23/26 at 10:43 AM revealed the facility process for consultations is that they come in 2 times a week and give orders. The nephrologist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of resident records, a facility reported incidents and a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 2 of 2 employee files reviewed for competencies and skill sets.The findings include:1. During the comprehensive review of residents during an immediate jeopardy, Resident #20 was reviewed on 1/21/26 at 9:30 AM. This review revealed a fall occurring in the bathroom where the resident was left alone on the toilet by the assigned GNA staff #14, who then attempted to transfer his/herself off the toilet and had a fall, the second fall while attempting to use the toilet in a week. According to the residents' care plan, reviewed on 1/22/26 at 9:56 AM, Resident #20 required moderate assistance of 1 staff for toileting-implemented on 4/4/2025.The fall investigation was requested by the facility and received on 1/22/26 and was discussed with the facility DON at 10:56 AM. It was noted in the investigation that the GNA…

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

Based on medical record review, interview and review of facility policies and procedures it revealed that the facility failed to ensure that the facility staff administered medication without ensuring there was duplicate therapy being administered. This was evident for 1 of 3 residents reviewed during the complaint survey for medication errors. The findings include:Review on 1/21/26 at 12:37 PM the medical record of Resident #16 revealed admission to the facility after a fall with subsequent rib fractures, for monitoring of routine healing. Additionally, Resident #16 was noted with an overactive bladder and benign prostatic hyperplasia (enlargement of the prostate gland affecting urination).A review of the residents' physician orders at this time and corresponding medication administration record (MAR) revealed an order for Oxybutynin Chloride ER (extended release) 5mg (2 tabs) every morning for bladder spasms and Oxybutynin Chloride ER 10mg every morning for urinary retention. Both medications were signed off by staff from 1/9/26 through the time of this review on 1/21/26. The…

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

Based on record review and interview, it was determined that facility staff failed to: 1) ensure appropriate conditions in place, including contracts and physician orders when having a consultant in their facility, 2) complete a facility assessment and use this information to develop and implement a training program for all staff 3) ensure that all staff, contracted staff and visitors had the required trainings on hire and ongoing, and 4) evaluate the skill performances of their nurses aides and ensure that they had 12 hours of training annually. This was evident throughout the complaint survey. The findings include:1. Review of the medical records for at least 5 residents of the facility starting on 1/21/26 revealed completed 'nephrology' consultations completed by a nurse practitioner. These consultations started back on November 9, 2025. It was also noted that after the consultation was completed, it was not being uploaded into the medical record for days even if there are recommendations or concerns. The DON was interviewed on 1/27/26 at 3:01 PM regarding the contract 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 record review and interview, it was determined that the facility failed to establish and implement a process for the mode of communication, how often communication occurs, and what was to be communicated between the administrator and governing body. This was evident during the complaint and extended survey.The findings include:A review of the Governing Body Policy and Procedure on 1/21/26 at 9:33 AM revealed there was no implementation date. Further review revealed that the governing body members' responsibility was to be active, engaged, and involved in the affairs of the facility; they were to have direct access to the administrator and the compliance officer by scheduling executive board sessions to allow for a free flow of information without potential conflict; and have involvement in the Quality Assurance and Performance Improvement (QAPI) program. In addition, there was a letter addressed to the administrator that designated the facility's administrator as the Compliance and Ethics Officer and the members of the Compliance and Ethics Committee were 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.

Based on record review and staff interview, it was determined that facility staff failed to complete a facility assessment as required. This was evident during the extended survey review.The findings include:On 1/16/26 at 10:55 AM the Nursing Home Administrator (NHA) was made aware that an extended survey was being conducted, and she was asked to provide a copy of the Facility Assessment.During an interview with the NHA and Nurse Educator/Infection Preventionist Staff #3 on 1/16/26 at 12:21 PM the NHA was asked if she had the Facility Assessment. She reported that she was unable to find it and had to request it from their corporate office. When asked if she had reviewed or developed a facility assessment since she took the position in 8/2025, she reported she had not.On 1/16/26 at 1:30 PM the NHA provided a copy of the facility assessment that was titled, Facility Assessment Tool. Upon review of the assessment, it had a date of completion of 1/5/26 and listed it had been completed by the NHA, Medical Director, Governing Body representative, and others. Further review revealed it 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 record review and interview, it was determined that facility staff failed to ensure that the Infection Preventionist was in attendance to the Quality Assurance and Performance Improvement (QAPI) committee meetings. This was evident for 5 of 10 meetings reviewed.The findings include:A review of the QAPI committee meeting sign-in sheets for 3/2025 - 12/2025 on 1/29/26 at 1:15 pm revealed that an Infection Preventionist (IP) had not attended the meetings quarterly.An interview with the Corporate Clinical Resource Nurse Staff #13 on 1/29/26 at 1:51 PM revealed she was the acting Quality Assurance coordinator and Infection Preventionist. She reported that the facility had not had a staff member assigned as an IP throughout the past 10 months.

Based on record reviews and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse and neglect. This was evident for 1 (Resident #2) of 9 facility-reported incidents reviewed for abuse and for 1 (Resident #4) of 9 facility-reported incidents reviewed for neglect.The findings include:1). Resident #2 has a history of Alzheimer's disease, depressive disorder, and a femur fracture, requiring assistance with daily activities and personal care. The surveyor reviewed Resident #2's allegations following a facility-reported incident (#2623382) in which the resident alleged that a Geriatric Nursing Assistant (GNA #2) had been rough during care. On 9/21/25 at 1:01 PM, the facility submitted a report to the Office of Health Care Quality (OHCQ) indicating that Resident #2 alleged that GNA #2 had been rough during care. On 10/20/25 at 12:46 PM, the surveyor reviewed the facility's internal investigation. The review revealed that on 9/21/25, Resident #2 reported to the Director of Nursing (DON) that GNA #2 had been rough while providing incontinent…

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

Based on record reviews and staff and resident interviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) received the necessary personal care. This deficient practice was evident in 3 of 9 facility-reported incidents reviewed during the complaint survey, affecting Residents #4, #5, and #8.The findings include:1) A review of the investigation of a facility-reported incident #2609546 on 10/20/2025 at 9:02 AM showed that Resident #4 was transferred to the emergency room on 9/5/25 around 4:00 AM. A review of the follow-up investigation report form contained a statement that EMT [emergency medical technician] reports state that [Resident #4] was soiled upon their arrival, which was confirmed by ER staff. A continued review of Resident #4's medical record contained a hospital emergency triage note dated 9/5/25 that stated that Resident #4 BIBA [brought in by ambulance] for neglect from nursing staff. Pt [patient] states [s/he] was sitting in their urine for over 2 hours, unable to get a hold of staff 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 ensure that resident records were accurate and complete. This was evident for 1 resident (Resident #8) of 2 residents reviewed for neglect.The findings include:On 10/20/25 at 8:30 AM a review of Resident #8's clinical record revealed that the resident was transferred to the hospital on 9/10/25 due to shortness of breath.On 10/21/25 at 10:04 AM an interview was conducted with the Director of Nursing (DON). When asked about treatment for the resident's shortness of breath, the DON explained that the resident experienced a change in condition on 9/09/25 and that Resident #8's on call provider gave new orders for oxygen and other treatments. The DON provided a copy of a document dated 9/09/25, titled Change in Condition, written by Licensed Practical Nurse (Staff #4). It noted that PRN [as needed] O2 [oxygen] 2L [at two liters/minute]. Further review of the record failed to reveal any physician's order for the oxygen use.On 10/21/25 at 11:43 AM the DON was interviewed again and she confirmed that no order…

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

Based on observation and interviews, it was determined that the facility staff failed to wear beard restraint in the kitchen. This was evident in 2 of 4 observations of meal preparation in the kitchen during the recertification survey. The findings include: On 5/8/25 at 7:05 AM, an observation of the facility's kitchen was conducted. During the observation, the Dietary Aide (Staff #16) was observed as he made pancakes. He had a long beard and did not wear a beard restraint. After he made pancakes, Staff #16 proceeded to prepare resident meal trays without a beard restraint in place at 7:16 AM. On 5/8/25 at 12:37 PM, the facility's kitchen manager (Staff #18) was informed of the deficiency related to Staff #16 without beard restraint. He made no acknowledgment of the deficiency. On 5/9/25 at 2:57 PM, an interview was conducted with the Nursing Home Administrator (NH) to review the finding that Staff #16 did not wear a beard restraint during meal preparation on 05/08/25. He acknowledged the finding. On 5/12/25 at 11:34 AM, another observation was conducted of the kitchen area during…

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

Based on observation and interview, it was determined that the facility failed to ensure that the most recent facility survey was readily accessible to residents, family members, and legal representatives of residents. This was evident for 1 Survey binder out of 1 survey binder reviewed during a survey. The findings include: On the morning of 5/8/25, an observation of the facility's entrance hallway revealed a binder titled Complete Care Hagerstown Survey Results. Further observation of the Binder failed to reveal the most recent Federal survey results. During a brief interview, the front desk receptionist (Staff #12) reported that she was unaware that the survey results were missing and would notify the manager. On 5/14/25 at 10:10 AM, during an interview with Staff #12, she confirmed that she did notify the administrator regarding the missing survey results. On 5/14/25 at 10:12 AM, the Regional Nurse Consultant Staff #2 confirmed that the Binder located in the entrance hallway titled Complete Care Hagerstown Survey Results did not contain the most recent federal survey results. 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 record reviews and interviews, it was determined that the facility failed to provide information to a resident to formulate an advanced directive. This was evident for 1 (Resident #4) of 4 residents reviewed for advanced directives. 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 can no longer make decisions for themselves because of illness or incapacity. Resident #4 was admitted into the facility in early 2022. A quick look into the resident's medical record indicated that the resident was cognitively intact and was certified to understand and make medical decisions. Further review of the medical record failed to reveal an advanced directive. A subsequent review of Resident #4's medical record on 5/12/25 at 3:36 PM revealed a document titled Social Services Assessment…

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

Based on record review and staff interviews, it was determined that the facility failed to notify attending physician, Residents' representative, and registered dietitian in a timely manner when there were documented changes in residents' condition. This was evident for one out of three complaints reviewed during the recertification survey and one (#56) out of three Residents reviewed for tube feeding. The findings include: 1) A review of complaint # MD00214514 on 5/14/25 at 8:22 AM contained an allegation that Resident #74's representative was not immediately made aware of a fall after the resident's admission to the facility. A review of Resident #74's record showed that s/he was admitted to the facility in November 2024 with diagnoses including post-right hip surgery. Continued review included a change in condition evaluation form completed for Resident #74 on 11/26/24. The form recorded that Resident #74 had a fall on 11/21/24. However, Resident #74's attending provider and representative were not notified of the change in condition until 11/26/24. Further review also found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to exercise reasonable care for the protection of the Resident's property from loss or theft. This was evident for one (Resident #18) reviewed during the recertification survey. The findings include: In an interview on 5/8/25 at 10:13 AM, Resident #18 reported that my body wash and shampoo were stolen. Money has gone missing- $12.00. My big concern is that my lock has been broken right now for about a month or two. I've told the nurses many times- they don't do anything. On 5/8/25 at 10:38 AM, the surveyor observed the opened bedside cabinet drawer. A bank envelope, with presumably money in it, was readily visible. Resident #18's hearing aid was observed on the bottom of the drawer. Resident #18 closed the drawer and could not lock it. On 5/12/25 at 8:59 AM, the surveyor observed that the top drawer of the bedside cabinet drawer was ajar. The Resident was not in his/her room. A staff member stated, [S/he's ] in the shower. On 5/12/25 at 2:36 PM, the Director of Nursing (DON) was made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and resident and staff interviews, it was determined that the facility failed to identify a Grievance Official in the facility's grievance policy, ensure that the policy in place processed grievances, and make prompt efforts to resolve a Resident's grievance. This was evident in one grievance investigation reviewed during the recertification survey. The findings include: On 5/9/25 at 12:59 PM, in an interview with a Registered Nurse (RN #25) and Certified Nursing Assistant (CNA #26) regarding how residents got hearing aids, Resident #24 stated, My hearing aids are missing. The surveyor asked staff, How will you help Resident #24? CNA #26 stated, I would tell the unit manager. RN #25 verbally acknowledged Resident #24's complaint. On 5/12/25 at 8:48 AM, a record review of the Grievance policy revealed a blank space for the Grievance Official's name and contact information. It also showed that the Grievance Official was responsible for overseeing the process, receiving and tracking…

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

Based on record review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication, as evidenced by the lack of documentation for non-pharmacological interventions (NPIs) and adequate indication for its use. This was evident for 1 (#35) of 5 residents reviewed for unnecessary medications. The findings include: Resident #35 was admitted into the facility in late 2020. A review of the resident's medical record indicated that the resident was on a combination of psychotropic medications, including Ativan (Lorazepam), given on an as-needed basis. Lorazepam (Brand name- Ativan) is used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. Lorazepam is a benzodiazepine that works in the brain to relieve symptoms of anxiety. Benzodiazepines are central nervous system (CNS) depressants, which are medicines that slow down brain activity and can cause a range of effects, including relaxation, drowsiness, and even unconsciousness. On 5/9/25 at 8:47 AM, a…

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

Based on record review and interviews, it was determined that the facility failed to provide written transfer notice and written bed hold policy to a Resident's representative upon transfer to an acute care facility. This was evident for 1 (#274) of 5 residents reviewed for hospitalization. The findings include: A review of Resident #274's medical record on 5/8/25 at 11:50 AM, showed that the resident was admitted to the facility in February 2025. And per an MDS assessment (Minimum Data Set assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident) dated 2/11/25, Resident #274 had a moderate cognitive impairment. A continued review found that Resident #274 was transferred to an acute care facility on 4/28/25. However, the review lacked documentation that the resident's representative was notified in writing of the facility's bed hold policy and the resident's transfer to an acute care facility along with the reason for the transfer. In an interview on 5/9/25 at 9:05 AM, staff #29, a licensed practical nurse, said she 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, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the residents' medication usage. This was evident for one (Resident #31) out of one resident reviewed for Resident Assessment. The findings include: The MDS is a federally mandated assessment tool that nursing home staff use to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. On 5/9/25, a review of Resident #31's medical record revealed a Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 3/8/25, documented that the resident had received insulin injections on 7 out of the 7 days of the assessment period. Insulin is a medication used to treat diabetes. Further review of the medical record failed to reveal documentation that the resident had a diagnosis of diabetes, failed to reveal current or past orders for insulin, and failed to reveal documentation to indicate the resident had received any injections during the look-back assessment…

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

Based on record review and staff interview, it was determined that the facility failed to ensure a required Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (#68) of 3 Residents reviewed for PASARR compliance during the recertification survey. The findings include: The PASARR is a federally mandated process designed to ensure that individuals with serious mental illness (SMI), intellectual disability (ID), or related conditions are not inappropriately placed in Medicaid-certified nursing facilities (NFs) for long-term care. The PASARR process helps determine whether a person 1.) Has a diagnosis of SMI, ID, or a related condition; 2.) Requires the level of services provided by a nursing facility; 3.) Needs specialized services for their condition. The PASARR is divided into two levels: Level I Screening is a preliminary screening conducted prior to admission to identify individuals who may have SMI, ID, or a related condition. Level II Evaluation is conducted by the State Mental Health or Developmental Disabilities Administration 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 record review, interviews, and observations, it was determined that the facility failed to develop and implement comprehensive resident-centered care plans for residents. This was evident for 2 (#7, #276) of 32 residents reviewed during the recertification survey. The findings include: 1) A review of Resident #7's medical record on 5/12/25 revealed that the Resident had resided at the facility for several years, had significant cognitive impairment and had limited physical mobility. A review of the 2/19/25 Minimum Data Set (MDS) assessment, Section F Preferences for Routine & Activities, revealed it was very important to the Resident to listen to music s/he likes, to be around animals such as pets, to do things with groups of people, and to go outside and get fresh air when the weather is good. The MDS is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide a Resident with the amount of assistance needed during meals. This was evident for 1 out of 3 complaints reviewed during the recertification 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. The information collected drives resident care planning decisions. A review of complaint # MD00214514 contained an allegation that Resident #74 did not receive assistance from staff with his/her meals. A review of Resident #74's medical record contained an MDS assessment dated [DATE] that showed that Resident #74 had severely impaired cognition and required set up or clean up assistance from the facility's staff with his/her meals. A continued review was completed of geriatric nurse aides' (GNAs) ADL (activity of daily living) documentation of assistance provided to Resident #74 during meals 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 medical record review, interviews, and observations, it was determined that the facility failed to provide an ongoing program of activities to meet the needs and preferences of residents. This was evident for 2 (#7, #276) out of 3 residents reviewed for activities. The findings include: 1) A review of Resident #7's medical record on 5/12/25 revealed that the resident has resided at the facility for several years and had significant cognitive impairment and limited physical mobility. A review of the 2/19/25 Minimum Data Set (MDS) assessment, Section F Preferences for Routine & Activities, revealed it was very important for the resident to listen to music s/he likes, to be around animals such as pets, to do things with groups of people, and to go outside and get fresh air when the weather is good. A review of the resident's care plans on 5/12/25 at 9:47 AM revealed a plan that addressed activities that had a focus of [name of resident] is dependent on staff etc. for meeting emotional, intellectual, physical and social needs r/t Cognitive deficits, physical limitations. 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 interviews, observations, and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services to maintain hearing abilities. This was evident for one resident (#18) investigated during the recertification survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that nursing home staff use to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. On 5/8/25 at 10:45 AM in an interview, Resident #18 stated, I'm legally blind and hard of hearing- I use a hearing aid in my right ear, but it doesn't work. Resident #18 confirmed that the staff knew about the broken hearing aid and did not address her/his needs. On 5/8/25 at 11:00 AM the surveyor observed Resident #18's hearing aid in the top bedside cabinet drawer. Resident #18 retrieved, inserted the hearing aid and stated, it needs a new battery or something. On 5/9/25 at 10:25 AM Resident #18 was observed in the hallway without hearing aid. On 5/9/25 at 10:30 AM a…

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

Based on medical record review, interview, and observation, it was determined that the facility failed to ensure wound care orders were entered correctly into the electronic health record and failed to ensure an air mattress was kept at the correct setting. This was evident for one (#7) out of three Residents reviewed for pressure ulcers. The findings include: Review of Resident #7's medical record on 5/12/25 revealed that the Resident had resided at the facility for several years, had significant cognitive impairment, and limited physical mobility. The Resident had a history of pressure ulcers, which included a stage 4 ulcer on the left hip that was first identified several years ago. A stage 4 pressure ulcer involves full thickness skin and tissue loss with exposed or palpable muscle or bone in the ulcer. Review of the medical record revealed documentation that the wound specialist assessed the Resident once per week, documenting wound status and treatment recommendations. Review of the 3/17/25 wound NP (Staff #36) Wound Assessment Report revealed documentation of the Stage 4 left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to ensure toxic chemicals were stored safely and appropriately. This was evident when toilet bowl cleaner was found in 1 ([NAME] Hall Pantry) of 4 nourishment pantries inspected during the recertification survey. The findings include: On 5/9/25 at 3:30 PM, an observation of the nourishment room refrigerators in the [NAME] Hall Pantry was conducted. The nourishment room was secured by keypad entry. A bottle of toilet bowl cleaner containing bleach was stored underneath the sink. Licensed Practical Nurse (Staff #3) and the unit manager for [NAME] Hall (Staff #5) were present during the observation and were immediately interviewed. Both staff members acknowledged that the chemical should not have been stored in that location. Staff #3 removed the bottle from the room and gave it to Staff #5. At approximately 4:00 PM on 5/9/25, the facility Administrator and the Director of Nursing were notified about the observed storage of a…

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

Based on record review and staff interview, it was determined that the facility failed to manage a resident's pain effectively. This was evident for 1 out of 3 complaints reviewed during the recertification survey. The findings include: A review of complaint # MD00214514 contained an allegation that Resident #74 did not receive adequate pain management when needed. A review of Resident #74's medical record showed that the Resident was admitted to the facility with diagnoses including post-right hip surgery for a fracture. A continued review contained an attending provider's order that was initiated on 11/20/24 for Resident #74 for the use of NPIs (Non-pharmacological Interventions - treatments without the use of medications, for example, repositioning, hot/ice pack, massage, music) before giving a PRN (as needed) pain medication and the specific interventions used to be documented in the Resident's record. Further review showed an attending provider's order dated 11/20/24 for Resident #74 to receive an opioid medication, one tablet every 4 hours as needed for pain levels 4-10 (A…

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

Based on record review and interviews, it was determined that the facility failed to ensure that a resident with a history of trauma received the appropriate trauma-informed care. This was evident for 1 (#74) of 32 residents reviewed during the recertification 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. Staff utilize care plans to provide resident-centered care that includes support, services, and resources to address a resident's needs. A record review contained a care plan initiated on 11/22/24 for Resident #74, which had recorded that Resident #74 had a history of past trauma related to surviving a house fire and the loss of [family] . The care plan recorded one intervention, which stated eval [evaluate] for psych consult. However, the care plan failed to address what Resident #74's triggers were for the traumatic event and how to mitigate or eliminate them to ensure the Resident was not traumatized again. During an interview on 5/13/25 at 2:42…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pertinent document review and interview, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance reviews. This was evident for 2 GNAs (GNA #14 and GNA #6) of 3 GNAs reviewed during the Sufficient and Competent staffing task portion of the recertification survey. The findings include: On 5/12/25 at 1:31 PM, the 2024 annual performance evaluations were requested for GNA # 13, GNA#14, and GNA #6. On 5/12/25 at 2:24 PM, the facility provided a performance evaluation for GNA Staff #13 but failed to give performance evaluations for GNA Staff #14 and GNA Staff #6. On 5/12/25 at 3:59 PM, during a brief interview with the Administrator, he confirmed that there was a lack of evidence that GNA#6 and GNA# 14 received an employee evaluation for 2024. On 5/14/25 at 8:25 AM, the above concerns were shared with the Director of Nursing. No additional information was provided before the end of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review, it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During observation of the facility's narcotic books, it was observed that 1 of 4 narcotic reconciliations was inaccurately documented during the recertification survey. The findings include: Standard practice for narcotic reconciliation count is conducted at the end-of-shift with two licensed personnel, the on-coming licensed personnel, and the outgoing licensed personnel, to count all controlled medications, verifying the count accuracy and documenting their initials in the narcotic book. Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications. The reconciliation process identifies the loss or potential diversion of controlled drugs to minimize the time between the actual loss or potential diversion and the time 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 records review and interviews, it was determined that the facility failed to 1a) ensure pharmacy recommendations were reported to the facility in a timely manner, 1b) specify all necessary timeframes for the steps in the Medication Regimen Review (MRR) policy and 2) ensure that an attending provider documented in residents medical record that pharmacist's recommendations were reviewed and stated what if any, actions were taken to address them. This was evident for 2 (#35, #18) of 5 residents reviewed for unnecessary medications. The findings include: 1a) Resident #35 had resided in the facility since late 2020. A review of Resident #35's medical records was conducted on 5/9/24 at 12:33 PM. The review revealed that monthly medication regimen reviews (MRR) were conducted. However, the attending physician signed the MRR report with a service date of 3/5/25 on 4/3/25, and the MRR report with a service date of 4/2/25 was not found in the resident's medical record. On 5/9/25 at 1:28 PM, the Director of Nursing (DON) was interviewed regarding the facility's process with MRR. 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 records review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary medications. This was evident in 1 (Resident #35) of 5 residents reviewed for unnecessary medications. The findings include: Resident #35 was admitted into the facility in late 2020 with diagnoses that include hypertension. Hypertension, or high blood pressure, is a condition where the force of blood pushing against the artery walls is consistently too high. It's often called a silent killer because it frequently has no noticeable symptoms but can lead to serious complications like heart attack and stroke if left unmanaged. Blood pressure is expressed as two numbers: systolic (top number) and diastolic (bottom number). Blood pressure medications, also known as antihypertensives, are a cornerstone treatment for hypertension and can significantly reduce the risk of serious complications. One of the most common side effects of blood pressure medication is dizziness or lightheadedness. This can occur due to a drop in blood pressure, especially when standing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to 1) maintain medical products within expiration dates and in a secure location and 2) have a system to secure access to controlled medications. This was evident during the recertification survey. The findings include: 1a) On [DATE] at 1:11 PM, an observation was made with the Assistant Director of Nursing (ADON) (Staff # 3) of the emergency cart located in the first-floor dining room. Further observation of the first drawer of the emergency cart revealed approximately 10 packs of jelly lubrication. A closer examination of the lubrication Jelly packets revealed an expiration date of 2/2025. On [DATE] at 11:17 PM, during a brief interview with ADON Staff#3, she reported that the lubrication jelly was used to facilitate airway procedures. The ADON confirmed that the packets with lubrication jelly had expired and removed them. She reported that she would replace the packets with lubrication jelly within the expiration date. 1b) 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 record reviews and interviews, it was determined that the facility failed to provide routine dental services to a resident. This was evident in 1 (Resident #19) of 1 resident reviewed for dental care. The findings include: Resident #19 had been a resident of the facility since late 2019. The resident's medical record indicated that the resident was cognitively intact. An interview with Resident #19 was conducted on 5/8/25 at 9:18 AM. During the interview, the resident stated, I've never seen a dentist here. On 5/12/25 at 1:34 PM, Resident #19's medical records were reviewed. The review revealed a care plan that indicated the resident had broken teeth and likely cavities. This care plan was initiated on 1/7/21. However, there was no documentation to indicate that the residents had dental services to address these concerns. On 5/12/25 at 2:42 PM, the Director of Nursing (DON) was interviewed regarding dental services. The DON reported that Healthdrive was a program that the facility uses to enroll residents for hearing, vision, and dental services. The DON was asked if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to ensure the orders for life sustaining treatment in the electronic health record matched the orders found on the Maryland Orders for Life sustaining Treatment (MOLST) form and failed to ensure the accuracy of physician orders. This was evident for one (#56) out of four residents reviewed for advance directives and one (Resident #71) of 3 system selected closed record reviews during the recertification survey. The findings include: 1) On [DATE], a review of Resident #56's medical record revealed a MOLST, dated [DATE], that included order for No CPR (cardiopulmonary resuscitation) Option A-1, Intubate: Comprehensive efforts may include intubation and artificial ventilation. This MOLST was found uploaded in the Miscellaneous Section of the electronic health record (EHR). Review of the physician orders section of the electronic health record revealed an order, dated [DATE], for DNR (Do Not Resuscitate, i.e. No CPR), DNI (Do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, it was determined that the facility failed to ensure staff use appropriate infection control practices. This was evident for 3 (#18, #51, #425) out of 32 residents reviewed during the recertification survey. The findings include: Personal Protective Equipment (PPE) refers to protective items such as masks, gowns, gloves, eye protectors, shoe covers, etc. worn to protect the body or clothing from hazards and to protect residents from cross-transmission. Enhanced Barrier Precaution (EBP) refers to an infection control practice designed to reduce the transmission of multidrug-resistant organisms (MDRO) that include donning a gown and gloves during high-contact care activities. There are certain criteria to place residents on EBP; when a resident has an infection or colonization with a MDRO or when a resident has a wound and/or when a resident has an indwelling medical device. 1) On 5/8/25 at 8:13 AM, it was observed that Residents #18 was on EBP and there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pertinent document review and interviews, it was determined that the facility failed to offer the current COVID-19 vaccination or document the refusal for the current COVID vaccine for their staff. This was evident for 5 out of 6 staff reviewed for Infection Control during a survey. The findings include: On 5/8/25 at 10:20 AM, the Administrator provided the employee files for 6 staff requested by the surveyor that were randomly chosen. On 5/8/25 at 2:20 PM, the Review of the employee files failed to reveal documentation that the most recent COVID vaccine was offered to the following staff: GNA (Staff #6), GNA (Staff #7), Housekeeping (Staff #8), Nurse LP (Staff # 10), and GNA (Staff # 11). Further review failed to reveal documentation that the aforementioned staff accepted or refused the COVID vaccine. On 5/12/25 at 10:10 AM the regional Nurse Consultant (Staff #2), confirmed that the facility did not have documentation that the above staff were offered the COVID vaccine. On 5/14/25 at 8:25 AM the Director of Nursing confirmed that the facility was able to obtain…

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

Based on record review, observations and facility interviews, it was determined that the facility failed to maintain safe operating condition of facility exits equipped with the WanderGuard System, potentially affecting six residents identified as elopement risk. This was evident for 1 of 2 exits alarmed with the WanderGuard System investigated during the recertification survey. The findings include: The WanderGuard System helps protect residents from elopement by ensuring resident safety with customizable door access. WanderGuard uses radio-frequency identification (RFID) technology that accurately detects wander-prone individuals by sounding alarms and automatically locking equipped exits. The facility identified six elopement risk residents (#2, #3,# 6, #18, #35, and #40.) On 5/12/25 at 10:02 AM, Resident #18 was observed in the main entrance lobby alone and unattended in a wheelchair. The top of the receptionist's head was observed as s/he was seated behind the welcome desk which was about 4 ft high from floor to countertop. On 5/13/25 at 8:41 AM, a review of Resident #18's…

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

Based on record review and interview it was determined that facility staff failed to ensure that all allegations of abuse were reported to the state agency within the required 2-hour timeframe. This was evident for 2 (#31 and #29) of 17 residents reviewed for abuse. The findings include: 1) On 1/6/25 at 1:27 PM a review of a copy of the facility's investigation file for the facility reported incident #MD00207032 revealed the initial report. According to the initial report form, on 6/24/24, at 9:53 PM R31 (resident #31) reported to geriatric nursing assistant (GNA) #9 an allegation of abuse. The resident reported that GNA #7 stated to him/her, she was going to get him/her back and called the resident a curse word. However, a review of the email confirmation for the initial report revealed that this report was sent to the state agency on 6/25/24, at 11:52 AM, which was over 24 hours later. Further review of the investigation file revealed a statement from GNA #9, that read she immediately reported the allegation of abuse to licensed practical nurse (LPN) #13. The statement did 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 observation, record review, and interview it was determined that facility staff failed to treat their residents with dignity. This was evident for 1 (#31) of 17 residents reviewed for abuse. The findings include: On 12/31/24, at 12:12 PM R31's (resident #31) call light was observed to be on. R31 was lying in bed slightly turned away from the doorway. Geriatric nursing assistant (GNA) #7 was observed going into the room, without knocking, and stated to the resident that she needed him/her to be patient because they [staff] were in the middle of passing lunch trays. GNA #7 failed to ask the resident what s/he needed, turned the call light off, and walked out of the room. The GNA came out of the room and continued to pass lunch trays. A medical record review for R31 on 1/2/25, at 3:21 PM revealed a minimum data set (MDS) with the assessment reference date of 10/29/24. Staff documented that the resident had no cognitive impairment and was able to make their needs known. Further review revealed the resident was dependent on a ventilator and was unable to get out of bed without…

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

Based on record review and staff interview it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse and to ensure that an employee had access to vulnerable residents until it was determined they abused the resident or not. This was evident for 1 (#31) of 17 residents reviewed for abuse. The findings include: On 12/31/24 at 2:25 PM a review of the facility's policy titled, Abuse, Neglect, Exploitation that was implemented on 3/14/23 was conducted. The policy stated in #6 titled as, Protection that the alleged perpetrator was to be removed from the resident care areas. Then under the section titled, Procedures for Response and Reporting Allegations of Abuse/Neglect/Exploitation it read under #2b the administrator was to initiate and conduct a thorough investigation and obtain statements related to the incident from the victim, individuals reporting incident, alleged perpetrator, and any witnesses. #2c. read the administrator was to remove the accused employee from the facility and place them on administrative leave pending completion 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 record review, staff interview, and review of facility policy Care Plans, Comprehensive Person-Centered , the facility failed to implement a care plan for 1 resident (R#1) of 8 residents reviewed. Findings include: Review of policy titled Care Plans, Comprehensive Person-Centered last reviewed 5/26/2023 revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. R#1 was admitted to facility 8/17/2023 with diagnoses including but not limited to Charcot's Joint Right Ankle/Foot, type 2 diabetes mellitus, venous thrombosis and embolism, hereditary motor and sensory neuropathy, tachycardia, chronic kidney disease stage 3, and pressure…

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

Based on observation, record review, and staff interview it was determined that facility staff failed to provide pain management in accordance with standards of professional practice. This was evident for 1 (#31) of 1 resident reviewed for pain management. The findings include: An observation on 12/31/24 at 12:12 PM revealed that the resident had his/her call light on and geriatric nursing assistant (GNA) #7 was observed going into R31's (resident #31) room and stated she was going to need the resident to be patient because they [staff] were in the middle of passing lunch trays. GNA #7 proceeded to turn off the resident's call light and left the room. She failed to ask the resident the reason they had turned on their call light. On 12/31/24 at 12:15 PM GNA #7 was observed going back into R31's room and asked the resident what they needed. The resident could not be heard, but the GNA was overheard stating the resident was having pain in their g-tube (gastric feeding tube) and that she would let their nurse know. An interview with R31 on 12/31/24 at 12:17 PM confirmed s/he was having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#32, #42) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) Review of Resident #32's medical record on 7/1/21 at 9:25 AM revealed a nursing note, dated 5/4/21 at 18:23 (6:23 PM), which documented that Resident #32 was lethargic, oxygen saturation was 85% on room air and had crackles in the lungs upon auscultation. The physician was notified and ordered for the resident to be transferred to the emergency room for further evaluation. Resident #32 was transferred via 911 to an acute care facility for treatment. A review of a concurrent review, dated 5/4/21 at 16:00 (4:00 PM), was done on 7/1/21 at 9:40 AM. There was no documentation in the concurrent review or any where in the medical record that the resident was informed and oriented that he/she was going to the emergency room in a manner that he/she understood. Further review 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 medical record review and resident and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan and a summary of their medications on admission. This was evident for 2 (#42, #1) of 5 residents reviewed for hospitalization, and 1 (#11) of 2 residents reviewed for Dementia Care. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1.1) On 6/23/21 at 12:35 PM, a review of Resident #42's medical…

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

Based on medical record review and staff interview, it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans with measurable goals. This was evident for 7 (#32, #63, #107, #64, #38, #1, #27) of 47 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1a) A review of Resident #32's medical record, on 6/24/21 at 8:00 AM, revealed an April 2021 physician's order for Carvedilol 6.25 mg. twice per day for hypertension. The order stated to hold for systolic (top number of a blood pressure reading) less than 120 or diastolic (bottom number of a blood pressure reading) less than 80. The medication was given on 15 days in April 2021 when it was outside of parameters. Cross Reference F757 A review of Resident #32's care plan for hypertension revealed the goal, will remain free of complications r/t (related to) CVA (cerebrovascular accident, also known as a stroke) 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.

Based on medical record review, observation and interview, it was determined that the facility failed to ensure that nursing staff administered medications via g-tube according to accepted professional standards resulting in the administration of more than the resident's entire daily requirement of water during the administration of morning medications; and failed to ensure that staff did not document the administration of a medication that had not been given. This was found to be evident for two out of four residents (Resident #1 and #4) observed during medication administration observation. The findings include: 1) On 6/29/21, review of the medical record and observation revealed that Resident #1 had a g-tube for the administration of nutrition and medications. On 6/29/21 at approximately 9:10 AM, surveyor began an observation of nurse #29's preparation and administration of Resident #1's medications. The nurse was observed to crush 8 medications, and pour each crushed tablet into it's own 16 ounce cup. The nurse then brought the eight cups into the resident's room and proceeded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow physician ordered blood pressure parameters for administering a blood pressure medication, 2) failing to have all medications included for a bowel regimen and have indications on when to administer, and, 3) failing to ensure a resident did not have duplicate orders for the same medication. This was evident for 2 (#32, #1 ) of 5 residents reviewed for unnecessary medications during an annual survey. The findings include: 1) A review of Resident #32's medical record on 6/24/21 at 8:00 AM revealed an April 2021 physician's order for Carvedilol 6.25 mg. twice per day for hypertension. The order stated to hold for systolic (top number of a blood pressure reading) less than 120 or diastolic (bottom number of a blood pressure reading) less than 80. The medication was given on 15 days in April 2021 when it was outside of parameters. On the following days, the medication was not held: 4/1 144/78 4/2 124/69 4/3…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication was prescribed as needed for 14 days was transcribed and administered as ordered. This was evident for 1 (#42) of 5 residents reviewed for hospitalization. The findings include: On 6/25/21 at 9:00 AM, a review of Resident #42's electronic medical record (EMR) was conducted. In the EMR, under the miscellaneous tab, revealed an uploaded, handwritten order for Ativan (Lorazepam) (anxiolytic) 2 mg (milligrams) tablet - give 1 tablet via peg tube (percutaneous endoscopic gastrostomy) (tube passed thru the abdomen into the stomach) every 12 hours as needed for anxiety for 14 days. Handwritten on the top of the order page was faxed 5/25/21 and the date the order was signed by the physician appeared to be 5/28/21. Review of Resident #42's June 2021 MAR (medication administration record) revealed an order for Ativan tablet 2 mg (Lorazepam) give 1 tablet via PEG Tube every 12 hours for anxiety, start 5/28/21 that was signed off as being given every 12…

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

Based on observation, interview and medical record review, it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 4 errors out of 28 opportunities for errors. This was found to be evident for 3 out of 4 residents (Resident #4, #2 and #1) observed during medication administration observation. The findings include: 1) On 6/29/21 at 8:05 AM, surveyor observed nurse #10 prepare and administer seven medications to Resident #4. After the observation, a review of the resident's medical record revealed an order, in effect since 6/24/21, for Peridex Solution give 15 ml by mouth three times a day for swish and spit. The Peridex had not been administered during the observation. Peridex is a prescription mouth rinse that provides antimicrobial activity. Further review of the medical record revealed the Peridex was scheduled to be given at 9:00 AM, 1:00 PM and 5:00 PM. Further review of the Medication Administration Record, at approximately 12:30 PM, revealed that nurse #10 had documented the administration of the Peridex at 9:00 AM. 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 interview and review of medical records and other pertinent documentation, it was determined that the facility 1) failed to ensure that the infection preventionist kept a line listing of residents and staff that were exhibiting signs and symptoms of infections to assist with the surveillance of infections in the facility, and 2) failed to ensure that facility staff failed to wear a face mask appropriately. This was found during review of the infection control program and surveyor observations and had the potential to affect all the residents. The findings include: 1) On 6/30/21, surveyor requested to see the line listing for the month of June from the infection control nurse. The infection control nurse reported they had no illness at present and did not have a line listing. A line listing is organized like a spreadsheet with each row representing one person or case of illness. Line listings allow for a quick review of the presence of infections. Depending on how it is set up, the line listing can also provide demographic information (age, room location), symptoms, testing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 during an annual recertification of the facility, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 3 resident rooms and one resident hallway. The findings include: On 6/22/2021 at 8:57 AM, room [ROOM NUMBER] was observed with 2 bedside commodes stacked on the floor under the paper towel dispenser with a gray bed pan on top. At 11:32 AM, Resident #50's wheelchair was observed in disrepair with the left armrest vinyl ripped on the inside edge. On 6/28/2021, two water stained ceiling tiles were observed in the hallway outside room [ROOM NUMBER]. On 7/1/2021 at 11:25 am, dirt and food crumbs were observed on the floor of room [ROOM NUMBER]. At 11:26 AM, room [ROOM NUMBER]'s bathroom was observed with a layer of white dust on top of the paper towel dispenser, soap dispenser and the toilet assist bar. The Administrator and Director of Nursing were made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents and staff interview, it was determined the facility failed to report an allegation of an injury of unknown injury to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation are made. This was evident for 1 (#59) of 11 residents reviewed for abuse. The findings include: On 6/23/21 at 9:46 AM, a review of facility reported incident MD00158868 related to an injury of unknown origin involving Resident #59 was conducted. The facility documentation indicated that, on 9/30/20, a nurse observed a discoloration to the right jaw line of Resident #59 and reported the injury of unknown origin to facility administration staff. The facility investigation determined the discoloration of the resident's right jaw was an injury of unknown origin. The email confirmation of the facility's report to the state agency documented that the injury of unknown injury was reported to the state agency on 10/1/20 at 2:53 PM, which was 1 day after the allegation of abuse was reported to the facility. The…

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

Based on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, including an injury of unknown injury. This was evident for 2 (#58-1, #59) of 11 residents reviewed for abuse. The findings include: 1) Review of facility reported incident MD00155082 for Resident #58-1 on 6/28/21 at 11:44 AM revealed that Resident #58-1 reported that a Geriatric Nursing Assistant (GNA) was rough and threw Resident #58-1 around in the bed. The GNA was suspended and Resident #58-1 was assessed for injury. On 6/28/21 at 11:44 AM, review of the facility's investigation revealed the incident allegedly occurred on 6/9/20 during the 11:00 PM to 7:00 AM shift. It was documented that Resident #58-1 reported the incident, but the investigation did not document who the resident reported the incident to. The previous Director of Nursing (DON) documented on 6/9/20 that police officers came and stated that Resident #58-1 was confused, had no concerns related to being assaulted, and denied injury. The DON documented 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 medical record review and staff interview, it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 1 (#32) of 5 residents reviewed for transfer to an acute care facility. The findings include: 1) Review of Resident #32's medical record on 7/1/21 at 9:25 AM revealed a nursing note, dated 5/4/21 at 18:23 (6:23 PM), which documented that Resident #32 was lethargic, oxygen saturation was 85% on room air and had crackles in the lungs upon auscultation. The physician was notified and ordered for the resident to be transferred to the emergency room for further evaluation. Resident #32 was then transferred via 911 to an acute care facility for treatment. On 7/1/21 at 9:40 AM, review of a concurrent review dated 5/4/21 at 16:00 (4:00 PM) was completed. There was no documentation in the concurrent review that a report was given to the receiving facility. Further review of the medical record failed to produce documentation that the receiving facility received…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #32) of 5 residents reviewed for unnecessary medications and 1 (#63) of 2 residents reviewed for neglect. 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. 1) Review of Resident #32's medical record on 6/24/21 at 8:00 AM revealed a 5 day Medicare MDS with an assessment reference date (ARD) of 5/19/21. Section N, Medications, documented that Resident #32 received an insulin injection on 5 days and antianxiety medication on 6 days during the lookback period. Review of Resident #32's…

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

Based on medical record review and staff interview, it was determined that the facility staff who evaluate care plans failed to revise the interdisciplinary care plans to reveal accurate interventions, and failed to evaluate the resident's response to care plan interventions and the effectiveness/ineffectiveness of the care plan. This was evident for 1 (#63) of 2 residents reviewed for neglect and 1 (#38) of 5 residents reviewed for accidents during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of Resident #63's medical record, on 6/28/21 at 8:18 AM, revealed a care plan, has potential for pressure ulcer development r/t immobility with the goal will have intact skin, free of redness, blisters or discoloration by/through review date. The interventions on the care plan stated, instruct/assist to shift weight in w/c every 15 mins, monitor nutritional status, serve diet as ordered, monitor intake and 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 review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #58) of 47 residents reviewed during an annual recertification survey. The findings include: Review of Resident #58's closed medical record on 6/30/2021 revealed that Resident #58 was discharged from the facility on 4/20/2021. Resident #58's medical record failed to reveal a completed discharge summary from Resident #58's attending physician that included a reconciliation of all pre-discharge medications with the post discharge medications. Interview with the Administrator, on 7/1/2021 at 9:54 AM, confirmed that the facility did not have a reconciliation of all pre-discharge medications with the post discharge medications included in Resident #58's discharge paperwork. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 7/2/2021.

Based on medical record review, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 1 (#58) of 47 residents reviewed during the annual survey. The findings include: Review of Resident #58's record on 6/30/2021 at 11:00 AM revealed the Control Drug Administration Record (CDAR) for Oxycodone 5mg/ml specified that oxycodone had been removed from the bottle on 3/1/2021 at 4:00 AM and 11:45 PM. Review of Resident #58's electronic medication administration record (eMAR) for March 2021 did not show any Oxycodone was administered to the resident on 3/1/2021. Further review of the CDAR for 3/2/2021 revealed that Oxycodone had been removed from the bottle on 3/2/2021 at 10:00 PM with no corresponding documentation of administration on the eMAR. On 3/3/2020, Oxycodone was removed from the bottle at 4:00 AM and 11:45 PM according to the CDAR but was only administered to the resident at 11:45 PM according to the eMAR. Additional review of the CDAR showed that Oxycodone was removed from the bottle on…

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

Based on medical record review and interview, it was determined that the facility staff failed to provide a resident with necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer. This was evident for 1 (#53) out of 47 residents reviewed during the annual survey. The findings included: 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 the 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) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). On 6/28/2021 at 9:19 AM, review of Resident #53's medical record revealed diagnoses of type 2 diabetes, pressure induced deep tissue damage of left heel, pressure ulcer of right heel - unstageable and pressure…

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

Based on record review and interview with the resident and staff, it was determined the facility staff failed to ensure that a physician, physician assistant, nurse practitioner or clinical nurse specialist provided orders for the immediate care and needs of a resident with an indwelling urinary catheter. This was evident for 1 (#28) of 1 resident reviewed for Urinary catheter. The findings include: During the entrance conference, the facility was asked to complete a Resident Matrix identifying pertinent care categories for all residents residing within the facility. Review of the Matrix on 6/23/21, at approximately 8:00 AM, revealed that Resident #28 had an indwelling urinary catheter. During an interview on 6/23/21 at 8:57 AM, Resident #28 indicated that he/she did not currently have an indwelling urinary catheter, but did when first admitted in May of 2021. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and interviews, it was determined that the facility staff failed to ensure that opened medications were dated when opened and documented with an expiration date. This was found to be evident in 2 out of 3 medication carts, and 1 out of 2 treatment carts during observation of medication storage and labeling. This deficient practice had the potential to affect all residents. Findings include: An observation of the Medication and treatment carts on the first floor was conducted on 06/22/2021 at 07:22 a.m. Unit Manager #14 accompanied surveyors during the inspection of medication cart #1. Surveyor noted that an inhaler medication for Resident # 11 was labeled as used on 6/5/21 and 6/22/2021, however, no expiration date was noted on the inhaler. Surveyor observed that Resident # 13's nasal spray medication was found unlabeled when opened and without an expiration date. Surveyors immediately interviewed LPN #13, who was currently using the cart for medication administration. LPN #13 stated that the inhaler and the nasal spray should have been labeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#107) of 4 residents reviewed for dental services. The findings include: On 6/22/21 at 8:52 AM, an interview was conducted with Resident #107's family member who stated that Resident #107 was missing his/her lower dentures. Review of Resident #107's medical record on 6/30/21 at 7:45 AM, revealed a progress note, dated 6/14/21 at 23:18 (11:18 PM), that stated, resident was observed missing lower dentures and son was updated. On 6/30/21 at 8:19 AM, an interview of geriatric nursing assistant (GNA) #30 revealed that Resident #107 would take his/her dentures out and wrap them in a napkin and would put them under the pillow on the bed and Resident #107 would hide them. Resident #107 had the top dentures but lost the bottom dentures. On 6/30/21 at 8:35 AM, an interview of LPN #14 revealed that Resident #107 had lost his/her…

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

Based on review of the medical record and interview with residents and staff it was determined the facility staff failed to maintain medical records on each resident that were complete and accurately documented for 6 (#9, #39, #28, #42, #1, #58) of 47 residents reviewed during the annual survey 1) Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. Per the MOLST instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. Resident #9's electronic medical record (EMR) was reviewed on 6/22/21 at 11:22 AM. The Advance Directive section revealed a…

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

Based on observations and interviews with staff, it was determined that the facility failed to ensure that residents had a means of directly contacting staff. This was evident for Resident #30. The findings include: On 6/22/2021 at 1:00 PM, Resident #30's call light was activated using the hand held controller at the bedside. The hallway alert light above Resident #30's door was observed to be not functional at this time. Staff #14 was notified at this time and indicated they would call maintenance. The Administrator and DON were made aware of these findings during the exit conference on 7/2/2021.