Creekside Center For Rehabilitation And Nursing

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #3) of 2 residents reviewed for pressure injuries. The findings include:Resident #3 had been residing in the facility since early 2024. On 2/2/26 at 1:42 PM, during a family interview, the resident's responsible party indicated that the resident had a wound. It was also observed at this time that the resident's bed was equipped with an air mattress with the control box located at the foot of the bed. The control had a dial to set the firmness based on weight. The setting was dialed up to max weight of over 350 lbs. A review of Resident #3's medical records was conducted previously on 2/2/26 at 10:46 AM. The review revealed the resident's most recent weight was taken on 1/27/26, and was documented as 160.2 lbs.On 2/3/26 at 8:27 AM, Resident #3 was observed in bed. The weight setting for the air mattress was still set to max.The Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, it was determined that the facility failed to monitor a resident's safety device. This was evident for 1 (Resident #51) of 1 resident reviewed for wandering/elopement. The findings include:A wanderguard is a wearable, electronic security device -typically a bracelet or tag-designed for senior living and healthcare facilities to monitor residents at risk of elopement. It uses radio frequency or Bluetooth technology to trigger alarms or lock doors when a patient nears unauthorized exits.Resident #51 was admitted to the facility in September 2025 with diagnoses that included, but was not limited to, Alzheimer's disease. On 10/08/25 an elopement assessment indicated that they were at high risk for elopement. On 11/13/25 the resident's cognition was assessed as severely impaired. A review of their Minimum Data Set (MDS) assessment dated [DATE] indicated a significant change in their condition related to a new onset of wandering behavior, and that a wanderguard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #52, #19) of 2 residents reviewed for pain management. The findings include: 1) Resident #52 was admitted into the facility in mid-2025. During an interview with the resident on 2/2/26 at 9:18 AM, s/he indicated that pain medications don't always help and non-pharmacological interventions (NPI) are not provided or attempted for pain management. A review of Resident #52's medical orders was conducted on 2/0/26 at 9:26 AM. The review revealed an as needed (PRN) pain medication with a start date of 7/14/25. A pain assessment order also had a start date of 7/14/25, included NPI's with instructions that read, Do you have pain? If Denies - Stop here. If Yes - Indicate Pain score 0-10, Offer a nonpharmacological intervention: 1. Repositioning/Turning, 2. Distraction, 3. Massage, 4. Hot/Cold Compress, 5. Emotional Support, 6. Quiet Environment, 7. Other, 8. Not Applicable.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the provider had a response and rationale to a medication regimen review recommendation and/or identified irregularity and that the response was documented in the resident's permanent medical record. This was evident for 2 (Resident #48, #3) of 6 residents reviewed for unnecessary medications. The findings include:1) Resident #48 was admitted to the facility in November 2025 after a hospitalization which included treatment in intensive care. The resident's diagnoses included but were not limited to, type 2 diabetes, heart failure, and malignant neuroendocrine tumors. On 2/02/26 at 12:13 PM an interview with Resident #48 was conducted in the resident's room. The resident was alert and oriented and described in detail their complicated medical history and recent treatment at a tertiary hospital where they were so sick they needed a ventilator. They also detailed their medication orders which they described as a complicated regimen with doses of insulin that were unusual. The resident stated…

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

Based on interview and record review it was determined that the facility failed to administer medications timely. This was evident for 1 (Resident #48) of 1 resident reviewed for insulin. The findings include:Resident #48 was admitted to the facility in November 2025 following an acute hospitalization that included care in an intensive care unit. Their diagnoses included, but were not limited to, type 2 Diabetes Mellitus, heart failure, and malignant neuroendocrine tumors. A review of their medical record revealed that they required multiple medications, which included significant doses of insulin before meals, and as needed at bedtime.On 2/02/26 at 11:23 AM an interview was conducted with Resident #48 in their room. The resident was alert, oriented, and able to describe their medical needs, including their medication regimen, in detail. On 2/04/26 at 11:42 AM an observation and interview were conducted with Resident #48 in their room. The resident stated that they had just received all of their morning medications together, which included insulin but was supposed to have been…

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

Based on observation and staff interviews, the facility failed to ensure that 1) staff performed hand hygiene during 8 of 8 breakfast observations and 2) failed to perform hand hygiene during 2 (R#37 and R#55) of 3 medication administration observations, and 3) failed to maintain a sanitary medication storage environment in 1 of 2 medication storage rooms observed.The findings include:1) On 02/01/2026 at 8:17 AM, the surveyor observed Staff #5, a Geriatric Nursing Assistant, and Staff #7, a Licensed Practical Nurse, delivered meal trays to resident rooms 406, 409, 410, 411, 412, 414, 415, and 416 on the 400 hall. Staff #5 and Staff #7 exited 8 of 8 resident rooms without performing hand hygiene before entry or after exit.No alcohol-based hand sanitizer was observed on the meal cart. The surveyor observed three wall-mounted hand hygiene dispensers in the 400 hallway and one dispenser inside each resident room.2) On 02/04/2026 at 8:35 AM, during medication administration observation on the 500 hall, the surveyor observed Staff #6, a Registered Nurse, fail to perform hand hygiene…

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

Based on interview and record review it was determined that the facility failed to offer COVID-19 vaccinations to staff and residents and failed to educate staff and residents regarding the COVID-19 vaccination. This was evident for 7 (Staff #6, #11, #12, #16, #17, #18, #19) of 7 staff members, and 4 (Resident #2, #8, #48, and #51) of 5 residents, reviewed for vaccinations during the infection control task during the recertification survey. The findings include:On 2/05/26 at 8:31 AM an interview was conducted with a Registered Nurse (RN) who was the facility's infection preventionist (Staff #1). She was asked about the facility's process for offering information regarding COVID-19 vaccinations to staff and residents. She explained that the new admission packet for residents included education sheets for COVID-19 vaccinations and that the education sheet had a place to indicate consent for the vaccine. She further explained that each year the facility's pharmacy let her know what vaccines were available and then she ordered what was needed and offered and gave vaccines to current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interview, the facility failed to ensure the call bell system was accessible. This was evident for 1 (Resident #45) of 1 residents reviewed during the annual recertification survey. The findings include: 02/01/2026 at 8:05 AM, the surveyor observed R#45 in room [ROOM NUMBER] with the call bell cord partially disconnected from the wall outlet and out of reach while R#45 was positioned near the edge of the bed, asking for assistance.R#45 stated to the surveyor that delayed staff response to call light activation was not unusual and reported waiting up to one hour for staff to respond.The surveyor reconnected the call bell and instructed R#45 to activate the adaptive pendant-shaped call button. The call signal was activated; however, after approximately eight (8) minutes, no staff responded.The surveyor assisted R#45 back into bed and ensured the call bell was placed within reach.On 02/03/2026 at 1:15 PM, these findings were reviewed with the Nursing Home Administrator and Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Geriatric Nursing Assistants (GNA) received required training. This was evident for 2 (Staff #11, #12) of 2 agency GNAs reviewed for training requirements during the recertification survey. The findings include:On 2/01/26 at 8:25 AM an interview was conducted with the Nursing Home Administrator (NHA) as part of the entrance conference for the annual survey. When asked about the percentage of agency staff the facility used, she said approximately 80%.On 2/03/26 at 5:31 PM an interview was conducted with the facility's staffing scheduler, (Staff #20). When asked what percentage of scheduled GNAs were from an agency, she replied about 80%.On 2/04/26 at 9:30 AM an interview was conducted with the facility's Human Resources Director, Staff #21 to ask about staff training. She said she was responsible for staff training but only for facility hired staff, and she explained the process for orientation and monthly training. When asked specifically about agency staff training, Staff #21 explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review the facility failed to ensure alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made and not later than 24 hours to other officials (including to the State Survey Agency and Adult Protective Services in accordance with State law through established procedures for 4 of 10 residents reviewed for abuse (R#11, R#2, R#6, and R#19).Findings Include: Record review of the abuse policy titled, Abuse Prevention Program last revised on 11/30/2022 documented, the administrator was responsible for the overall coordination and implementation of the facility's abuse prevention program policies and procedures. The administrator had the authority to delegate, coordinate and implement various components of the abuse policies and procedures to other individuals within the facility. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injures of unknown origins and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to maintain documentation that an abuse allegation was thoroughly investigated. This deficient practice was identified for 1 of 10 residents reviewed for abuse (Resident #2). The findings included: The facility policy titled Abuse Prevention Program; Policies, Procedures, & Information last reviewed on 11/30/22, revealed that witness reports will be obtained in writing, either the witness will write their statement and sign and date, or the investigator may obtain the stated and read it back to the member and have them sign it. The policy further stated that upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances, Parkinson's disease, and delusional disorder. The Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews it was determined that the facility failed to follow infection control practices and guidelines by failing to notify the local health department of a gastrointestinal outbreak and failed to post a sign in the facility and at the entrance to inform staff and visitors of the outbreak. This was evident for 1 day of a complaint survey. The findings include: On 2/21/25 at 8:30 AM a tour of the facility was conducted. While walking down the 400 hallway observation was made of several rooms with contact isolation signs on the door with PPE (personal protective equipment) outside of the door. PPE consists of gowns, masks, and gloves. Observation was made in room [ROOM NUMBER] of a resident with 4 cups on the over the bed tray table and a basin in the resident's lap. The surveyor asked the resident how he/she was and the resident stated he/she was nauseated, the reason for the basin. On 2/21/25 at 11:26 AM an interview was conducted with the Assistant Director of Nursing (ADON),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review, it was determined that facility staff failed to develop a comprehensive, resident centered care plan for a resident with a prosthetic eye. This was evident for 1 (#3) of 3 residents reviewed during a complaint 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. On 2/21/25 at 8:45 AM a review of Resident #3's medical record revealed that Resident #3 was admitted to the facility in July 2023 with diagnoses that included late onset Alzheimer's disease, neurocognitive disorder with Lewy Bodies, and age-related physical debility. Resident #3 also had a prosthetic left eye since the age of 4. Review of January 2025 physician's orders revealed Resident #3 had a prosthetic left eye which required daily cleaning. The left eye was to be removed from the socket, cleansed with NSS (normal saline solution), patted dry with dry paper towel, and replaced back in the eye socket. Review of Resident #3's care plans failed…

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

Based on medical record review and interview, it was determined the facility failed to renew cleaning of a resident's prosthetic eye after the resident returned from the hospital on multiple occasions. This was evident for 1 (#3) of 3 residents reviewed during a complaint survey. The findings include: On 2/21/25 at 8:45 AM a review of Resident #3's medical record revealed the resident was admitted to the facility in July 2023 with diagnoses that included, but were not limited to, Alzheimer's disease with late onset, neurocognitive disorder with Lewy Bodies, dementia, and age-related physical debility. Review of the history of Resident #3 revealed Resident #3 had a left prosthetic eye since the age of 4 years old. Review of Resident #3's physician's orders revealed an order that was written on 1/16/25 that documented, left glass eye (prosthetic) qd (every day) cleaning. Remove left eye from socket, cleanse eye with NSS (normal saline solution), pat dry with dry paper towel, replace in eye socket. Further review of the medical record revealed the resident had the order to clean the…

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

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to hold a medication when outside of physician ordered parameters and failure to notify the physician when the blood pressure was outside of physician ordered parameters. This was evident for 1 (#3) of 3 residents reviewed during a complaint survey. The findings include: On 2/21/25 at 8:45 AM a review of Resident #3's medical record was conducted and revealed Resident #3 had hypertension and was taking Lisinopril 40 mg. every day and Clonidine 0.1 mg. 2 times a day to treat the hypertension. Review of a physician's order for Clonidine 0.1 mg, documented to hold for systolic greater than 150. Systolic blood pressure, the amount of pressure in the arteries during the contraction of the heart muscle, is the top number of the blood pressure reading. Review of the January 2025 Medication Administration Record (MAR) documented on 1/18/25 at 9:00 AM and 8:00 PM the blood pressure was 155/63. The medication was administered both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and medical records and interview with staff, it was determined the facility staff failed to provide discharge planning for a resident requesting transfer to another facility. This was evident for 1 (Resident #903) of 28 residents reviewed in relation to facility reported incidents. The findings include: Facility reported incident #MD00203381 was reviewed on 7/25/24 at 9:32 AM. The report included: 3/6/24 & 3/7/24 resident stated to facility Social Worker [he/ she] wanted to return to [another facility], that [he/she's] only at Creekside because [his/her] daughter wanted [him/her] closer to her. This was day 2 and 3 after his/her admission. On 3/7/24 Resident #903 called 911, was transferred to the hospital then discharged from the hospital to another facility. Review of the medical record at that time revealed Resident #903 was capable of making informed decisions on his/her own behalf. The record failed to reveal the Social Worker or other staff acted upon the resident's two transfer requests including any actions taken by the facility staff to address…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Director of Nursing (DON) was working in that capacity on a full-time basis due to currently being assigned the duties of the infection prevention nurse in addition to being the Director of Nursing. This practice has the potential to affect all residents in the facility. The findings include: During an interview with the Nursing Home Administrator (NHA) on 8/2/24 at 8:17 AM, she reported that the Infection Preventionist (IP) nurse had resigned without notice and left the faciity on the same day, on 7/22/24. Since then, the DON had been assigned to take over the role of the IP nurse on top her duties as the DON. On 8/2/24 at 9:40 AM, the DON was interviewed and reported that she has the certification for the IP but knew that she should not be the IP nurse as well. The DON indicated that this was because of her other responsibilities in the facility as the DON. The DON also reported that another staff in the facility was currently in training to be the IP nurse. A Review of the state…

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

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) Geriatric Nursing Assistant (GNA) staff reviewed and has the potential to affect the care received by all residents. The findings include: On 7/30/24 at 1:35 PM, the surveyor reviewed the employee files of 5 (Staff #29, #31, #32, #33, #34) geriatric nursing assistants (GNAs) who were employed by the facility for more than 12 months and selected from a list of employees provided by the facility. a) of Staff #29's employee file revealed a hire date of 11/30/22. No documentation was found that an annual performance review had been conducted in the past year. b) Review of Staff #31's employee file revealed a hire date 5/9/17. No documentation was found that an annual performance review had been conducted in the past year. c) Review of Staff #32's employee file, revealed a hire date. No documentation was found that an annual performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews of medical and administrative records, observations and interviews, it was determined the facility administration failed to develop and implement procedures based on the regulatory requirements to effectively attain and maintain the highest practicable wellbeing of each resident. This was evident for 6 (R#932, R#937, R#933, R#938, R#940 and R#931) of 43 residents reviewed during the revisit survey and has the potential to affect all residents in the facility. The findings include: 1) Resident (R) #932's medical record was reviewed on 10/21/24 at 10:40 AM. The record revealed a Notice of Transfer/Discharge indicating that R#932 was transferred to the hospital emergency room (ER) for evaluation and treatment on 10/14/24. R#937's medical record was reviewed on 10/22/24 at 9:55 AM. The record revealed a Notice of Transfer/Discharge indicating the resident was transferred to the hospital ER on [DATE] for evaluation and treatment. R#933's medical record was reviewed on 10/21/24 at 1:05 PM. The 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 on record review of facility documentation and staff interview, it was determined that the facility staff failed to conduct and document a comprehensive facility-wide assessment as evidence by failing to address: 1) the facility's average number of residents, 2) staff competencies necessary to provide the level and types of care needed for the resident population, 3) an evaluation of the facility's training program to ensure that any training needs are met for all new and existing staff, and contractual individuals providing services and volunteers, consistent with their expected roles and 4) Failed to have a facility-based and community-based risk assessment, utilizing an all hazards approach. This was evidenced during a Sufficient and Competent Nurse Staffing review, and extended survey review. This deficient practice has the ability to affect all residents in the facility. The findings include: The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services…

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

Based on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior recertification survey. The findings include: On 8/5/24 at 3:06 PM, a review of the last recertification survey with a plan of correction date of 9/15/19, and a recertification survey concluded in 2/2018 revealed that effective processes were not put in place to prevent repeat deficiencies. The corrective actions implemented by the facility after the recertification surveys failed to effectively correct deficiencies related to reasonable accommodation of needs (F 558), Pharmacy services/procedures/pharmacist/records (F755), drug regimen is free from unnecessary drugs (F757), and free of medication errors rates 5 percent or more (F759). These failures resulted in a continuation of the deficient practices as identified during the current recertification and complaint survey. Cross…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, records review, and interview, it was determined that the facility failed develop and implement infection prevention and control policies and prodedures as evidenced by 1) facility staff's failure to don appropriate personal protective equipment (PPE) before giving direct care to 1a) a resident with a central line (an IV access to a person's veins), and 1b) a resident with an open wound, 2) facility staff's failure ot follow infection prevention and control practices during medication administration, 3) the failure to process laundry in a manner that prevents the spread of infection, 4) the failure to have a system in place to identify and prevent the growth of legionella in the facility's water system, and 5) the failure to review infection prevention and control policies and procedure annually. This was evident for 1 resident (#68) reviewed for dialysis, and 1 (#64) of 2 residents reviewed for pressure ulcers, 1 out of 5 medication administrations observed and has the potential to affect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files, pertinent documents and interview, it was determined that the facility failed to include effective communications as mandatory training for direct care staff. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) employees reviewed for the extended survey. The findings include: Effective communications describe a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. On 7/30/24 at 1:35 PM, a review of 5 randomly selected employee files failed to reveal documentation to indicate that the employees had received effective communications training: a) Staff #29, GNA, with a date of hire (DOH) of 11/30/22, had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files, pertinent documents, and staff interviews, it was determined that the facility failed to ensure that required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was completed. This was evident for 3 (#29, #31, #41) of 5 staff members reviewed during the survey. The findings include: On 7/30/24 at 1:35 PM, a review of the employee files for Staff #29, GNA, with a date of hire of 11/30/22, Staff #31, GNA, with a date of hire of 5/9/17, Staff #32 GNA with a date of hire of 6/29/10, Staff #33, GNA, with a date of hire of 5/18/20, and Staff #34, with a date of hire of 9/21/29 failed to reveal documentation to indicate the employees had received abuse and dementia management training. On 7/31/24 at 9:33 AM, Staff #10, Human Resources (HR) was made aware there was no training found in the employee files and responded that the employee files were in place prior to her hire at the end of late 2023. Staff #10 indicated she was unsure how HR previously tracked mandatory in-service training but was told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files, pertinent documents and interview, it was determined that the facility failed to provide infection prevention and control training mandatory training that included the written standards, policies, and procedures for the program. This was evident for 4 (Staff #29, #31, #32, #34) of 5 employee records reviewed for the extended survey. The findings include: A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program On 7/30/24 at 1:35 PM, a review of 5 randomly selected employee files failed to reveal documentation to indicate the employees had received mandatory infection prevention and control training. a) Staff #29, GNA, with a date of hire (DOH) of 11/30/22, had no evidence of training, including infection prevention and control training in his/her employee file. b) Staff #31, GNA, with a DOH 5/9/17, had no evidence of training, including infection prevention and control training in his/her employee file c) Staff #32, GNA, with 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 the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given 1) in-service training no less than 12 hours per year, 2) abuse prevention and dementia management training, 3) a yearly performance review, and 4) training for GNA's that provide services to residents with cognitive impairments. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) GNA employee records reviewed for sufficient and competent nursing staffing reviewed during the survey and has the potential to affect the care received by all residents. The findings include: On 7/30/24 at 1:35 PM, the surveyor reviewed 5 randomly selected employee files of geriatric nursing assistants (GNAs) who were employed by the facility for more than 12 months. Review of the employee file for Staff #29, GNA, with a date of hire of 11/30/22, Staff #31, GNA, with a date of hire of 5/9/17, Staff #32 GNA with a date of hire of 6/29/10, Staff #33, GNA, with a date of hire of 5/18/20, and Staff #34, with a date of hire 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 review of employee files, pertinent documents and interview, it was determined that the facility failed to include effective communications as mandatory training for direct care staff. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) GNA employee records reviewed for during the survey. The findings include: Effective communications describe a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. On 7/30/24 at 1:35 PM, a review of 5 randomly selected employee files failed to reveal documentation to indicate the employees had received effective communications training: a) Staff #29, GNA, with a date of hire (DOH) of 11/30/22, had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the residents' dignity by staff hovering over residents while assisting them to eat. This was evident for 3 (Resident #127, #62 and #14) of 3 residents observed being fed by staff. The findings include: On 07/29/24 at 8:09 AM, the surveyor observed GNA (Staff #43) standing over Resident #127 while feeding him/her in bed. On 07/30/24 at 12:37 PM, the surveyor observed GNA (Staff #44) standing over Resident #62 while feeding him/her in the smaller dining room. On 07/30/24 at 12:59 PM, the surveyor observed GNA (Staff #21) standing over Resident #14 while feeding him/her in the smaller dining room. On 07/30/24 at 01:04 PM, an interview with Staff #21 revealed that she was not aware of a feeding policy but knew to be in direct eye contact with the resident while feeding them. On 07/30/24 at 01:29 PM, an interview with the Director of Nursing (DON) revealed she would have to check if they have a feeding policy and that the expectation is to have eye contact with the resident and not be hovering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that thorough investigations were completed for injuries of unknown origin and allegations of abuse and neglect. This was found to be evident for 5 (Resident #917, #928, # 926, #922, and #900) out of 28 residents reviewed in relation to facility reported incidents. The findings include: 1) A review of the facility's investigation file for facility reported incident #MD00207144 revealed an initial report which read that Resident #917 was found to have a bruise to the right chest, the right inner arm, and on the top of the left 2nd toe. According to Geriatric Nursing Assistant (GNA) #42's statement, she was caring for the resident on 6/26/24 around 9:30 AM, and when she removed the resident's gown, she found the bruising. She also reported that she had cared for the resident on 6/25/24 during the 3 PM - 11 PM shift and the resident had no bruising at that time. GNA #40 who was assigned to the resident on the 11 PM - 7 AM shift starting on 6/25/24 was suspended pending the investigation.…

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

Based on record review and interview with staff, it was determined the facility staff failed to notify the resident and his/her representative in writing when the resident was transferred to the hospital. This was evident for 3 (#924, #45, and #33) of 4 residents reviewed for hospitalization during the survey. The findings include: Review of Resident #924's medical record on 7/24/24 at 12:17 PM revealed that the resident was transferred to the hospital emergency room on 7/20/22 for evaluation of lethargy, low blood pressure and low sodium level. A Nursing progress note, dated 7/20/22 at 10:36 AM, by the former Director of Nursing (DON) (Staff #20), included Call placed to POA (Power of Attorney) for notification. However, the note did not indicate that the resident and his/her representative were notified in writing of the hospital transfer. In an interview on 7/29/24 at 8:55 AM, the Director of Nursing (DON) was made aware that the surveyor was unable to find evidence that the resident and representative were notified in writing of his/her transfer to the hospital on 7/20/22. No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview with complainants and facility staff, it was determined that the facility failed to have a process in place to ensure that physician notes were available in the medical record and failed to ensure that a review of the residents' total treatment was completed each visit. This was evident for 4 (Resident #911, #921, #9 and #914) of 6 residents reviewed for quality of care during a complaint survey conducted during the recertification survey. The findings include: 1) Review of the complaint for Resident #911 on 7/25/24 revealed concerns with his/her admission to the facility and the availability of their medications. A comprehensive review of their hospital discharge on [DATE] at 7:46 AM revealed discharge medications to include a regimen of Lasix, a diuretic, 1 tablet of 40 mg Tuesday-Thursday and Saturday and Sunday, while receiving 2 tablets of the 40 mg on Mondays and Fridays for edema. S/he was also ordered pain medication, hydrocodone-acetaminophen every 6 hours as…

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

Based on observation, interview, and medical record review, it was determined the facility failed to ensure a medication error rate of less than 5%. This was found to be evident based on errors identified during medication observations of 4 residents (Resident #5, #11, #54, and #476) out of 5 residents observed. The observations were made on each of the three hallways of the facility and involved three different staff members including an agency certified medication aide, one agency Licensed Practical Nurse (LPN), and one staff LPN. The findings include: 1) On 07/29/24 at 08:02 AM, the surveyor observed LPN (Staff #2) prepare medications for Resident #5. The nurse was observed to obtain the following medication from the medication cart: 1 Finasteride 5mg 1 Isosorb 30 mg 1 Extra strength probiotic support 1 Metoprolol 25mg 1 Bumetanide 1mg 1 Lovastatin 40 mg 1 Gabapentin 100mg and placed these 7 medications in a medicine cup. The nurse also obtained a cup of nutritional shake. The LPN administered the 7 medications listed above. On 07/29/24 at 09:42 AM, after the observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, it was determined that the facility failed to accommodate resident needs by 1) failing to ensure that a resident's call bell was within reach and 2) failing to respond to call bells in a timely manner. This was evident for 1(#64) of 24 residents reviewed in the initial pool and 4 (room [ROOM NUMBER], #501, #512, #503) of 4 rooms observed with activated call bells on 2 of 3 nursing units observed during the survey. The findings include: A call bell system is a method to ensure that residents in a long-term care facility have timely access to assistance by using the call bell system. 1) A medical record review on 7/23/24 at 2:45 PM found that Resident #64 was admitted to the facility in April 2024 with diagnoses that included Dementia. Continued review revealed an admission MDS assessment, dated 4/14/24, for Resident #64. The MDS had documentation that Resident #64's dignosis included moderate cognitive impairment and was dependent on staff for all his/her self-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 record review and interviews, it was determined that the facility failed to resolve repeated concerns that were reported during Resident council meetings. This was evident in resident council meetings between January 2024 and June 2024. The findings include: A review of resident council meeting minutes for 2024 was completed on 7/25/24 at 10:09 AM. The review revealed that the following concerns were voiced during the monthly Resident Council Meetings: January- Call lights were not answered promptly, and staff used their phones while providing care to the residents. February -Call lights were not answered promptly, and the staff used their cell phones while caring for residents. March- Call lights were not answered promptly and some not answered at all. April- Call lights were unanswered, and ice water was not passed on days and afternoons. May- Call lights were not answered, Ice water was not passed on days and afternoons, and staff used their phones while providing care to the residents. June- Ice water was not passed on days and afternoons, staff were using their phones…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to ensure that residents were verbally provided with a notice of their rights and services during their stay. This was evident during a resident council meeting conducted during the annual survey. The findings include: On 7/26/24 at 2:15 PM, the surveyor held a resident council meeting with six residents, including the resident council president. During the meeting, it was reported that no one reviewed residents' rights at the monthly council meetings. On the same day, a review of the meeting minutes from January to June 2024 showed a statement that Residents Rights reviewed for every month. In an interview on 7/29/24 at 4:50 PM with staff #51, activities director, she stated she did not review residents' rights at the monthly meetings as documented on the meeting minutes. Staff #51 said she would begin reviewing the rights at monthly council meetings. On 7/30/24 at 6:57 AM, the nursing home administrator was informed of the concern that residents were not verbally informed of their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to have a system in place to ensure that an advanced directive was obtained for each resident and that there is only one active MOLST for each resident. This was evident for 2 (Resident # 59 and #127) of 4 residents reviewed for advanced directives. The findings include: 1) On [DATE], review of Resident #59's medical record revealed that the resident was admitted to the facility in [DATE] and was deemed incapable by two physicians to make health care decisions in [DATE]. An initial review of the Maryland Orders for Life Sustaining Treatment (MOLST) on [DATE], revealed that these orders were discussed with the Health Care Agent as named in the resident's advance directives. Further review of the medical record failed to reveal documentation of the resident's advance directives. On [DATE] at 9:52 AM, the surveyor reviewed the concern with the Social Worker (SW Staff #19) that the MOLST was completed per the Advanced Directive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of medical records, complaint allegations, and facility policies, it was determined that the facility failed to ensure that staff timely notified resident representatives and physicians of a changes in condition and the occurance of a resident falls. This was evident for 2 (Resident #915 and #900) of 5 residents reviewed for of an allegation of neglect with injuries of unknown origin and 1 (Resident #914) of 11 residents reviewed for falls. The findings include: 1. Review of the complaint related to Resident #915 revealed concerns related to neglect. A comprehensive review of Resident #915's medical record on 7/23/24 at 11:15 AM revealed admission to the facility for their after care related to a fall with fractures. A review of the progress notes documented that, on 5/27/24, Resident #915 was found on the floor in the bathroom. A note was entered on 5/28/24 that the resident's representative was notified, 24 hours later. At the time of the incident, resident was not noted as their own representative and was documented on the physician admission history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and prevent the misappropriation of resident property. This was evident for 1 (#21) out of 2 residents reviewed for neglect. The findings include: A medical record review on 7/24/24 at 10:07 AM showed that Resident #21 had been residing at the facility since December 2022. A continued review contained an attending provider's order, dated 12/9/22, for Resident #21 for oxycodone 10mg, one tablet every 8 hours as needed for pain. A review of a facility-reported incident related to Resident #21 with MD #00193982 showed that, on 6/15/23, staff #52, a nursing supervisor, received 90 tablets of oxycodone 10 mg from the pharmacy for Resident #21. Continued review revealed that Resident #21 requested pain medicine on 6/29/23; however, it was discovered that all 90 tablets of oxycodone were missing from the narcotic box where they were stored. A review of the packing slip for 90 pills of 10mg oxycodone from the pharmacy was signed on 6/15/23 by staff #52. Further review of the Narcotic drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a process to ensure that injuries of unknow origin and allegations of abuse were reported to the state agency. This was evident for 1 (#9) of 5 residents reviewed for injuries of unknown origin and 2 (#376 and #59) of 13 residents reviewed for abuse. The finding include: On 7/23/24 at 9:00 AM, a review of complaint #MD00206718 revealed that Resident #9 had been transported to the local hospital for treatment of a 15 cm laceration of their right lower leg. The complainant was concerned because facility staff were unable to explain how this injury occurred. Secondly the resident reported that two staff were transferring him/her from the wheelchair to the bed and s/he caught it on something cutting it open. An interview was conducted with the Director of Nursing (DON) on 7/23/24 at 12:45 PM, with the Regional Director of Clinical Operations present. The DON reported that geriatric nursing assistant (GNA) #22 and GNA #23 were unable to tell her how the injury occurred. They reported…

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

Based on record review and interview with staff, it was determined the facility staff failed to provide the minimal information required to the receiving provider at the time of transfer. This was evident for one (Resident #924) of four residents reviewed for hospitalization during the survey. The findings include: Review of Resident #924's medical record on 7/24/24 at 12:17 PM revealed that the resident was transferred to the hospital emergency room on 7/20/22 for evaluation of lethargy, low blood pressure, and low sodium level. A Hospital Transfer form was not found in the medical record. A Nursing progress note, dated 7/20/22 at 10:36 AM, by the former Director of Nursing (DON) (Staff #20), revealed Resident MOLST [Medical orders for Life Sustaining Treatment], capacity, current med orders, and copy of bed hold policy sent with resident. Resident prepared for transfer. 911 called and resident left facility via stretcher with 2 attendants in stable condition. Report called to ER. However, the note did not indicate that resident's Comprehensive Care Plan goals, identification and…

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

Based on medical record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 3 (#33, #45, #68) of 3 residents reviewed for hospitalization. The findings include: 1) A review of the medical record for Resident #33 revealed that, on 5/26/24, the resident was sent to the hospital for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the resident and /or the resident representative were given written notice of the bed hold policy. An interview with the Assistant Director of Nursing (ADON), on 07/31/24 at 01:45 PM, revealed that sometimes the facility keeps a paper copy of the bed hold policy for a resident if they are able to complete it, but occasionally, it is a verbal notice to the admissions director. Further interview with the ADON revealed that the bed hold policy was not provided in writing to the resident /resident representative when a resident…

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

Based on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice care. This was evident for 1 (#45) of 3 residents reviewed for hospitalization. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The nursing home should complete a Significant Change in Status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. A medical record review on 7/24/24 at 12:41 PM showed that Resident #45 had lived in the facility since May 2023. A continued review found that Resident #45's order summary report for July contained an attending provider's order, dated 7/2/24, that stated the Resident was admitted to hospice care 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 of a facility reported incident and interview with facility staff, it was determined that the facility failed to develop a care plan related to a resident's elopement potential. This was evident for 1 (Resident #922) of 6 residents reviewed for elopement. The findings include: A care plan is a comprehensive and personalized document that outlines the specific needs, goals, and preferences of a patient. Care plans also address the specific services needed to attain and maintain a resident's highest practicable well-being through focus, goals and interventions. The review of the facility reported incident on 7/25/24 regarding Resident #922 revealed a completed elopement assessment on 5/1/23, showing a score of 15, and an actual elopement on 5/2/23, but failed to reveal a care plan related to these findings. A care plan related to these findings was never developed during the resident's 2 week stay in the facility. This was reviewed with the current facility Director of Nursing on 7/25/24 at 9:29 AM who verbalized that a care plan related to this concern…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct an assessment and neurological checks according to standards of professional practice after a resident had a fall. This was evident for 1 (Resident #914) of 11 residents reviewed for falls. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Neurological checks is a set protocol to check the resident in set intervals that may include the following; vital signs, orientation, level of consciousness, pupils reaction and size, responsiveness, pain, and checking extremities for strength and feeling. 1) On 7/26/24 at 1:50 PM, a review of the facility investigation file for a facility reported incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and observations, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) were provided with showers. This was evident for 2 (#59 and #64) of 4 residents reviewed for ADL. The findings include: 1) A review of MD00196837 from September 2023 revealed an allegation that Resident #59 only had two showers in two months since their admission in July 2023. A review of the MDS, with an assessment reference date of 10/12/23, revealed that Resident #59 needed partial to moderate assistance with showers. Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. On 08/02/24 at 8:32 AM, the surveyor requested the shower task sheet for July 2023 to October 2023 for Resident #59. On 08/02/24 at 10:06 AM, an interview with the Director of Nursing (DON) revealed she was not able to provide documentation of showers for Resident #59 from July 2023 to October 2023. On 08/02/24 at 12:03 PM, the…

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

Based on pertinent document review, observation, and interview, it was determined that the facility failed to implement preventative measures to prevent pressure injuries. This was evident for 4 residents (Resident #25, #47, #2, #75), out of 43 residents reviewed during a survey. The findings include: 1. On 7/26/24, the review of medical records for Resident #25, a long-term resident at the facility, revealed that the resident had a recently healed stage 3 pressure injury on the buttocks. A stage three pressure injury is when the full thickness of the skin is lost. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. On 7/26/24 at 10:10 AM, the Director of Nursing (DON) was interviewed regarding the facility's documentation for the turning and positioning of a resident to prevent pressure injuries. The Director of Nursing (DON) reported that the facility considers turning and repositioning part of the standard of care and that there was no order for turning and repositioning, nor documentation when turning and repositioning is done. The DON reported that she…

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

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 1 (#24) of 4 residents reviewed for position and mobility. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. On 7/26/24 at 2:15 PM, during a resident council meeting, it was reported that Resident #24 was supposed to be wearing a splint on the left hand; however, staff was not providing it. On 7/29/24 at 4:03 PM, Resident #24 was observed sitting at the nurses' station with no splint on his/her left hand. A record review on 7/29/24 at 4:30 PM showed that Resident #24 had been residing in the facility since 2017, and their diagnoses included left-sided weakness due to stroke. Further review contained an…

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

Based on interviews, and record reviews, it was determined that the facility failed to accurately document a resident's dietary consumption to ensure the resident received adequate nutritional intake. This was evident for 1 Resident (Resident #12) out of 3 residents reviewed for nutrition during the survey. The findings include: On 8/2/24, intake #MD00208140 was reviewed. Review revealed a concern that Resident #12 did not receive adequate nutrition. Further review revealed that Resident #12 was admitted for rehabilitation. On 8/2/24 at 1:52 PM, review of the dietician progress note, dated 7/11/24, revealed that Resident #12 received nutrition by mouth (PO) and, through a feeding tube. Further review revealed the registered dietician was monitoring the resident's PO intake and prescribing tube feedings based on Resident #25's weight and his/her PO intake. On 8/2/24 at 11:15 AM, Registered Dietician (RD) Staff # 25, was interviewed via phone. Staff #25 reported that she had monitored the percentage of meals the resident had eaten at every meal. She continued that, if the resident's…

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

Based on observation, interview and record review, it was determined that the facility failed to 1) administer respiratory therapy (oxygen) according to professional standards and 2) maintain respiratory care equipment for residents who required continuous oxygen via nasal cannula. This was evident for 2 (#25 and #68) of 2 residents reveiwed for respiratory care. The findings include: 1) Resident #25 was a long-term resident of the facility with a history of chronic obstruction pulmonary disease (a chronic lung disease, that can make it difficult to breath). On 7/26/24 at 9:50 AM, review of the medical record revealed the following orders: An order with a start date of 4/10/24, Check O2 sat every shift, (oxygen saturation rate) and an order with a start date of 4/10/24, for 02 L/min via nasal cannula, as needed, for SOB [shortness of breath] related to Chronic obstructive pulmonary disease. Please indicate when 02 has been applied. See nurse notes for detail. On 7/29/24, multiple observations were made of Resident #25. Observations revealed that the resident was on O2 via nasal…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure that a resident received pain medication according to an attending provider's order and failed to document pain assessments to include the location of the pain and type of pain for a resident reporting pain. This was evident for 1 (#64) of 1 Resident reviewed for pain management. The findings include: A pain scale is 0-10; 0 means no pain, and 10 represents the worst pain. It is used to assess the level of pain a patient is experiencing for better treatment. Non-pharmacological pain management is an intervention without the use of medications. A review on 7/25/24 at 1:25 PM of complaint record #MD00208061 indicated that Resident #64 was usually in pain; however, staff failed to assess and manage his/her pain. A medical record review on 7/2524 at 2:30 PM showed that Resident #64 had been residing in the facility since April 2024 with diagnoses including cervical spine fracture. The review also noted that the resident had pressure sores on both buttocks and his/her sacral area. 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, observation, and interviews, it was determined that the facility staff failed to obtain pre- and post-dialysis treatment records for a resident. This was evident for 1 (#68) of 1 resident reviewed for dialysis. The findings include: A medical record review on 7/23/24 at 10:10 AM showed that Resident #68 was admitted to the facility in June 2024 with diagnoses including chronic kidney disease, with dependence on hemodialysis. Hemodialysis, also known as dialysis, is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. Further review found an attending provider's order for Resident #68 to receive dialysis 3x a week on Tuesday, Thursday, and Saturday @ 10:30 AM. The order stated, On dialysis days please send a new dialysis form filled in patients' full vitals including weight for the morning. Additionally, there was an order for Post Dialysis Weight every Tuesday, Thursday, and Saturday. An observation on 8/1/24 at approximately 10:00 AM, showed Resident #68 going for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to ensure that the resident's care was overseen by a physician. This was found to be evident for 3 (#905, #920, and #9) of 6 residents reviewed for quality of care during the investigation of a complaint conducted during a recertification survey and 1 (#57) of 4 residents reviewed for unnecessary medications. The findings include: 1) A review on 7/26/24 at 11:30 AM based on facility treatment of Resident #905 after multiple consecutive falls that occurred on the day of admission, revealed concerns related to the resident's admission including the physician's medication review. Resident #905 was admitted to the facility on an anticoagulant, Eliquis. On the day of admission, s/he had 2 unwitnessed falls, the second sustaining a bloody nose. Secondary to the bleeding, and due to additional concerns for a gastrointestinal bleed and unwitnessed falls, s/he was transferred to the hospital for further assessment. Upon readmission to the…

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

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that physicians visits were conducted every 30 days for the first 90 days and at least every 120 days after, and the nurse practitioner (NP) visiting in between to ensure the resident had a visit every 60 days. This was evident for 2 (Residents #9 and #914) of 6 residents reviewed for quality of care. The findings include: On 8/1/24 at 10:56 AM, a review of the facility's policy titled Physician Visits revealed there was no date when the policy was written or implemented. The policy read in #3 that NPs may visit the resident after the initial physician visit and #4 read that NPs may alternate with the physician during the first 90 days of admission, which does not align with the regulatory requirement that the physician must visit the resident every 30 days for the first 90 days. The policy failed to mention the method in which the facility would track these visits to ensure they were done. At the bottom of the policy, it was noted under references the previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, pertinent document review and staff interview, it was determined that the facility staff failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This was evident during a review for sufficient and competent nurse staffing and has the potential to affect all residents. The findings include: On 7/30/24 at 10:58 AM, a review of the nurse's station revealed a Daily Staffing Report that had the facility's name, with a space to document the date, the facility census, and the PPD (patient per day), which documented the shift census for day, evening and night shifts, and the number and projected hours worked by licensed and unlicensed staff directly responsible for resident care per shift. In the morning on 8/1/24, the surveyor requested the Daily Staffing Reports for February 2024. Review of February 2024's Daily Staffing Reports provided to the surveyor failed to reveal a Daily Staffing Report for 16 (2/3, 2/4, 2/7, 2/8, 2/9, 2/10, 2/11, 2/12, 2/14, 2/17, 2/18, 2/19, 2/24, 2/25, 2/27,2/28,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's behaviors were being monitored and documented consistently. This was found to be evident for one (#62) of one resident reviewed for behavioral health care. The findings include: On 7/23/24 at approximately 8:05 AM, Resident #62 was observed lying on the floor near the nursing station. Several residents and staff were in the area at the time of this observation. On 7/23/24 at 11:42 AM, Resident #62 was observed sitting on the floor next to his/her wheelchair in the hallway near the doorway of the resident's room. The resident then proceeded to lie down on the floor. No staff were present at the nursing station or within view of the resident at this time. On 7/23/24 at 11:46 AM, the Director of Nursing (DON) arrived at the unit and acknowledged the resident on the floor. The DON commented that the resident is care planned for this [behavior]. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate 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 the medical record and interview with facility staff, it was determined that the facility failed to implement appropriate interventions for a resident with identified elopement potential on a resident with documented altered mental status. This was identified during the review of 1 of 6 residents (#922) reviewed for elopement. The findings include: Review of the facility reported incident on 7/25/24 reported on 5/2/23 an incident where Resident #922 was found outside the facility by the previous Director of Nursing (DON). According to the report, the resident was not known to the DON, she just found an individual on his/her knees outside the facility when she arrived to work on 5/2/23 at 7:29 AM. The nurse and the DON escorted the individual into the facility for an assessment and determined at that time that s/he was the missing resident identified as Resident #922. Resident #922 identified him/herself and stated that s/he was going home to pay my bills and see my dog. According to the facility investigation's initial and 5-day report, an elopement assessment is…

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

Based on review of medical records and interview, it was determined that the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at the change of shift. This was evident for three out of the three medication carts reviewed for medication storage during the survey. The findings include: On 7/30/24 at 12:50 PM, the surveyor obtained copies of the narcotic shift count sheet from the 400 hall medication cart. A review of this sheet failed to reveal two licensed nurses' signatures on 7/19/24 7 PM shift, 7/23/24 6 AM shift, 7/25/24 11 PM shift, and 7/26/24 from the 7 PM shift change. On 7/30/24 at 12:58 PM, the surveyor obtained copies of the narcotic shift count sheet from the 200 hall medication cart. A review of this sheet failed to reveal two licensed nurses' signatures on 7/27/24 from the 7 AM shift change. On 8/1/24 at 9:34 AM, the surveyor obtained copies of the narcotic shift count sheet from the 500 hall medication cart. A review of this sheet failed to reveal two licensed nurses' signatures on 7/24/24 7 AM, 3 PM, and 5 PM shifts,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacist failed to comprehensively review the medical record and identify medication errors and alert the staff; and and the facility failed to develop policies and procedures for the monthly Medication Regimen Review (MRR) that include time frames for different steps in the process. This was evident for 1 (Resident #911) of 13 residents reviewed for medication concerns. The findings include: 1) Review of the medical record for Resident #911 related to a complaint revealed that on their admission they were inadvertently ordered Lasix incorrectly (a diuretic). On 7/31/24 at 10:13 AM, the facility pharmacist (Staff #13) was interviewed. His process for reviewing medications and audits was reviewed at that time. He stated that he would review discharge summaries of new admits, medications administration records and physician orders. The concern and findings related to Resident #911 was reviewed. Resident #911 was admitted on 80 mg of Lasix 7 days a week. Right away, Staff #13 stated…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure residents received their medications according to the attending physician's orders. This was evident for 2 (#24, #72) out of 6 residents reviewed for unnecessary medications. The findings include: 1) A record review on 7/29/24 at 4:30 PM showed that Resident #24 had been residing in the facility since 2017, with diagnoses that included hypertension. Further review contained an attending provider's order, dated 1/13/2023, for an antihypertensive medication to be administered daily to Resident #24. The order had a parameter to hold (not to give) the medicine for SBP less than 130 mmHg (millimeters of mercury). Blood pressure (BP) is often written as an upper and lower number. Systolic blood pressure (SBP) is the upper number. It measures the pressure in the arteries during heart muscle contraction. A review of Resident #24's medication administration records (MAR)for June 1- July 29, 2024, was completed on 7/29/24 at 6:06 PM. The review showed that Resident #24's antihypertensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review and interviews, it was determined that the facility failed to maintain complete and accurate medical records. This was evident in 1 (Resident #127) of 26 residents reviewed during the survey. The findings include: Resident #127 has been residing in the facility since July of 2022. The resident's record indicated that s/he was hospitalized on [DATE] for hyperglycemia. Hyperglycemia occurs when there's too much sugar (glucose) in your blood. It's also called high blood sugar or high blood glucose. This happens when your body has too little insulin (a hormone) or if your body can't use insulin properly (insulin resistance). On 7/25/24 at 9:32 AM, a review of Resident #127's progress notes revealed the resident's blood sugar (BS) was 600 mg/dl, and the doctor ordered to give 12 units of insulin and recheck the BS after an hour. This was documented by the Licensed Practical Nurse (LPN Staff #2) with an effective date of 7/2/24 at 4:52 PM. On 7/25/24 at 10:17 AM, Resident #127's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, it was determined the facility staff failed to ensure thatthe Infection Preventionist (IP) attended and participated in the facility's quality assessment and assurance (QAA) committee at least quarterly. This was evident during a review of the Quality Assurance Program (QAPI) and has the potential to affect all residents in the facility, The findings include: On 8/5/24, at approximately 3:00 PM, a review of the sign-in sheets for the facility's Quality Assurance (QA) Committee meeting attendance sheets revealed that, from July 2023 through July 2024, there was a QA committee meeting held monthly on 7/20/23, 8/15/23, 9/22/23, 10/2/23, 11/16/23, 12/19/23, 1/18/24, 2/22/24, 3/21/24, 4/11/24, 5/9/24, 6/13/24, and 7/11/24. A review of the attendance sheets revealed that the IP only attended 1 meeting, on 10/2/23, out of the 13 monthly meetings held. There was no evidence to indicate the infection preventionist attended the QA meetings at least quarterly. On 8/5/24 at 3:45 PM, during an interview, the Nursing Home Administrator (NHA) verified 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 interviews, it was determined that the facility failed to ensure that residents were offered the pneumococcal vaccine. This was evident in 1 (Resident #54) out of 5 residents reviewed for immunizations during the survey process. The findings include: Resident #54 has been a resident of the facility since July of 2023. On 8/5/24 at 9:28 AM, Resident #54's electronic health record (EHR) was reviewed and revealed no evidence that the pneumococcal vaccine was offered or administered. On 8/5/24 at 10:09 AM, the Assistant Director of Nursing (ADON) was interviewed about documentation for immunizations. The ADON reported that all vaccines administered in the facility should be documented in the resident's EHR under the immunization tab, and if it was a vaccine that they received outside, then the facility would request a copy of the record to be scanned in the EHR and saved under the miscellaneous tab. The DON further reported that when residents decline a vaccine and/or immunization, the documentation can also be found in the miscellaneous tab under the consent…

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

Based on record review, observation, and staff interview, it was determined that the facility failed to keep residents free of misappropriation of medications. This was evident for 6 (#18, #42, #228, #229, #30, and #129) of 18 residents reviewed. The findings include: 1a. On 7/23/19 at 11:06 AM, a review of the facility's investigation report for the facility reported incident #MD00132061, dated 10/2/18, revealed that the facility identified missing medications when verifications to orders were completed. An audit of all resident's medication profiles was done by administration. The audit found that 5 Residents (#42, 228, 229, 18, and 30) were identified to have had medications that did not have a physician's order in the electronic medical record. However, it was not indicated that these medications were controlled substances and the medications were being signed out as being given to the resident mainly by one nurse, Registered Nurse (RN) #32. During an interview with the Nursing Home Administrator (NHA) on 7/24/19 at 9:50 AM, it was revealed that the NHA had received a report…

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

Based on resident interview, medical and investigation report review, and resident interview it was determined that the facility staff failed to thoroughly investigate 1) an injury of unknown injury and 2) misappropriation of controlled substances. This was evident for 6 of 18 residents reviewed. 1 (#67) of 3 residents reviewed for skin conditions (non-pressure) 5 (#18, #42, #228, #229, and #30) of 18 residents reviewed. The findings include: 1) Review of the facility's incident report on 7/12/19 at 1:50 PM, revealed that, on 7/6/19, a Geriatric Nursing Assistant (GNA) #46 reported to Licensed Practical Nurse (LPN) #24 that she found a bruise on the resident's left upper arm while performing care. On 7/12/19 at 2:02 PM, an interview with LPN #24 revealed that she had reported the incident to her supervisor, Registered Nurse (RN) #45 and the Director of Nursing (DON). An interview with the DON on 7/15/19 at 10:11 AM, revealed that she did not have evidence that she conducted a thorough investigation regarding the cause of the resident's injury. Her conclusion stated that the resident…

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

Based on medical record review and interview with staff, it was determined that the facility staff failed to develop and implement comprehensive person centered care plans including measurable objectives. This was evident for 8 (#10, #70, #68, #181, #23, #11, #62 and #67) of 43 residents reviewed during the investigation phase of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) On 7/11/19 at 11:10 AM, a review of Resident #62's active care plan revealed the following problem dated 6/13/19, [Resident #62] has the potential for mood impairment related to diagnosis of anxiety. The goal documented was [Resident #62's] symptoms of anxiety will be controlled with minimal side effects over the next 90 days. This goal did not provide staff with a minimal and an acceptable level of anxiety for this resident. Therefore, the staff would not be able to determine if the goal has been met. During an interview with Unit Manager #11 on 7/12/19 at 10:18 AM,…

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

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to review and revise the resident's plans of care based on changing goals, preferences and needs and in response to current interventions. This was evident for 1 (#68) of 1 residents reviewed for dementia care, and for 1 (#23) of 5 residents' reviewed for pressure ulcer/injury. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The findings include: 1) Resident #68's medical record was reviewed on 7/16/19 at 8:53 AM. Care plan evaluation notes, dated 7/3/18, 10/3/18, 1/2/19, 4/3/19 and 7/10/19 reflected a brief summary of the resident's status. The note, dated 7/10/19, indicated Requires assist with adls (activities of daily living), no adverse reactions from psychotropic medications, no skin issues, no falls, weight stable, slight decline on intake, no behaviors, mood stable. The notes did not measure Resident #68's progress or lack of progress toward reaching 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to 1) have an effective system in place to ensure the implementation and provision of functional maintenance programs as recommended by the therapists for 2 (#10 and #70) of three residents reviewed for activities of daily living and 2) failed to have a process in place to continue restorative therapy to allow residents to maintain their highest level of functioning and prevent contractures for 2 (#67 and #12) of 2 residents reviewed for rehabilitation and restorative care. The findings include: 1) Review of the medical record revealed that Resident #10 was admitted to the facility in October 2018 with diagnoses which included, but were not limited to, history of fall with hip fracture, dementia, hypertension and cognitive communication deficit. On 7/12/19 at 12:02 PM, the therapy supervisor #17 reported that, if a resident was going to be a long term resident, a functional maintenance program (FMP) is often established. It…

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

Based on observations, record review, and resident and staff interview, it was determined that the facility failed to have sufficient staffing to 1) answer call lights during meals and shower times and 2) provide restorative care for residents to make sure they maintained their highest functional level. This was evident for 5 (#59, 39, 49, 70, and 31) of 5 residents attending Resident council meeting. This was evident for 2 (#67 and #12) of 29 residents reviewed for Rehabilitation and Restorative services. The findings include: 1) On 7/15/19 at 9:34 AM, the Resident Council Meeting minutes for June 2018 - May 2019 were reviewed and revealed that there were some concerns that were continually mentioned. One of the continued concerns listed in the meeting minutes was delay in the call lights being answered. During a Resident Council Meeting held on 7/15/19 at 11:30 AM, which was attended by Resident #59, #39, #49, #70, and #31, they reported the delay in call lights being answered was continuing. They reported that during shower time, because it took two Geriatric Nursing Assistants…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pertinent documentation, observation and interview, it was determined that the facility failed to have a process in place to monitor pharmacy provision of controlled drugs received into the facility and to ensure that each resident receiving a controlled drug had a corresponding physician's order. This was evident for 2 (#MDOO132061 and #MD00134506) of 2 facility reported incidents of misappropriation of medication. The findings include: On 7/23/19 at 11:06 AM, a review of the facility's incident report #MD00132061, dated 10/2/18, revealed that the facility identified missing medications. An audit of all resident's medication profiles conducted by administration revealed that 5 Residents (#42, 228, 229, 18, and 30) were identified to have received medication without a corresponding physician's order. An interview with the Nursing Home Administrator (NHA) on 7/24/19 at 9:50 AM, revealed that the facility's investigation failed to recognize and determine how Controlled Substance Prescription (II - V) (C2) forms were being sent to the pharmacy and filled, without a…

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

Based on medical record review and interview with staff, it was determined the facility failed to ensure each that resident's drug regimen was free from unnecessary drugs by: 1) failing to follow the physician's order for pain management, 2) Administering insulin when none was indicated, 3) Administering a narcotic outside of ordered parameters and 4) failing to identify and eliminate duplicate and conflicting medication orders. This was evident for 3 (#179, #128 and #181) of 5 residents reviewed for unnecessary medications. The findings include: 1) A medical record review, conducted on 7/9/19 at 10:55 AM, revealed a physician's order summary, dated July 2019, that documented an order dated 6/27/19, hydromorphone HCL 2mg tablet oral (by mouth) as needed every 4 hours for pain in right knee and documented in the note section of the order, for moderate to severe pain (4-10). In addition, there was an order dated 6/27/19, Acetaminophen Extra Strength 500 mg give 2 tablets 3 times a day for chronic other pain. Further review of the Medication Administration Record (MAR) for July 2019,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a medication error rate below 5% as evidenced by 2 errors identified out of 29 opportunities for error, resulting in a medication error rate of 6.9 %. The errors were found to be evident for medications administered to two out of the four residents (Resident #35 and #9) observed during medication administration observations. The findings include: 1) On 7/11/19 at 8:11 AM, surveyor observed nurse #25 prepare and administer medications to Resident #35. Surveyor observed the nurse administer bumex 1 mg(milligrams) to the resident. Bumex is a diuretic medication used to treat fluid retention. After the medication observation was completed, review of the medical record revealed an order, written on 7/8/19, for Bumex 0.5 mg to be administered one time daily starting on 7/9/19. Further review of the medical record revealed that nurse #25 had documented that 0.5 mg tablet had been administered on 7/11/19. On 7/11/19 at 11:26 AM, nurse #25 confirmed that she had administered the 1…

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

Based on observation, resident and staff interview, it was determined that the facility failed to provide adequate staff to serve residents in the dining room in a timely manner. This was evident for 2 of 2 observations in the dining room. The findings include: On 7/9/19 at 12:29 PM, an observation was made of lunch being served in the dining room. Lunch time was scheduled for 12:00 PM, however, at 12:30 PM staff had not served all residents in the dining room. Review of Resident Council meeting minutes on 7/15/19 at 9:34 AM, revealed that residents had discussed issues with dining services in June 2018, July 2018, August 2018, September 2018, November 2018, February 2019, and May 2019. The timeliness of staff (Geriatric Nursing Assistance) arriving to serve the food was mentioned often and the staff scheduler was assigned to ensure that staff arrive on time to serve. During a Resident Council meeting on 7/15/19 at 11:30 AM, all the Residents (#59, #39, #49, #70, and #31) in attendance reported that the dining issues continued. According to these residents, the delay in dining…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards. This was evident for 4 (#10, #128, #68 and #181) of 43 residents reviewed during survey investigations. The findings include: 1) Review of Resident #10's medical record revealed that the resident was admitted to the facility in 2018 with diagnoses which included but not limited to dementia, hypertension and cognitive communication deficit. On 7/10/19, review of the medical record revealed the resident had sustained a fall on 7/8/19 resulting in a hematoma [bruise] to the head. Further review of the medical record failed to reveal any documentation that the resident's physician or responsible party had been notified of the fall and injury. Review of the incident report revealed documentation regarding physician notification on 7/8/19 at 10:00 PM by nurse #29 via phone. The section for Resident Representative notification was incomplete with the sections for time and by whom…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reviews of records, current survey findings and the facility's prior annual and complaint surveys, it was determined that the facility failed to have an effective Quality Assessment Performance Improvement program to develop and implement effective plans of action to correct identified quality deficiencies. This was evident during review of the Quality Assurance Program. The findings include: A review of the facility's prior annual and complaint survey results and current survey findings on 7/25/19 at 5:56 AM revealed deficient practices identified during the prior years' annual survey were again evident during the current recertification survey. A review of the Quality Assurance Program with the Administrator and Director of Nursing on 7/25/19 at 10:38 AM revealed that the facility failed to effectively correct deficiencies identified during the annual survey dated 2/5/18. This failure resulted in the recurrence of the same deficient practices. The repeat deficient practices included but were not limited to: reasonable accommodations of needs and preferences…

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

2) On 7/9/19 at 10:05 AM, an observation was made of Resident #179's room. There was a bedside toilet wedged between the resident's bed and the wall on the left side, which was blocking the bedside stand that was sitting behind it. Furthermore, at the time of the observation, the resident was interviewed and when asked about the room and his/her ability to get around, the resident reported that since the bedside toilet was placed there, he/she could not get in the bedside stand drawers without assistance. He/she stated that staff had been made aware of the concern but did not move the bedside commode. During a walk through with the Chief Executive Officer (CEO) and Housekeeping Manager on 7/19/19 at 2:03 PM, the CEO was made aware of and acknowledged the concern. Based on surveyor observation and resident and staff interviews, it was determined the facility staff failed to provide reasonable accommodation of resident needs by 1) failing to ensure that a resident's call bell was within his/her reach and 2) failing to maintain an environment that allowed a resident to have access to…

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

Based on review of facility records and interview with staff it was determined the facility failed to ensure residents were free from abuse. This was evident for 1 (#183) of 3 residents reviewed for Abuse. The findings include: A facility reported abuse allegation was reviewed on 7/10/19 at 1:53 PM. The report indicated that Staff #34 was alleged to have been verbally abusive while providing care to Resident #183. The facility's investigation included statements by the resident and Staff #35 who witnessed the incident. The facility substantiated that the resident was verbally abused by Staff #34 and reported this finding to the state agency in their follow up report. During an interview on 7/12/19 at 2:14 PM, the Administrator confirmed that she was aware and involved in the abuse investigation, and that Staff #34 was terminated as a result of this incident. The facility failed to ensure that the residents remained free from abuse. These concerns were reviewed with the Director of Nursing on 7/25/19 at 12:37 PM. Cross reference F 609.

Based on review of facility reports and medical records and interview with staff and resident's family, it was determined that the facility failed to have an effective system in place to ensure appropriate reporting of abuse and neglect as evidenced by: 1) failure to ensure that a witnessed incident of verbal abuse was reported to the administrator of the facility for 1 (#183) of 3 residents reviewed for Abuse, 2) Failure to report an injury of unknown origin to the appropriate reporting agencies for 1 (#67) of 3 residents reviewed for skin conditions (non-pressure), 3) failure to provide evidence that a report of misappropriation of resident's medications was reported to the appropriate reporting agencies within the required time frame for 1 (#MD00132061) of 2 facility reported incidents reviewed and 4) failure to report the results of an investigation of an elopement to the state survey agency for 1 (#181) of 8 residents reviewed for accidents. The findings include: 1) A facility Reported Incident was reviewed on 7/10/19 at 1:53 PM. The report indicated that Staff #34 was verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with residents and staff, it was determined the facility staff failed to provide written notice to the resident/representative upon transfer to the hospital. This was evident for 2 (#76 and #5) of 4 residents' reviewed for hospitalization. The findings include: During an interview, on 7/8/19 at 2:34 PM, Resident #76 indicated that he/she was hospitalized at the end of May or June. Review of the medical record revealed that Resident #76 was hospitalized [DATE] - 6/20/19. Resident #5's medical record was reviewed on 7/12/19 at 1:47 PM. A nursing progress note, dated 7/8/19 at 11:21 AM, revealed that the resident experienced a decline while at his/her scheduled dialysis appointment and was sent to Meritus Medical Center Emergency Room. He/She was later admitted to the hospital. No documentation was found in Resident #76 nor Resident #5's medical records' indicating they or their representative were provided with the required written notification of transfer to the hospital,…

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

Based on record review and interview with staff, it was determined the facility staff failed to provide written notice of bed hold policy to the resident/representative upon transfer to the hospital. This was evident for 1 (#5) of 4 residents' reviewed for hospitalization. The findings include: Resident #5's medical record was reviewed on 7/12/19 at 1:47 PM. A nursing progress note, dated 7/8/19 at 11:21 AM, revealed that the resident experienced a decline while at his/her scheduled dialysis appointment and was sent to Meritus Medical Center emergency room (ER). He/She was later admitted to the hospital. No documentation was found in Resident #5's medical record indicating that the resident/representative was provided with a notice of the facility's bed hold policy upon his/her transfer. During an interview on 7/12/19, the Director of Nursing indicated that the bed hold policy notice is usually sent with the resident to the hospital, but was not sure when it was sent to Resident #5, since he/she went to the hospital from dialysis. She indicated that she would look into it. As 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, resident interview, and staff interview, it was determined that the facility failed to have a process in place to ensure that residents received a summary of their baseline care plan and a list of their medications within 48 hours of admission. This was evident for 1 (#179) of 18 residents reviewed for care plans. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A base line care plan is developed to care for the immediate needs of the resident until the comprehensive care plan can be developed. A medical record review, on 7/9/19 at 10:55 AM, revealed a Care Transition Readiness Summary, dated 7/1/19, with a corresponding progress note, dated 7/1/19 at 12:30 PM, signed by Unit Manager (UM) #4. The summary documented a care plan meeting with the interdisciplinary team, the resident and spouse. The note did not document whether the care plan and medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident record and interview with the resident and facility staff, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan by failing to recognize and avoid a resident's documented food allergen. This was evident for 1 (#11) of 3 residents reviewed for Nutrition. The findings include: Resident #11's medical record was reviewed on 7/23/19 at 12:28 PM. The Resident Information tab in the EMR (electronic medical record) listed the residents allergy to peanuts and tree nuts. The physicians diet orders, dated 6/30/19 7:42 PM, included ALLERGY:PEANUTS AND TREE NUTS A Nutritional Risk Assessment, dated 7/10/19, included Food Allergies: peanuts and tree nuts. A Nutrition Progress note, dated 7/14/19 8:50 AM indicated that the Dietitian felt the resident's diet did not likely meet his/her nutritional requirements, that she discussed this with the resident. The resident indicated that he/she felt his/her appetite was improving and desired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff, it was determined that the facility failed to ensure resident received interventions to prevent the development of pressure ulcers. This was evident for 1 (#47) of 5 residents reviewed for pressure ulcers. The findings include: On [DATE], review of Resident #47's medical record revealed that the resident had resided at the facility for several years and whose diagnoses included, but were not limited to, heart disease, dementia, diabetes and contracture of one leg. The resident is dependent on staff for bed mobility and transfers. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Review of the Minimum Data Set assessment with an assessment reference date of [DATE] revealed that Resident # 47 did not have any pressure ulcers at that time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the medical record and interviews with staff, it was determined the facility staff failed to implement measures to ensure the resident received the required number of calories and total fluid volume per the dietitian recommendation. This was evident for 1 (#181) of 3 residents reviewed for nutrition. The findings include: Resident #181 was observed on 7/18/19 at 6:49 AM lying in bed. He/She had a G-Tube (a gastric tube inserted through the abdominal wall into the stomach to provide nutrition). A feeding pump was at the resident's bedside. A 1000 ml bottle of Glucerna 1.5 cal with carbsteady (a nutritional formula) and a bag of water were connected via tubing to Resident #181's feeding tube. The tubing was running through the feeding pump. The pump was beeping at that time and displayed flow error clog in line downstream of pump. The Glucerna bottle was labeled: 7/17, Start 2000, 85ml/hr. (milliliters per hour) approximately 625 ml was remaining in the bottle. The nurse, Staff #26, entered the room and attended to the pump. The display on the pump…

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

Based on medical record review and interview with staff, it was determined that the facility 1) failed to ensure that pharmacy reviews were addressed by attending physicians in a timely manner, 2)failed to ensure that recommendations were made for the correct resident and 3) the facility's clinical pharmacist failed to identify the facility's failure to address a GDR (gradual dose reduction) for a resident receiving psychotropic medications. This was evident for 3 (#31, #128, and #68) of 5 residents reviewed for unnecessary medications. The findings include: 1) On 7/15/19, review of Resident #31's medical record revealed that the resident had resided at the facility for more than one year and whose diagnoses included, but were not limited to, diabetes and high blood pressure. Documentation was found that indicated the pharmacist was completing monthly medication regimine reviews and identified irregularities in December 2018; February 2019; March 2019 and April 2019. When irregularities are identified, a Consultation Report is generated. Review of the Consultation Reports 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 review of the medical record and interview with staff, it was determined that the facility staff failed to ensure that a resident who used psychotropic drugs received a gradual dose reduction unless clinically contraindicated, and documented as per standards of practice, in an effort to discontinue these drugs. This was evident for 1 (#68) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds, and Med Regimen Review. The findings include: Review of Resident #68's medical record, on 7/16/19 at 8:53 AM, revealed diagnoses which included but were not limited to Alzheimer's Disease and Non-Alzheimer's Dementia, Anxiety Disorder and Depression. Current physicians orders included, but were not limited to, Quetiapine (Seroquel) (an antipsychotic medication)50 mg (milligram) tablet 2 times daily, Quetiapine 100 mg tablet (HS) hour of sleep; Related diagnoses listed for both orders was major depressive disorder, recurrent severe with psychotic symptoms, Dementia in other diseases classified elsewhere with behavioral disturbance; and Trazodone (an antidepressant medication)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pertinent documentation, observation and interview, it was determined that the facility administration failed to 1) address the need for upgraded doors to assist in the prevention of resident elopements for 7 out of 9 exits accessible to residents, 2) keep residents free of misappropriation of controlled drugs for 6 (#42, #228, #229, #18, #129, and #30) of 6 Resident identified in the facility's investigation reports and 3) provide dining services in a timely manner. This was evident for 7 months of Resident Council Meeting Minutes out of 12 months reviewed. The findings include: 1) Review of the facility assessment revealed under Maintenance that the Door Alarms were not sufficient and that they were acquiring quotes for enhancement. The facility did provide evidence of a quote for a new wander management system, dated 1/21/19, but no documentation was provided that a new system had been approved or was being implemented. On 7/16/19, while discussing an elopement that occurred in February 2019, the Director of Nursing reporting that the facility was looking into…

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