Hagerstown Healthcare Center

Based on interviews and record review, it was determined that the facility failed to accurately reflect a resident's discharge plan on their individualized care plan. This was evident for one (Resident #32) of three residents reviewed for discharge planning.The findings include: Based on interviews and record review, it was determined that the facility failed to accurately reflect a resident's discharge plan on their individualized care plan. This was evident for one resident (Resident #32) of three residents reviewed for discharge planning. The findings include: Resident #32 has medical diagnoses of Cerebral Palsy, a neurological disorder that affects movement, posture, and muscle tone due to permanent brain damage occurring during fetal development or infancy, and Fragile X Chromosome, which prevents the production of a protein crucial for brain development. This can lead to a range of intellectual, developmental, and behavioral problems, including learning disabilities, speech difficulties, and autistic-like behaviors. A care plan is a personalized document that outlines a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined that the facility failed to ensure interdisciplinary care plan meetings were conducted following the completion of Minimum Data Set (MDS) assessments. This was evident for 3 ( Resident #11, #5, and #10) out of 41 Residents reviewed during the recertification survey.The findings include:A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. It must be developed within 7 days of completion of a resident's comprehensive Minimum Data Set (MDS) assessment. It must be reviewed and revised by the interdisciplinary team (IDT), including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable) after each assessment, including both the comprehensive and quarterly review assessments.The Minimum Data Set (MDS) assessment is a federally mandated assessment tool that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 1 (#10) out of 2 residents reviewed for activities.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. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care.During an initial tour of the first-floor unit on 11/20/2025 at 10:30 AM, Resident #10 was observed lying in bed and not involved in any activity.A record review on 11/25/2025 at 7:22 AM included a hospital discharge summary that recorded that Resident #10's diagnoses included Altered mental status with underlying Dementia.Further review of Resident #10's MDS assessment dated…

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

Based on record review, observations, and interviews, it was determined that the facility failed to provide an assistive device to residents during smoking breaks to prevent accidents. This was evident for one Resident (Resident #40), who was reviewed for accidents.The findings include:A review of a smoker log report provided by the director of nursing (DON) showed that Resident #40 was a smoker and required an apron and staff supervision while s/he smoked.A continued review of a smoking assessment completed on 11/6/25 and provided to the surveyor by DON for Resident #40 showed that the Resident needed an apron and staff supervision during his/her smoking times.On 11/19/2025 at 1:01 PM, during the facility's scheduled smoke break, Resident #40 was with other residents outside the building at the facility's designated smoking area, with staff #3, an activities assistant, in attendance. Resident #40 was observed smoking without an apron. The Resident was asked where his/her apron was and reported that no one had ever offered him/her an apron. Staff #3 was asked about Resident #40'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 staff record review and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) was provided education based on issues identified during the employee's annual performance evaluation. This was evident for one staff member (Staff #8) out of six employees reviewed for sufficient and competent staffing.The findings include:Long-term care facilities are required to provide nurse aide (NA) in-services and education that address areas of weakness identified in the NA's performance reviews.On 11/19/25 at 4:25 PM, the surveyor reviewed employee performance evaluation records, which indicated that Staff #8, a GNA in the facility, had received a verbal warning. The evaluation did not include any details regarding the reason for the warning.On 11/24/25 at 1:45 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA), who stated that she was unsure of the reason for Staff #8's corrective action because she is new to the facility, but that she would look into it. The surveyor asked the NHA to identify the reason…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the residents' Matrix accurately. This was evident during the recertification survey. The findings include:The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. The facility completes the resident name, resident room number, and corresponding care categories. All information entered on the form should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of the survey.After the initial entry to the facility for this survey on 11/19/25, the director of nursing (DON) presented a completed matrix dated 11/19/25 at 10.01 AM to the survey team for all residents.A review of the Matrix showed that Residents #35, #57, and #76 received parental feedings (a method of providing nutrients directly into a person's bloodstream through an intravenous (IV) catheter when they cannot eat or receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to 1) follow physician orders and 2) implement resident's non-pharmacological interventions prior to administration of pain medication and identify individualized non-pharmacological interventions for behaviors. This was evident for 2 (#1 and #3) of 3 residents reviewed during the survey.The findings include:1) Low Blood Pressure (hypotension) occurs when the blood pressure is less than 90/60 Hg and can be caused by dehydration, certain medications and underlying health conditions such as heart disease, diabetes, thyroid problems, or severe infection (sepsis). On 10/21/24 at 9:23 AM, a review of complaint #2641697 alleged the facility did not provide Resident #3 with adequate care prior to sending the resident out for an appointment with a vascular (vein) specialist on 10/8/25. The complaint alleged when Resident #3 arrived for his/her vascular appointment on 10/8/25, the resident was lethargic, there was blood in his/her urinary drainage bag, and his/her blood pressure was 80/44. The complaint…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records by failing to ensure a resident had only one unvoided MOLST in the medical record. This was evident for 1 (#3) of 4 residents reviewed during a complaint survey.The findings include: Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. Per the MOLST instructions: Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form. Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations, the facility failed to maintain an environment free from Resident-to-Resident sexual abuse. Specifically, Resident #34 (R#34) made unwanted sexual contact with Resident #13 (R#13) one time. The facility census was 111 and the sample size was 34.The findings include:During an observation on 7/17/25 at 11:00 a.m., R#13 entered the room while this surveyor was speaking to his/her roommate. He/she was pleasant and engaging, sharing how R#13 and his/her roommate were close friends and always look out for one another. R#13 was clean and well-groomed without signs of distress. During an observation on 7/18/25 at 9:00 a.m., R#13 had no notable adverse reactions or concerns when asked about the incident with R#34, and he/she agreed to speak about the incident without hesitation. Review of the facility's policy titled, Maryland Abuse, Neglect, and Misappropriation, and dated 10/01/2024 revealed, Scope: This policy is applicable to all adult living centers in 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 medical records review and staff interview, it was determined that the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 4 (Resident #86, #50, #83, #26) of 4 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. 1) On 12/4/23 at 2:02 PM, a review of Resident #86's electronic medical record (EMR) and paper medical record failed to reveal evidence that Resident #86 had an advanced directive in place and no documentation was found to indicate that Resident #86 had been informed of his/her right to formulate an advanced directive, or that the facility periodically reviewed with the resident and/or the resident representative regarding treatment, experimental research and any advance directive and its provisions, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records review, and interviews, it was determined that the facility failed to have a process in place for staff to install and maintain bed rails in a safe manner for their residents. This was evident for 3 (Resident #69, #42, and #58) of 5 residents reviewed for use of bed rails. The findings include: 1) An observation of Resident #69 on 12/04/23 at 9:41 AM, revealed the resident had ½ bed rails centered on both sides of the bed and were in the up position. A medical record review for Resident #69 on 12/13/23 at 2:52 PM revealed a minimum data set (MDS), with an assessment reference date of 11/4/23, that documented in section C that the resident's cognitive skill for daily decision making was severely impaired. In section I, it was documented that the resident had suffered from a neurological disorder, dementia, and contractures in the left and right wrist. A review of the bed rail assessments for the resident, dated 2/11/23, 5/10/23, 7/10/23, and 10/13/23, revealed that staff had 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 interviews of the facility staff and observations, it was determined that the facility failed to provide frequently scheduled consultations between a qualified dietitian and the facilities food service director for oversight of food preparation and daily kitchen operation. This has the potential to affect all residents. The findings include: On 12/5/23 at 8:46 AM, the Food Services Director (FSD) Staff #48 was interviewed. During the interview, he reported he had been in his position since January 2023. He reported that he had a ServSafe (Trademark) certification but was not a certified dietary manger (CDM) nor enrolled in a CDM course. The FSD reported he had a 2-year associate degree in the culinary arts, and he had previous employment as a chef but had no prior experience in healthcare. On 12/05/23 at 11:32 AM, a second interview was conducted with the FSD. He reported he had not had any contact with the two dieticians that provided the facility with dietician services in September through December 5th, 2023. He reported his last consultation with a dietician was in…

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

Based on observations, record review, and staff interviews, it was determined that facility staff failed to ensure that residents were able to make choices about their daily schedules. This was evident for 1 (Resident #19) of 4 residents reviewed for choices. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 12/4/23 at 10:33 PM, an observation of Resident #19 revealed the resident was in bed and had not been bathed or dressed for the day. There was a sign posted next to the light switch in the resident's room that read the resident had a preferred time to be out of bed in the morning. An interview with Resident #19 at the time of the observation on 12/4/23 at 10:33 PM revealed that s/he 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 interview, it was determined that the facility failed to have an effective system in place to ensure that maintenance concerns were reported and addressed. This was found to be evident for rooms on 2 out of the 2 units in the facility. The findings include: During the initial information collecting portion of the survey, the following observations were documented by surveyors: On 12/4/23 at 11:21 AM in room [ROOM NUMBER], the bottom of the door frames for the 2 interior doors in the bathroom were noted to appear rusted from the floor to approximately 4-5 inches from the floor. On 12/4/23 at 10:17 AM in room [ROOM NUMBER], there was a 1 inch gap where the piping under the bathroom sink goes into the wall. On 12/4/23 at 2:30 PM, in room [ROOM NUMBER]'s bathroom, a gash in the wall was observed, approximately 6 inches x 1 inch. On 12/05/23 at 11:46 AM, in room [ROOM NUMBER]'s bathroom, a hole in the wall to the right of the toilet with pipe poking thru the wall. On 12/19/23 at 10:20 AM, 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 medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure grievances regarding allegations of abuse were immediately reported to the administrator; and failed to ensure documentation of summary of investigation or follow up with the complainant. This was found to be evident for 2 (Resident #87 and #61) out of 37 residents reviewed for abuse during the survey. The findings include: 1) Review of Resident #87's medical record revealed the resident was admitted in 2022. Review of a Concern Form, dated 10/5/23, revealed the resident reported missing money from his/her wallet that was kept in the resident's drawer. Review of the facility's form used for grievances revealed they were titled Concern Form and included an area on the top half of the form to document: date, name of resident, room number, name of family member, relationship to resident, person presenting the concern (a check off for: resident, family or other), and description of concern(with lines for text to be added). The bottom portion of 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 reviews and interviews, it was determined that the facility failed to protect a resident from abuse. This was evident for 1 (Resident #11) of 37 residents reviewed for abuse. The findings include: Resident #11 had been residing in the facility for more than a year. On 12/4/23 at 1:11 PM, Resident #11 was interviewed and reported that one geriatric nursing assistant (GNA staff #50) was mouthy and refused to change him/her. Resident #11 stated she looked in here and made an issue that she wouldn't change me, and she didn't. This was last Friday. Another girl came in and changed me. On 12/4/23 at 3:14 PM, the nursing home Administrator (NHA staff #1) reported to the surveyors that it was brought to his attention that there was an allegation of an employee to resident abuse and that a facility reported incident (FRI) has been initiated and the involved GNA was suspended pending investigation. On 12/11/23 at 10:21 AM, Resident #11's medical records were reviewed and revealed that the resident was cognitively intact, always incontinent for bowel and bladder, and required 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 other pertinent documentation and interviews, it was determined that the facility failed to ensure allegations of abuse were reported in a timely manner. This was found to be evident for 3 (Resident #31, #61, #86) of 37 residents reviewed for abuse during the survey. The findings include: 1) Resident #31 has been residing in the facility since 2021. On 12/15/23 at 9:12 AM, a facility reported incident (FRI) related to MD00190005 for misappropriation of resident property was reviewed and revealed that it was reported by Resident #31 him/herself on 3/1/23 using the facility's Concern Form. Based on this form, it was documented that the Nursing Home Administrator (NHA), Director of Nursing (DON), and Social Services (SS) were notified on the same day. The email confirmation sent by the NHA dates the initial report as being sent on 3/7/23 at 2:47 PM. On 12/18/23 at 3:41 PM, the current NHA (staff #8) was interviewed about his process when there was an allegation of misappropriation of resident property. Staff #8 indicated that he would report the…

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

Based on records review and interviews, it was determined that the facility failed to conduct a thorough investigation regarding a misappropriation of property allegation. This was evident in 1 (Resident #31) of 37 residents reviewed for abuse. The findings include: On 12/15/23 at 9:12 AM, a facility reported incident (FRI) related to MD00190005 was reviewed and revealed that an allegation of misappropriated property was reported by Resident #31 using the facility's Concern Form on 3/1/23. According to the Concern Form, the Nursing home Administrator (NHA), Director of Nursing (DON), and Social Services (SS) were all notified on the same day. On 12/15/23 at 9:21 AM, further review of the FRI revealed an interview conducted by the NHA (staff #8) with Resident #31 on 3/3/23. No other interviews were found regarding this allegation of missing property. On 12/18/23 at 12:30 PM, the Social Services Director (SSD staff #16) was interviewed about her process when she received a report about misappropriation of property or abuse. The SSD reported that she would notify the NHA and local…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, observations, and interviews, it was determined that the facility staff failed to document the residents Minimum Data Set (MDS) assessments accurately. this was evident for 3 (Resident #69, #81, #86) of 64 residents investigated during this survey process. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities (NFs) be given a preliminary assessment to determine whether they might have serious mental illness and/or intellectual disability. This is called a Level…

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

Based on record review and interviews, it was determined that the facility failed to ensure that a discharge summary was completed for all discharged residents within a reasonable time frame. This was evident for 2 residents (Resident #110, Resident #111) out of 3 residents reviewed for closed record review during a survey. The findings include: 1) On 12/07/23 at 10:45 AM, a review of Resident #110's medical record revealed s/he was a resident at the facility that received hospice care. Review of a social service note, dated 10/19/23, revealed that Resident #110 was transferred to the hospital and was then discharged from the emergency room to his/her home. On 12/11/23 at 12:28 PM, review of resident's progress notes from 10/10/23 through 11/30/23, around the time of his/her transfer to the hospital, failed to reveal a discharge summary for Resident #110. 0n 12/11/23 at 12:12 PM, during an interview with the Director of Nursing (DON) and the Corporate Clinical Nurse (CCN staff #33), both the CCN and DON confirmed that the expectation was that residents transferred 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, it was determined that staff failed to ensure that residents were given assistance with activities of daily living (ADL which include but are not limited to showering, bathing, personal hygiene, dressing, and toileting) as needed. This was evident for 1 (#99) of 3 residents reviewed for ADL care. The findings include: An interview was conducted with a complainant on 12/5/23 at 1:22 PM regarding Resident #99's care. They revealed that, when they had visited the resident on several occasions at the beginning of the resident's admission to the facility, the resident appeared unkempt and had an odor. The complainant reported that she would take the resident home a couple times a week to allow the resident to get a shower and shave. She reported the resident was able to shower, dress, and shave independently, but needed a reminder to do so and determine which clothes were clean. The family member reported that the facility staff had hung a sign in the resident's room reminding him/her to take a shower, however, the resident still needed someone 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 observation, record review, and staff interviews, it was determined that the facility failed to develop and implement an activities program to meet the needs of their residents. This was evident for 1 (Resident #42) of 6 residents reviewed for activity programs. The findings include: Multiple observations of Resident #42 failed to reveal the resident involved in meaningful activities on 12/03/23 at 10:08 AM, 12/04/23 at 10:04 AM, 12/04/23 at 2:19 PM, 12/5/23 at 10:06 AM, 12/14/23 at 10:00 AM, 12/14/23 at 3:01 PM, 12/15/23 at 7:38 AM, and 12/20/23 at 10:48 AM. A medical record review for Resident #42 on 12/13/23 at 3:16 PM revealed an minimum data set (MDS) with an assessment reference date of 11/8/23, that documented in section C that the resident's cognitive ability to make daily decisions was severely impaired. In section I staff documented that the resident had a history of a stroke, was unable to speak, and had dementia. A review of the resident's activity care plan revealed a focus that was initiated on 11/9/22, that read the resident attended activities of interest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interviews it was determined that facility staff failed to follow an order for enhanced barrier precautions. This was evident for 1 (Resident #18) out of 1 resident reviewed for urinary catheter and urinary tract infection during the survey. The findings include: Resident #18 is a long-term resident at the facility. On 12/19/23, a review of Resident #18's progress notes, nurses note, dated 11/15/2, revealed that the resident was re-admitted to the facility from the hospital with a urinary catheter in place. On 12/4/23 at 9:00 AM, an observation was made of Resident #18's room. Observation of the resident's door revealed a sign that indicated enhanced barrier precautions. Further review of the sign revealed instructions that everyone must wear gloves and a gown for certain high contact activities, including urinary catheter care. Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce…

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

Based on record review, observations, and interviews, it was determined that the facility failed to implement the physical therapist's therapeutic recommendations to prevent the worsening of contractures. This was evident for 1 (Resident #103) out of 3 residents reviewed for position and mobility during a survey. The findings include: On 12/12/23, review of residents medical records revealed that Resident #103 was admitted for rehabilitation following a hospital stay and then transitioned to long term care. While at the facility, the resident received occupational therapy services. On 12/12/23 at 2:55 PM, a review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/16/23 section GG0100 revealed that Resident #103 was totally dependent on the assistance of staff for all his/her activities of daily living. Further review of MDS section GG0115 revealed resident had functional limitations in the upper extremities. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that pain management was provided to the resident that is consistent with professional standards of practice. This was evident for 1 (Resident #31) of 2 residents reviewed for pain management. The findings include: Resident #31 has been residing in the facility for several years. On 12/4/23 at 8:55 AM, a review of the resident's medical records indicated that Resident #31 had a diagnosis of chronic pain and was seen regularly by a pain management provider. On the same day at 11:16 AM, Resident #31 was interviewed. When Resident #31 was asked about how the facility manages his/her pain, Resident #31 stated, They give me opiates and it's not enough. Opioids - Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. Opioid is the proper term, but opioid drugs may also be called opiates, painkillers, or narcotics. On 12/6/23 at 12:36 PM, Resident #31's 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 records review, interviews, and observations, it was determined that the facility failed to provide a resident with dementia purposeful and meaningful activities to maintain his/her highest practicable physical, mental, and psychosocial well-being. This was evident in 1 (Resident #7) of 2 residents reviewed for dementia care. The findings include: Resident #7 was admitted to the facility in 2023 with a diagnosis of dementia. On 12/6/23 at 2:34 PM, Resident #7 was observed sitting in a wheelchair outside his/her room with no activity being provided. On 12/6/23 at 3:14 PM, Resident #7's record was reviewed and revealed no care plan for activities, and the dementia care plan indicated that the resident was at risk for impaired psychosocial well being related to personal health practices, beliefs/values, cultural needs/preferences, and/or linguistic needs/preferences. But review of the admission Initial Evaluation, dated 8/8/23, revealed that the resident does not have any cultural, spiritual, religious, or ethnic beliefs and/or values that could impact treatment and this…

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

Based on medical records review and staff interviews, it was determined the pharmacist failed to identify a medication order discrepancy during a monthly pharmacy medication review. This was evident for 1 (#86) of 5 residents reviewed for unnecessary medications. The findings include: On 12/6/23 at 12:13 PM, a review of Resident #86's medical record was conducted. Review of Resident #86's December 2023 Medication Administration Record (MAR) revealed a 7/10/23 order for Lorazepam Injection Solution Inject 1 milligram (MG) intramuscularly (IM) as needed (PRN) once a day for seizures. The as needed order for Lorazepam was not limited to 14 days and the order did not have a discontinuation date. Review of the medical record failed to reveal physician documented rationale for continuing the order beyond 14 days. On 12/7/23 at 1:00 PM, a review of Resident #86's monthly medication regimen review (MRR) in the electronic medical record (EMR) failed to reveal evidence that the consultant pharmacist identified the irregularity with the as needed Lorazepam order during monthly MRR on 7/24/23,…

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

Based on pertinent document review and interviews, it was determined that the facility failed to administer medication according to a physician's orders.This was evident for 1 (Resident #37) out of 4 residents reviewed for unnecessary medications during the survey. The findings include: Resident #37 was a long-term resident of the facility. On 12/14/23, the pharmacy recommendation reviews for Resident #37 were reviewed. Review of these documents revealed that Consultant Pharmacist (Staff #36) recommended that, prior to the administration of the medication epoetin, the resident's hemoglobin blood values should have been checked. If the resident's hemoglobin levels were greater that 10g/dl, the resident should not have received the medication. Further review revealed the rationale of the recommendation indicated that the administration of the medication, Epoetin, to a resident that had a hemoglobin value greater than 10g/dl may increase the risk of cardiovascular events and strokes according to clinical studies. Hemoglobin (Hb or Hgb) is a protein in red blood cells that carries…

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

Based on medical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication and failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#86) of 5 residents reviewed for unnecessary medications. The findings include: As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order On 12/6/23 at 12:13 PM, a review of Resident #86's medical record was conducted. Review of Resident #86's December 2023 Medication Administration Record (MAR) revealed a 7/10/23 order for Lorazepam Injection Solution Inject 1 milligram (MG) intramuscularly (IM) as needed (PRN) once a day for seizures. The as needed order for Lorazepam was not limited to 14 days and the order…

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

Based on observation, record review, and interview, it was determined that facility staff failed to have a medication administration error of less than 5%. This was evident for 1 of 3 staff observed for medication administration. The findings include: An observation of Licensed Practical Nurse (LPN Staff #54) during his preparation and administration of Resident #21's medications on 12/7/23 at 7:57 AM revealed Staff #54 prepared and administered Calcium 600 + D5 micrograms (mcg) (calcium and vitamin D supplement) and while preparing a laxative powder (for bowel stimulation) he prepared and administered 30 milliliters (mL) in approximately 60 mLs of water and approximately 60 mLs of Ensure (a protein based dietary supplement). During the observation, Staff #54 reported that the resident was supposed to have prantoprozole 40 mg in the morning, but was out of the medication. A medical record review for Resident #21 on 12/11/23 at 11:36 AM revealed an order for Calcium 500 + D3 500/400 mg, which was not the formula administered. An order for laxative powder read [laxative powder] 17…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 family interview, observation, record review, and staff interview, it was determined that facility staff were disposing of medications in an open trash can on the medication cart. This was evident for 1 of 1 medication disposed of during an observation of medication administration. The findings include: An interview with a resident's family member on 12/5/23 at 1:22 PM revealed that she had observed staff throwing unused medications in the open trash bin on the side of the medication cart and had observed an unattended medication cart trash bin to have a medication cup with 2 white pills in it. While observing Licensed Practical Nurse (LPN Staff #54) during his preparation and administration of Resident #21's medications on 12/7/23 at 7:57 AM, Staff #54 was observed discarding a medication that he had pulled accidentally directly into the open trash bin on the side of the medication cart. An interview with Staff #54 on 12/14/2/3 at 10:13 AM, revealed he was aware that medications had to be stored in a locked location, however, he was not aware of the facility policy for…

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

Based on interviews, pertinent documentation, and observation it was determined that the facility failed to develop menus that take into consideration the resident's food preferences. This deficient practice has the potential to affect all residents. The findings include: On 12/3/23 through 12/5/23, residents in the facility were interviewed. 13 out of 26 residents interviewed voiced some concerns regarding the food served at the facility. The residents' concerns included but were not limited to the following: Residents #95, #313, #31, #29, #66, #26, #11 and # 19 reported they were not satisfied with the food choices offered by the facility. On 12/05/23 at 8:46 AM, the Food Service Director (FSD) staff #48 was interviewed. During the interview he reported that he received the menu for the facility from the facility's parent company (Staff #61) and he received consultations regarding the menu from a separate healthcare consulting company (Staff #62). The FSD continued that he had the ability to make slight alterations to the menu but has not made any, since he was employed by the…

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

Based on observations, interviews, and pertinent documentation reviews, it was determined that the facility failed to practice proper hygiene, properly store food, monitor food and refrigerator temperatures, and maintain clean sanitary equipment to prevent foodborne illness. This was evident for 1 kitchen during the survey. This deficient practice has the potential to affect all the residents in the facility. 1) On 12/3/23 at 9:23 AM, an observation of the kitchen was made. The observation revealed a Dietary Aide (Staff #59) walking in the kitchen without a hairnet. On 12/3/23 at 9:28 AM, during an interview with Staff #59, he reported that he did not need to wear a hair net when washing the dishes. On 12/5/23 at 8:46 AM, the Food Service Director (FSD) Staff #48 was interviewed. He reported that his expectation is that all dietary aides wear hairnets 100 percent of the time while working in the kitchen. 2) On 12/3/23 at 9:26 AM, an observation of the kitchen's walk-in refrigerator was made with the [NAME] (Staff #42) accompanying the surveyor. The observation revealed a deep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a complete resident medical record. This was evident for 2 (Resident #50, #31) of 64 residents investigated during the survey. The findings include: 1) On 12/05/23 at 11:14 AM, Resident #50 was observed wearing oxygen (O2) nasal cannula (n/c) tubing that was attached to an oxygen concentrator set at 3 L (liters). On 12/15/23 at 9:58 AM, a review of the resident's medical record revealed Resident #50 was initially admitted to the facility in March 2023, with diagnoses that included COPD (chronic obstructive pulmonary disease), respiratory failure and the resident was dependent on supplemental oxygen. The medical record documented that Resident #50 had a change in condition on 12/6/23, was transferred to the hospital, then readmitted to the facility on [DATE] with diagnoses that included COPD, respiratory failure, and Respiratory Syncytial Virus (RSV). On 12/14/23 at 10:30 PM, in a nurse's note, the nurse documented…

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

Based on observation and interview, it was determined that the facility failed to ensure that staff sanitized their hands prior to the start of administering medications; and failed to keep a barrier in place between clean and dirty laundry. This was found to be evident during 1 out of 3 medication observations and 1 out of 1 observation of the laundry room. The finding include: 1) During an observation of Licensed Practical Nurse (LPN) Staff #54 administering medications to Resident #21 on 12/7/23 at 7:49 AM, it was observed that Staff #54 failed to sanitize his hands prior to the start of administering medications. At one point, he had to go to another medication cart and to a medication room to look for medication he did not have in his cart and when he returned to the medication cart to continue to pull the medications, he failed to sanitize his hands. Upon entry into the resident's room, he failed to sanitize his hands and after he had administered the medications to the resident, he failed to sanitize his hands before leaving the room. He moved the medication cart down the…

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

Based on observation, record review, and staff interview, it was determined that the facility failed to have a preventative maintenance program to ensure that bed rails remained properly attached to the bed to ensure resident safety. This was evident for 3 (#81, #69, and #42) of 5 residents reviewed for bed rails. 1The findings include: 1) An observation of Resident #81's bed on 12/4/23 at 10:27 AM revealed the right bed rail was loose. A subsequent observation was made of Resident #81's bed with the Maintenance Supervisor present on 12/15/23 at 8:53 AM and he confirmed that the right bed rail was loose as well as the left side. When asked if he thought that an annual check was enough to properly maintain the bed rails for safety, he stated that they should be checked more frequently and based on how much the resident uses them. However, he failed to mention that they should be maintained according to the manufacturer's recommendations. A review of the data for annual maintenance on 12/15/23 at 8:30 AM revealed that the last time the resident's bed had been checked was on 6/14/23.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined the facility 1) failed to ensure resident care plans were reviewed and revised by the interdisciplinary team after each assessment, and 2) failed to ensure that a resident and resident representative, if applicable, had the opportunity to participate in the development, review, and revision of the resident's care plan after each assessment. This was evident for 4 (#84, #81, #83, #26) of 5 residents reviewed for care plan timing and revision. 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 resident's care plan must be reviewed by the interdisciplinary team (IDT) after each assessment, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview and medical record review, it was determined that the facility failed to include the resident/representative in the development and implementation of the resident's person-centered care plan by failing to have a care plan meeting to review the updated care plan. This was evident for 2 (#42, #199) of 6 residents reviewed for care plans and 1 (#70) of 1 reviewed for hospice care. The findings include: 1) Resident #70's medical record was reviewed on 3/25/19 at 1:29 PM. The record revealed that a 15 page care plan had been developed to address resident #70's needs. On 3/26/19 at 1:51 PM, the surveyor conducted an interview with Staff #31 regarding the coordination of Resident #70's Hospice care. Staff #31 indicated that the facility had not held a care plan meeting since the resident's admission in the middle of February 2019. He/She added we're aware that the care plans haven't been done. When asked why they have not been done, Staff #31 replied it's just something we are trying to get done. He/She was unsure of how far behind the facility's 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 complaint allegations, resident and family interviews, observations and review of facility documents, it was determined that the facility failed to maintain sufficient staff to provide care to residents to maintain the highest practical physical, mental, and psychosocial well-being of each resident as evidenced by residents failing to receive sufficient help with activities of daily living (ADL) This was evident on 2 of 2 nursing units. The findings include. 1.) Review of the Resident Census and Conditions CMS 672 form that was completed by the Director of Nursing at the beginning of the survey indicated that 112 of the 118 residents in the building were either totally dependent on staff for bathing or required assist of 1 or 2 staff members. 115 of the residents were either totally dependent on staff or required the assist from one or two staff for dressing. There were 91 residents documented with occasional or frequently incontinent of the bladder, and 73 residents with occasional or frequent incontinent of bowel. 91 residents were on a urinary toilet program. Review of…

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

Based on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensured sanitary food service operations and failed to utilize appropriate hair restraints for employees preparing meals for residents. This was identified during multiple observations of the facility's kitchen and food services operation. The findings include. Observation of the food service operation in the kitchen on 3/25/2019 at 12:15 PM, revealed that a dietary employee (staff #43) with a goatee was working the tray line without a hair restraint covering beard/goatee. The certified dietary manager (CDM) staff #4 was in the kitchen during the meal service operation. The CDM also had exposed facial hair and was asked if the facility had hair/beard restraints/shields? Staff #43 was observed preparing meal plates to all the residents in the dining room without a beard restraint/protector at 12:30 PM. The person-in-charge failed to ensure that effective hair restraints were utilized to keep hair from contacting food 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 review of facility records and interview with staff, it was determined that the facility failed to document a facility-wide assessment that included staff competencies that were necessary to provide the level and types of care needed for the resident population. This was evident during sufficient staffing review. The findings include: During an interview on 4/5/19 at 2:40 PM, the facility's Acting Administrator (staff #1) indicated that he/she did not have access to Relias (a program used to provide staff training). The Facility Assessment was reviewed on 4/5/19 at 4:10 PM and revealed that the section related to staff competencies for meeting the needs of each resident was blank. The Acting Administrator confirmed this finding and stated, all we have to do is pull it up in Relias. He/She was asked to provide the surveyor with the staff competency information, however it was not provided.

Based on review of the facility's last recertification and complaint surveys, deficient practices identified during the current survey and interview with facility staff, it was determined that the facility was noted to have an ineffective Quality Assurance and Performance Improvement (QAPI) program by failing to monitor measures that were developed to correct deficient practices. This was evident during Quality Assurance review. The findings include: A MOLST(Maryland Orders for Life Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. It includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. The medical record of Resident #327, a hospice patient, was reviewed on 4/3/2019 at 11:25 AM. The record revealed that the facility failed to ensure that a clear and accurate MOLST form was present in the medical record that reflected the Resident's wishes for life sustaining treatment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, it was determined that the facility staff failed to maintain an effective infection control program by failing to ensure that resident care equipment and supplies were maintained in a in a manner to minimize the resident's exposure to infectious organisms. This was evident for 5 (#122, #29, 84, #96, #4) of 34 residents on both floors of the facility observed during the initial pool selection. These practices have the potential to affect all residents, staff, visitors, and volunteers in the facility. The findings include: 1.) Resident #122 was observed on 3/20/19 at 10:19 AM sitting in a wheelchair at his/her bedside. A urinary catheter drainage bag was lying directly on the floor beneath the resident's wheelchair. 2.) The surveyor observed Resident #29's bathroom on 3/20/19 at 10:52 AM. A pink fracture bed pan (a wedge shaped bed pan) and an open package of depends undergarments were lying directly on the floor to the right of the toilet. Neither were stored in a manner to minimize…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff and resident interview, it was determined that the facility failed to maintain an effective pest control program. This was evident for 2 of 2 nursing units. The findings include: 1.) An interview with Resident #96 on 3/20/19 at 7:33 AM, revealed that there was an issue with mice in the room. An observation made during this time, revealed mouse droppings near a chair and leading back to the wall. Also, He/she revealed a drawer in the bedside stand that belonged to Resident #4 that had a large amount of mouse droppings almost covering the bottom. 2.) The surveyor observed room [ROOM NUMBER] on 3/20/19 at 8:11 AM. [NAME] cereal and sunflower seed shells were scattered on the overbed table and the floor to the right of the first bed and a cardboard saltine cracker box was under the head of the bed. One of the 3 residents who reside in the room indicated at that time that a couple of mice had been caught in the room and that, on one occasion, 2 mice ran out from under a box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility staff failed to protect and value residents' private space by failing to knock and request permission before entering a resident's room. This was evident, but not limited to, 3 (#69, #122, #174) residents observed on both units of the facility. Based on observation, record review and staff interview, it was determined that the facility failed to treat residents with dignity and respect by labeling and identifying resident's as feeders, hovering and standing over a resident, or staff conversing with other staff while assisting residents to eat, and failing to serve all residents at the same table at the same time. This was identified for 3 (#13, #41, #109) residents observed during dining observations. The findings include. 1.) On 3/21/19 at approximately 1:20 PM, the surveyor was conducting an initial interview with Resident #122 in his/her bedroom. The room contained 3 resident beds. At 1:30 PM, Staff #29 entered the room and tended to the resident lying in the first bed, then left the room. At 1:34 PM, Staff #30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident and staff, it was determined that the facility failed to notify the physician when a resident's prescribed medication was not available to administer, failed to notify physician and family of a resident falling and failed to provide prior notification to a resident of a room change. This was evident for 3 (#178, #69, #112) of 40 residents reviewed during the investigative stage of the survey. The findings include: 1.) During an interview with Resident #69 on 3/21/19 at 10:47 AM, it was reported that the resident was moved from his/her room while at an appointment, and when he/she returned he/she all their belongings were in a different room. An interview with the Social Worker Staff # 31 on 3/22/19 at 2:54 PM, revealed that the facility process was that resident are verbally informed and given written notices of a room change prior to the change. A medical record review on 3/22/19 at 3:01 PM, revealed no documentation that this resident was informed of the room change verbally or in writing. A subsequent interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 2 of 2 nursing units. The findings include: 1.) On 3/20/19 at 10:34 AM, observation of room108's shared bathroom revealed the toilet seat was dirty and there was a brown ring of dried debris around the base of the toilet. 2.) On 3/21/19 at 10:58 AM, observation of room [ROOM NUMBER] revealed that the door knob insert was missing on the outer closet door. In the room, there was a blue vinyl chair with a loose chair back. Observation of room [ROOM NUMBER]'s shared bathroom revealed there was an over the toilet commode seat that had rust on top of the frame, rust under the metal bar in front of seat frame and there was rust on the lower legs of the frame. The floor around the toilet was soiled brown. 3.) The surveyor observed room [ROOM NUMBER] on 3/20/19 at 8:11 AM. A cardboard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare residents for an orderly discharge or transfer from the facility. This was evident for 4 (#66, #126, #325, #4) of 7 residents reviewed for hospitalization and for 1 (#120) of 5 residents reviewed for accidents. The findings include: 1) Resident #66's medical record was reviewed on 3/22/19 at 9:57 AM. During the review, it was determined that the resident had been hospitalized at the beginning of January and the beginning of February, 2019. Review of the medical record failed to reveal evidence that facility staff provided sufficient preparation and orientation to the resident to ensure safe and orderly transfer from the facility. 2) Resident #126's medical record was reviewed on 4/3/19 at 3:22 PM. During the review, it was revealed that Resident #126 was hospitalized prior to the beginning of the survey. Review of the medical record failed to reveal evidence that facility staff provided sufficient preparation and orientation to the resident to ensure safe…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded . This was evident for 1 (#69) of 5 residents reviewed for activities of daily living (ADLs), 2 (#59, #120) of 2 residents reviewed for activities, for 1 (#112) of 9 residents reviewed for nutrition, and 1 (#7) of 4 residents reviewed for urinary catheter care The findings include: The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1.) During an interview with Resident #69 on 3/21/19 at 10:38 AM, it was reported that the resident needed assistance to take a shower because he/she becomes shaky and unsteady at times. The residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical records and interviews with staff, it was determined that the facility staff failed to develop and implement baseline care plans that included instructions needed to provide effective and person-centered care of the resident with physicians' orders and initial goals. Additionally, the facility failed to provide the resident and/or their representative a summary of the baseline care plan including medications. This was evident for 5 (#122, #70, #23, #174 and #60) of 40 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) Resident #122's record was reviewed on 3/25/19 at 8:53 AM. The resident was admitted [DATE]. A Plan of care note, dated 3/24/19 17:08, indicated: admission care plan completed. Further review of the record failed to reveal an admission baseline care plan. At 10:18 AM on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review and interviews with a resident and staff, it was determined that the facility failed to develop accurate, resident centered care plans with measurable goals and objectives and failed to follow a resident's care plan. This was evident for 13 (#108, #8, #23, #70, #122, #105, #69, #84, #14, #41, #76, #86 and #120) of 40 residents reviewed during the investigative phase of the survey. The findings include: 1) During an interview on 3/20/19 at 8:22 AM, Resident #8 indicated that he/she was scheduled to have cataract surgery that day, but it had to be cancelled. Review of the resident's record on 3/26/19 at 11:12 AM revealed a Cataract evaluation dated 2/25/19, which indicated Cataract, mixed; Both eyes. The Director of Nursing (DON) confirmed that the resident was scheduled to have Cataract surgery. Further review of the record revealed a plan of care for: Eye infection and allergies affecting eyes initiated 12/6/18. The resident's goal was: (Resident #8's) eye infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interview with residents and facility staff, it was determined that the facility failed to review and revise care plans as resident needs change and at least quarterly. This was evident for 11 (#42, #108, #8, #23, #53, #105, #109, #325, #120, #59, #82) of 40 residents reviewed during the investigation phase of the survey. The findings include: 1) Resident #53's medical record was reviewed on [DATE] at 1:45 PM. During the review, the resident's Maryland Orders for Life Sustaining Treatment (MOLST) form was located. The MOLST form reflected that the resident did not wish to have cardiopulmonary resuscitation (CPR) performed if the resident developed cardiac arrest. This was different from what was listed in the resident's care plan which stated that the resident did want to have CPR performed in the event of cardiac arrest. The MOLST form, which contains physician orders and can be considered more authoritative than care plan interventions, had been updated more recently than…

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

Based on observation and interview with facility staff, it was determined that the facility failed to store medications in a manner that protected the medications during storage. This was evident for 1 (2nd floor) of 2 medication storage rooms. The findings include: Medications requiring specific refrigeration temperatures are at risk for breaking down or for changing in their effectiveness when exposed to temperatures that are either too high or too low. Insulin is known to be particularly sensitive to colder temperatures and can become ineffective at lowering blood sugar levels if the insulin is frozen (drops below 32° Fahrenheit). After review of the recommendations of the three manufacturers of insulin in the United States (Lilly, Sanofi-Aventis, and Novo Nordisk), all unopened insulin should be stored between 36° and 46° Fahrenheit (F) and no insulin should be used if it has been exposed to freezing temperatures. During an observation of the 2nd floor medication storage room that took place on 3/20/19 at 7:21 AM, it was noted that the medication refrigerator was measuring 22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that resident's medical records were maintained in an accurate and complete manner. This was evident for 5(Residents #53, #109, #178, #82, #122) of 40 residents reviewed during the investigation phase of the survey. The findings include: 1) Resident #53's medical record was reviewed on [DATE] at 1:45 PM. During the review of the paper medical record, a form called the MOLST form (Maryland Orders for Life Sustaining Treatment) was found that had been completed for the resident. The MOLST form contains physician orders for treatment that the resident wishes performed in the case of cardiac arrest. Resident #53's MOLST form reflected that the resident did not wish to have cardiopulmonary resuscitation (CPR) performed in the event of cardiac arrest. The MOLST form was dated February, 2019. During contemporaneous review of the resident's electronic medical record, an electronic order was found for…

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

Based on observation, resident interview, and record review, the facility failed to assess a resident's preference for activities and promote their participation in those activities by not assisting Resident #86 out of bed to attend their preferred scheduled events. This was evident for 1 (#86) of 2 residents reviewed for activities. The findings include: During an observation made at the time of entrance into the facility on 3/20/19, resident #86 was lying in bed yelling out. Resident #86 was noted in bed over multiple observations. A resident interview conducted on 3/20/19 at 11:33 AM revealed that resident #86 wanted to get up for activities, but stated that the staff doesn't assist her/him to get out of her/ his bed. Activities that interested the resident included bingo and gardening. In an interview conducted on 3/28/19 at 9:00 AM with staff members #16 and #17, both staff members stated that they can't always get resident #86 up due to working short staffed, but they felt that resident #86 seemed to not holler out as much when out of bed for activities. During an interview…

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

Based on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff, it was determined that the facility staff failed to provide 2 (#277, #278)) of 3 Medicare beneficiaries reviewed with a written notice of Medicare Provider Non-Coverage. The findings include: The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 3/22/19, a review of the SNF Beneficiary Protection Notification Review worksheet completed by the facility indicated that Resident #277 was discharged from skilled services on 10/28/18 with benefit days remaining. The worksheet indicated that a SNFABN form and NOMNC form had not 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 review of resident, facility records, and staff interviews, it was determined that the facility staff failed to thoroughly investigate alleged abuse and prevent further potential abuse by failing to address an alleged staff to resident altercation. This was evident for 1 (#179) of 1 residents reviewed for abuse. The findings include: On 4/01/19 at 1:47 PM, a record review of a facility reported incident, MD # 00134760, revealed that facility staff failed to thoroughly investigate allegations of verbal abuse between a staff member and Resident #179. The investigation and witness statements contained very little information on the incident. An interview with the Regional nurse and the Director of Nursing on 4/1/19 at 2:15 PM, failed to reveal insight on the investigation.

Based on medical record review, it was determined that the facility failed to document the hospital transfer in the medical record for 1 (#76) of 1 residents. The findings include: On 3/27/19 at 10:22 AM, a review of the nursing notes revealed that Resident #76 was sent to the emergency room (ER) at 5p on 3/26/19. The concurrent review was not filled out and the nursing note failed to document that the transfer notice was given or that the family was notified of transfer.

Based on medical record review and staff interview, it was determined that the facility: 1) failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer and, 2) failed to notify the Office of the State Long-Term Care Ombudsman of a transfer/discharge of a resident. This was evident for 4 (#102, #66, #4, and #76) of 7 residents reviewed for hospitalization and 1 (#120) of 5 residents reviewed for accidents. The findings include: 1) On 3/22/19, a review of Resident #102's medical record revealed on 2/22/19, in a progress note, the nurse documented that Resident #102 developed a fever and mild confusion, an order was given to send the resident to the hospital, the resident was sent to the hospital and admitted for Sepsis (potentially life-threatening complication of infection). There was no documentation found in the medical record that the resident or representative was notified in writing of the resident's transfer to the hospital. On 3/22/19 at 4:32 PM, during an interview, the Staff #31, stated that,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with residents and review of the medical record, it was determined that the facility failed to ensure that newly admitted residents had physician orders for the resident's immediate care at the time of admission. This was evident for 1 (Resident #328) of 40 residents reviewed during the investigation phase of the survey. The findings include: Resident #328 was admitted on [DATE] with a hip replacement that had been performed two days prior on 4/2/2019 at a nearby hospital. Resident #328 had come to the facility to receive rehabilitation services related to the hip replacement. Resident #328 was interviewed on 4/5/2019 at 2:33 PM. During the interview, the resident stated that s/he had been newly admitted the prior day, having arrived at the facility at about 2:30 PM on 4/4/2019. The resident stated that, despite being in the bed closer to the door with the door wide open, (indicating that s/he was clearly visible to staff walking by), nobody came in to welcome him/her, provide any services, or…

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

Based on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident for 2 (#59, #86) of 2 residents reviewed for activities. The findings include: 1.) Intermittent observations were made of Resident #59 by the surveyor during the morning and afternoon of 3/20/19, 3/21/19, 3/22/19 and 3/28/19. On each of these surveyor observations, Resident #59 was observed sitting up or lying down in his/her bed, in a quiet room without TV or a radio on. Resident #59 was not observed to be out of his/her room in a group activity and was not observed in a 1 to 1 with activity staff during the surveyor observations. On 3/28/19, Resident #59's medical record was reviewed. On 12/6/18 at 7:01 PM, in an annual Activity Preference Interview, the activities assistant documented Resident #59's current interest in activity pursuit patterns were: 1) crafts/arts/hobbies (coloring), 2) music, watching TV,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional standards of practice by failing to ensurethat physician orders were accurately transcribed, medications were administered as prescribed, and failing to inform a resident when there was a change in his her treatment. This was evident for 2 (#82, #328) of 6 resident's reviewed for care plans. The findings include: On 3/22/19, a review of Resident #82's medical record was conducted and revealed that, on 3/18/19, in a progress note, the physician documented that Resident #82's history of present illness included still has swelling of legs, under the heading review of systems, the physician circled peripheral edema (swelling due to accumulation of fluid) and under assessment/plan, the physician documentation included Increase Lasix (Furosemide) (diuretic) to 40 mg in AM. Continue Lasix 20 mg in PM. Review of Resident #82'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 interview with the resident and facility staff and surgical center staff, and review of the medical record, it was determined that the facility staff failed to ensure that a resident received proper treatment to maintain vision abilities by failing to obtain required preoperative evaluations resulting in the cancellation of the resident's cataract surgery. This was evident for 1 (#8) of 2 residents reviewed for Communication-Sensory concerns. The findings include: During an interview on 3/20/19 at 8:22 AM, Resident #8 indicated that he/she was supposed to have cataract surgery that day, but it was cancelled because pre-operative blood work and EKG were not done. A technician came to obtain an EKG as the surveyor was leaving the resident's room. The resident's record was reviewed on 3/26/19 at 11:12 AM. A physicians order was written 1/25/19 for Ophthalmologist consult for possible cataract. A telephone physicians order was written 3/15/19 10:45 AM for NPO (nothing by mouth) after midnight for eye surgery. During an interview on 3/26/19 at 3:09 PM, Staff #11 confirmed that…

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

Based on observation and interview with facility staff, it was determined that the facility failed to 1) maintain an environment free of environmental hazards for confused residents as evidenced by having treatment carts unlocked and unattended in the hallway of the second floor unit. This was evident for 2 of 2 carts observed on the 2nd floor on the day of survey entry. The findings include: During an observation of the 2nd floor nursing unit, made on 3/20/19 at 7:48 AM, there were two treatment carts on the 2nd floor both unlocked and unattended by facility staff. Two surveyors made this observation at 7:48 AM. The carts were reviewed for contents and the following supplies were identified: a bottle labeled iodoform gauze, a bottle labeled hydrogen peroxide, and several loose razor blades. At 7:55 AM, 8:10 AM, and 8:32 AM, both carts were noted to still be unlocked and unattended. Multiple staff were observed walking past both carts without locking them during this time. At 8:50 AM, a brief interview was conducted with licensed practical nurse (LPN) #11. During the interview, LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with the resident and staff and review of the medical record, it was determined that the facility failed to ensure a resident admitted with an indwelling urinary catheter was assessed for removal of the catheter, or ensure that the record demonstrated that catheterization was necessary. This was evident for 1 (#122) of 3 residents reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The findings include: During an interview, on 3/21/19 at 1:30 PM, Resident #122 indicated that he/she was not sure why he/she had a urinary catheter and thought the physician had told him/her about 3 weeks prior that it would be removed, but he/she had not heard anything since that time. Review of the resident's record on 3/25/19 at 8:53 AM revealed that the resident was admitted with the urinary catheter from the hospital. A urology evaluation from the hospital, dated 2/21/19, indicated: the Foley catheter should be removed for a voiding trial when His/her renal function has stabilized. 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, medical record review and staff interview, it was determined that the facility staff: 1) failed to ensure that oxygen was administered at the rate ordered by the physician, 2) failed to accurately document the resident's oxygen rate in the treatment record and 3) failed to follow the resident's care plan related to oxygen administration.This was evident for 1 (#102) of 6 residents reviewed for respiratory care. The findings include: Resident #102 was observed by the surveyor in his/her room on 3/20/19 at 9:14 AM and on 3/22/19 at 2:29 PM receiving oxygen (O2) set at 3 l/min (liters per minute) via a nasal cannula (n/c) connected to an oxygen concentrator. On 3/22/19 at 3:30 PM, the unit manager (Staff #50) accompanied the surveyor to the resident's room and confirmed the oxygen rate setting. On 3/22/19, review of Resident #102's medical record revealed a 2/27/19 physician's order for Oxygen 2 l/m via nasal cannula every shift. Review of Resident #102's March 2019 TAR (treatment administration record) revealed an order for Oxygen 2 l/m via nasal cannula 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.

Base on random review of staff postings, and comparison to other daily staffing sheets, it was determined that the facility failed to accurately document staff posting, including the correct census at the beginning of each shift. This was exemplified by a review of 5 Federal staffing sheets with 3 days found to be inaccurate for the actual hours worked by licensed and unlicensed staff. The findings include. The Federal staffing sheets were found to be displayed on a bulletin board on the ground level of the facility across from the administrator's office. The staffing sheets were prepared once per day for all three shifts. The staffing for 2/2/19 was requested. Comparison of the daily staffing sheets with employee's name to the Federal staff sheets found discrepancies. The census for the day was posted once for the whole day and did not reflect changes related to discharges or new admissions (there was at least one discharge for evening shift on 2/2/19) The day shift listed 40 hours to mean a total of 5 Licensed Practical Nurses (LPN) on Day shift, but only 4 LPNS were identified on…

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

Based on medical record review and staff interview, it was determined that the pharmacist failed to identify excessive medication doses being administered to a resident who was to have medications tapered. This was evident for 1 (#20) of 3 residents reviewed for medical record accuracy. The findings include: Review of Resident #20's medical record on 7/24/19 revealed a handwritten physician's order for the medication Aricept to be given every other day for 2 weeks and then discontinued. A 6/27/19 physician's progress note documented the plan to taper Aricept. Review of Resident #20's June 2019 Medication Administration Record (MAR) documented that the resident received Aricept on 6/27/19, 6/28, 6/29 and 6/30/19 at 8:00 AM and on 6/27/19 at 3:39 PM and 6/29/19 at 3:50 PM. Review of the July 2019 MAR documented that the resident received Aricept on 7/1, 7/2 and 7/3 at 8:00 AM and then twice per day,at from 7/4/19 to 7/17/19 at 8:00 AM and 5:00 PM and then received a dose on 7/18, 7/20, 7/22 and 7/24 at 8:00 AM. The order was transcribed incorrectly, therefore the Aricept was not…

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

Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow the physician's order to taper and discontinue a medication and 2) failing to follow physician ordered blood pressure parameters for administering blood pressure medication. This was evident for 1 (#20) of 3 residents reviewed for medical record accuracy and 1 (#6) of 3 new admissions reviewed. The findings include: 1) Review of Resident #20's medical record on 7/24/19 revealed a handwritten physician's order for the medication Aricept to be given every other day for 2 weeks and then discontinued. A 6/27/19 physician's progress note documented the plan to taper Aricept. Review of Resident #20's June 2019 Medication Administration Record (MAR) documented the resident received Aricept on 6/27/19, 6/28, 6/29 and 6/30/19 at 8:00 AM and on 6/27/19 at 3:39 PM and 6/29/19 at 3:50 PM. Review of the July 2019 MAR documented that the resident received Aricept on 7/1, 7/2 and 7/3 at 8:00 AM and then twice per day from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to ensure that the medication error rate was not greater than 5%. This was evident from observations made during the medication administration observation facility task. The findings include: Over the course of the survey, 28 medications were observed during the medication administration observation task. Of these 28 medications, errors were made during the administration of 2 of the medications, resulting in a medication error rate of 7.14%. During an observation of medication administration that took place on 3/26/19 at 8:45 AM, Licensed Practical Nurse (LPN) #11 was observed preparing and administering two medications intramuscularly to Resident #76. One medication was 4 mililiters (mL) of a steroidal anti inflammatory and the other was 4 mL of a diuretic. LPN #11 prepared 2 syringes containing 2 mL of medication for each of the medications and took these 4 syringes into the resident's room. LPN #11 asked the resident whether s/he would like the…

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

Based on review of facility records it was determined the facility failed to ensure that the required committee members attended the quality assessment and assurance meetings quarterly. This was evident during review of the quality assessment and assurance review. The findings include: The QAPI committee sign in sheets from April 2018 to present were reviewed on 4/5/19 at 3:47 PM. The facility had sign in sheets for monthly meetings as required by the Code of Maryland Regulations, however the sign in sheets for 8/2018 and 3/2019 meetings were missing. The sign in sheets for 1/2019 and 2/2019 revealed the Medical Director was not present at those meetings. During an interview at that time the Administrator was made aware of the above findings and indicated that the 3/2019 meeting was not held because the survey was in progress. She indicated that the DON could not find the sign in sheet for 8/2018 but it was OK since (a meeting) only had to be held quarterly. The Medical Director was not present 1/2019, 2/2019 and no meeting was held 3/2019 therefore the Medical Director failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with facility staff, it was determined that the facility staff failed to ensure that residents had a means of directly contacting caregivers by failing to ensure the call bell system was operational for each resident. This was evident for 1 of 32 resident rooms observed on the second floor of the facility. The findings include: During an observation of room [ROOM NUMBER] on 3/20/19 at 8:35 AM, the surveyor attempted to test the call bell for the first bed by pressing the activation button. The light in the hallway above the room door failed to light when the button was pressed. A test of the call light for the second and third beds in the room also failed to activate the light in the hallway. The staff developer (Staff #44) was made aware and confirmed these findings.