Julia Manor Nursing And Rehabilitation Center

Based on record review, interviews, and observations, it was determined that the facility failed to ensure that residents received their meals at an appropriate and palatable temperature. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen. The findings include:A review of the facility's grievance summary report revealed that a concern regarding the facility's food was reported to the Social Services Director on 9/4/25, stating that the facility's food was still cold. The report was reviewed by the Nursing Home Administrator and resolved on 9/5/25.Continued review of the facility's Nutrition Policies and Procedures contained a statement that Hot foods are maintained at 135 F or higher and cold foods are maintained at 40 F or below at the point of service.During a tour of the facility on 9/9/2025, Residents #4, #8, and #9 reported that the facility's food was often cold for foods that needed to be warm and warm for foods that required to be cold.During an observation of the facility's dinner tray line service on 9/11/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat residents with respect and dignity during mealtime. This was evident for 3 out of 5 meal observations during the survey.The findings include:1) A record review for Resident #71 showed that s/he required physical assistance from staff with eating.An observation of breakfast on the 3rd floor Unit on 9/10/2025, at 8:35 AM, showed staff #15, an occupational therapy assistant, feeding Resident #71 in his/her room. Resident #71 was lying in bed while staff #15 was standing by the right side of the Resident's bed.Staff #15 was interviewed at that time and stated that she was aware that standing to feed a resident was undignified; however, she stood to feed Resident #71 because it was comfortable for the Resident when she stood up. A review of Resident #71's medical record later that day failed to show documentation that indicated that staff were to stand while feeding the Resident.A subsequent observation of Resident #71 on 9/11/2025, at 8:37 AM, revealed that staff #16, a geriatric…

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

Based on observation and interviews it was determined that the facility failed to ensure a sanitary and homelike environment. This was found during random observations of two residents' rooms (Resident #97 and #67) and 1 out of the 2 nursing units.The findings include:1.On 9/10/25 at 9:45 AM surveyor observed a privacy curtain that was pulled between Bed A and Bed B in Resident #97's room. Surveyor noted several dark red splotches covering an area approximately 2 inches in length on the privacy curtain. This area was noted to be at the far end of the curtain at about five feet above the floor.Review of Resident #97's medical record revealed the resident has resided at the facility for more than one year. Review of the most recent Minimum Data Set assessment, with a reference date of 7/30/25 revealed the resident is cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.On 9/12/25 at 11:25 AM surveyor again observed the dark red splotches on the curtain between Bed A and Bed B in Resident #97's room. Resident #97 reported the stain is blood and…

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

Based on medical record review, resident and staff interviews and observations, it was determined that the facility failed to ensure that the activities of Daily living needs of a dependent resident were adequately provided and documented. This was evident for 3 of 5 residents (Residents #20, #58, and #60) reviewed for ADL care. The findings include:1) On 9/12/25 at 8:30 AM, review of Intake #303291 revealed that Resident #20, a long-term resident, was interviewed by the Social Services Director (SSD)(Staff #9) on 6/27/25. Documentation showed the resident expressed concerns regarding personal hygiene and shower care. On 9/12/25 at 9:00 AM, the surveyor requested any grievance forms or documentation showing that the residents' concerns had been addressed. On 9/12/25 at 12:48 PM, the Director of Nursing (DON), reported being unable to provide any grievance form or documentation indicating the complaint had been addressed. On 9/12/25 at 1:15 PM, Resident #20 was interviewed and reported being scheduled for a shower on 9/11/25 but instead received a bed bath. The resident 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 interviews and record review, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards by not including diabetes-related interventions in the care plan. This was evident for 1 (Resident #92) of 1 resident reviewed for insulin use.The findings include:Resident #92 resides at [NAME] Manor for physical therapy and nursing care following a surgical amputation (removal) of one leg. Resident #92 has a long history of Type 2 Diabetes and associated medical conditions including heart disease and chronic kidney disease.Hypoglycemia refers to a condition where blood sugar (glucose) levels drop below normal (below 70 for diabetics). Severe hypoglycemia can occur when blood glucose levels drop below 40 mg/dL. This can lead to serious complications such as seizures, coma, and even death.Glucagon injection (or oral medication) is used for emergency treatment of very low blood sugar (severe hypoglycemia).On 9/09/2025 at 11:07 AM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and observation it was determined that the facility failed to ensure adequate supervision and staff assistance during a resident's mechanical lift transfer. This was evident for 1 (Resident #90) of 5 residents reviewed for activities of daily living during the recertification survey. The findings include:A review of Resident #90's clinical record revealed a care plan intervention that stated the resident required assistance of two staff to transfer out of bed with a mechanical lift.A review of the facility's mechanical lift policy revealed that transfers with a mechanical (Hoyer) lift required two staff.On 9/09/2025 at 9:26 AM Resident #90 was interviewed during the initial screening for the recertification survey process. S/he stated that s/he was afraid of Hoyer lift transfers, and that s/he was not sure staff used it right.On 9/11/25 at 4:21 PM Resident #90 was observed in bed as a Geriatric Nursing Assistant (GNA #14) left their room pushing a mechanical lift. Another unidentified person was observed standing in the room.On 9/11/25 at 4:23 PM an…

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

Based on record review and interviews, it was determined that the facility failed to have an effective process to ensure that medication recommendations made by the pharmacist were delivered to the physician for review. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications during a survey. The findings include:On 9/10/25 at 1:07 PM, a review of Resident #10's revealed a monthly pharmacy review note dated 12/11/24. The note referenced Omeprazole 20 mg BID for GERD, administered at 0800 and 2000. The pharmacist recommended reviewing and considering a time change to administer the medication either 1 hour before or 2 hours after other medications and food. No other recommendations were noted. On 9/10/25 at 2:02 PM, an interview was conducted with the Director of Nursing (DON) regarding the monthly pharmacy medication review. The DON reported that when the pharmacist made a recommendation, a hard copy was delivered to the facility with the next pharmacy delivery. The document was first received by the DON, who then gave it to the appropriate nurse…

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

Based on records review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary medications. This was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications.The findings include: Resident #8 was admitted into the facility in early 2025 with diagnosis that include hypertension. Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia.Blood pressure is classified by two measurements, the systolic (first number) and diastolic (second number) pressures.A review of Resident #8's medication orders was conducted on 9/12/25 at 1:09 PM. The review revealed medications that treat hypertension that include:1) Carvedilol, to be taken 2x a day with instructions to hold if systolic…

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

Based on observation, interview and review of medical records it was determined that the facility failed to ensure medication error rate of less than 5% as evidenced by 3 errors out of 29 opportunities. These errors were identified for 2 (Resident #73 and #10) out of the three residents observed during the medication administration observation task. The findings include: 1)On 9/09/25 at 8:30 AM surveyor observed Nurse #2 prepare and administer medications for Resident #73. One of the medications prepared was Clear Lax which is a laxative that comes in a powder form that needs to be mixed with a liquid. The active ingredient in Clear Lax is polyethylene glycol 3350.Nurse #2 was observed to use the lid of the Clear Lax to measure the powder. The lid was observed to be purple with an inner white section. The nurse filled the powder to approximately 3/4 of the way up the white part of the lid. The nurse then proceeded to mix the powder with water in one of the disposable cups kept on the medication cart. The nurse reported this was a 120 ml cup (120 ml is approximately 4 ounces).On…

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

Based on record reviews and interviews, it was determined that the facility failed to ensure education was provided to residents and/or responsible parties (RP) regarding the benefits and potential risks associated with the COVID 19 vaccine. This was evident for 1 (Resident #31) of 5 residents reviewed for immunizations.The findings include: Resident #31 had been a resident of the facility since 2023. A quick look into the resident's medical record indicated an intact cognitive function.A review of Resident #31's immunization record was conducted on 9/10/25 at 1:25 PM. The review revealed the resident's preventive healthcare documentation that indicated the resident had declined the COVID 19 vaccine dated 8/8/23. However, the designated area at the bottom of the document to indicate if education was provided to the resident/family/power of attorney, was left unanswered.The finding was discussed with the Infection Preventionist (IP) Nurse (Staff #1) on 9/10/25 at 2:50 PM. Staff #1 indicated that she would review Resident #31's medical record.On 9/10/25 at 3:21 PM, Staff #1 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility documentation review, and interview, it was determined that the facility administration failed to identify allegations of abuse and thoroughly investigate them to determine the cause to implement a plan of correction and failed to allow residents to exercise their rights freely. This was evident throughout the annual survey and had the potential to affect all residents. The findings include: 1) On [DATE] at 5:45 PM, a review of the facility's investigation file for a facility reported incident #MD00181072 revealed the facility received an allegation of neglect and wrongful death on [DATE] via an email from Resident #112's family member. The email reported how the family had come to visit the resident on [DATE] and found him/her unresponsive and insisted that facility staff send the resident to the hospital. Furthermore, the family reported that the hospital physician reported that Resident #112 had a urinary tract infection and pneumonia, and the outcome was not good.…

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

Based on interview and record review, it was determined that the facility failed to offer and/or obtain advance directives for residents. This was evident for 5 (#10, # 30, # 98, #94, and #13) of 16 residents reviewed for advanced directives. The findings include: An Advance Healthcare Directive is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves, due of illness or incapacity. A POA (Power of Attorney ) may be assigned for the Advanced Directive. During an interview on 7/10/23 at 2:45 PM, The Director of Social Services (Staff #9) reported that advanced directives are placed in the resident's electronic medical documents under Advanced Directive/POA/Guardianship. The Director of Social Services reported if there is not an advanced directive in electronic record, there would be documentation regarding the discussion of advance directives in the admission care plan notes, found in the progress notes. 1) Resident #10 was admitted to the facility for rehabilitation following a…

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

Based on record review, policy review and staff interview, it was determined that the facility failed to implement their abuse prevention policies and procedures. This was evident for one out of one abuse policy reviewed. The finding include: On 8/2/23 at 3:03 PM, a review of the abuse policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed that there was no facility name, date of policy implementation, and noted the last date of the policy's revision was on 11/1/17. Under the education section, it was noted that staff will receive annual abuse and neglect training. In the Prevention section, adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors such as, ignoring the patient's/residents needs, requests. #5 Ongoing assessment, care planning and monitoring of those patients/residents with special needs that may lead to neglect, for example: E. Patients/Residents requiring excessive nursing care or staff attention. In section titled Identification #2 Neglect is the failure to provide goods and services or treatment and 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.

3) On 8/8/23 review of Resident #76's medical record and MD00187490 revealed the resident was admitted in 2021 with diagnoses that included, but were not limited to, dementia and diabetes. The resident is dependent on staff for asssistance with activities of daily living. On 1/6/23 between 3:00 - 4:00 PM, the resident was noted to have a discoloration to the right chin and scratches to the left upper arm. The physician and the responsible representative were notified on 1/6/23 and an investigation was initiated by the facility. Review of email confirmation documentation revealed the initial report of this injury of unknown origin was sent to the State Survey Agency on 1/8/23 at 11:35 AM. On 8/8/23 at 11:51 AM, surveyor reviewed the concern with the Director of Nursing regarding the late reporting of this injury of unknown origin. As of time of survey exit on 8/14/23 at 4:00 PM no additional documentation was provided regarding this concern. Based on review of facility documents and interviews, it was determined the facility failed to report an allegation of abuse to the State…

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

Based on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, injuries of unknown origin and misappropriation of property. This was evident for 7 (#48, #37, #35, #76, #112, #102 and #8) out of 19 resident's reviewed for abuse and an additional three residents (#17, #302, and #303) identified during these investigations. The findings include: 1) On 8/3/23 at 11:09 AM, a review of the facility's investigation for the self-report #MD00194272 was conducted. The facility's initial self-report documented Resident #48 reported h/she recalled 2 incidents where abuse allegations were suspected. Resident #48 reported that a resident who was seen sitting at the nursing station, from early morning until late evening was not provided care. Resident #48 also reported that a GNA (geriatric nursing assistant) had gotten physical with the resident. Resident #48 reported the 2 allegations of abuse occurred 4 to 5 months ago. The facility's final self-report indicated that Resident #48 reported that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) On 8/9/23 review of Resident #107's medical record revealed the resident was admitted to the facility in April 2022 with diagnosies that included, but were not limited to, diabetes and high blood pressure. Further reveiw of the medical record revealed a physician order, in effect from April 2022 until the resident's discharge in January 2023 for monthly weight. No weight was found for the month of October. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/6/22 failed to reveal documentation of a weight. Section K0200 B. Weight was noted to be blank. Section K0300 Weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months was documented as 0 for No or unknown. Review of the [NAME] for the completion of the MDS assessment revealed that the weights should be based on the most recent measure in the last 30 days, and if the last recorded weight was taken more than 30 days prior to the ARD, the resident should be weighed again. Further review of the medical…

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

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 3 (#82, #106 and #86) of 84 residents reviewed during the survey. The findings include. A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a summary of their medications, is given to the resident/resident representative and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1) On 7/10/23 at 3:10 PM, during an interview, Resident #82 indicated that h/she was recently admitted to the facility for long term care. At that time, the…

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

Based on medical record review and interview, it was determined that the facility failed to ensure the primary care providers reviewed the resident's total program of care during required visits and failed to ensure that notes related to those visits were completed and signed in a timely manner. This was found to be evident for 5 (Resident #107, #58, #117, #9 and #8 ) out of 84 residents reviewed during the survey. The findings include: 1. On 8/9/23, review of Resident #107's medical record revealed the resident was admitted to the facility in April 2022 with diagnoses that included, but were not limited to, diabetes and high blood pressure. Review of the vital signs section of the medical record revealed the resident's weight on on 8/9/22 was 228.4 lbs and on 9/9/22 was 227.9 lbs. Further review of the medical record revealed a weight of 200.8 lbs was obtained on 11/8/22. This 27.1 lbs weight loss represents a loss of more than 10% in two months. A weight loss is considered to be severe if it is greater than 7.5% in 3 months, or greater than 10% in 6 months. The resident was seen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, family and resident interviews, review of medical records, facility documents, facility reports and complaints, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 2 of 2 nursing units. The findings include: 1) During the initial pool selection of the survey process, 26.47%, which was 9 of 34, residents interviewed, indicated that at times, the facility did not have enough staff to care for the residents. When asked is there enough staff available to make sure the residents get the care they need without having to wait a long time, the following responses were given to the surveyors: PBJ (Payroll Based Journal) Report are quarterly reports from long-term care facilities to the Centers for Medicare and Medicaid Services (CMS) that detail direct care payroll and staffing data. Review of staffing data submitted via the PBJ system revealed that the facility had a one star staffing quality rating. On 7/9/23 at 10:25 AM, Resident #28 indicated that the facility had a staffing shortage…

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

Based on record review, observation and interview, it was determined that the facility staff failed to ensure that residents were able to exercise their right of self-determination, as evidenced by failing to ensure a resident was able to choose his/her preference for bathing and failed to accommodate resident choices when a policy affecting resident smoking was significantly changed. This was evident for 3 (#11, #48, and #8) of 3 residents reviewed for choices. The findings include: 1) On 7/10/23 at 9:00 AM, a review of complaint #MD00177541 was conducted. The complainant alleged that Resident #11 was not receiving a shower 2 times a week as s/he was supposed to, and that Resident #11 had gone a month without a shower. On 7/10/23 at 1:20 PM, during an interview, Resident #11 stated that s/he was only able to get a shower once a week even though s/he was scheduled to get a shower 2 times a week and indicated it was because the facility was short staffed. Review of Resident #11's admission assessment with an ARD (Assessment Reference Date) of 10/27/21 revealed the assessment…

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

Based on medical record review and interview, it was determined the facility staff failed to notify the physician and the resident representative when a resident had a significant weight loss. This was evident for 2 (#45 and #118) of 84 residents reviewed during the survey. The findings include: 1) On 7/11/23 at 10:18 AM, a review of Resident #45's medical record was conducted. Review of Resident #45's weight summary report in the EMR (electronic medical record) revealed documentation that, on 6/8/2023 2:52 PM, the resident weighed 174 lbs (pounds). On 07/10/2023 at 1:01 PM, Resident #42's weight was documented as 136.4 lbs which was a 21.61 % loss in one month and a significant weight loss. On 7/28/23 at 12:00 PM, further review of Resident #45's medical record revealed that, on 7/13/23 at 1:07 PM, in a Nutrition note for weight review, the dietician wrote that Resident #45's current weight was 137.4, which represented a 36.6 lb weight loss (21% body weight) as documented within the past 30 days. Continued review of the medical record failed to reveal documentation in the medical…

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

Based on document review, interview, and observation, it was determined that the facility failed to provide a safe place for the resident to keep valuable items. This was evident for 1 (Resident #8) out of 2 residents reviewed for personal property. The findings include: On 7/14/23 at 9:55 AM, review of the facilities grievance log provided by the Social Service Director (Staff #9) revealed that Resident #8 filed a grievance on 5/7/23. Review of the grievance revealed that Resident #8 reported that s/he was missing $20 from his/her bag. Further review revealed that the resolution to the grievance was for the Resident to have a locked box installed in the resident's room. Further review documented that the Resident, Resident power of attorney and the Social Service Director agreed with the resolution. During an interview with Resident #8 on 7/14/23 at 12:43 PM, Resident # 8 reported that s/he had asked for a lock box but did not receive one. An observation of resident's room failed to reveal a lockbox or cabinet with a locked drawer. On 7/14/23 at 1:50 PM, during an interview with…

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

Based on review of the medical records and other pertinent documentation, it was determined that the facility failed to protect a resident from misappropriation of narcotics. This was found to be evident for one (Resident #43) out of 4 residents reviewed in relation to a facility self report of drug diversion. The findings include: On 8/4/23, review of facility report MD00184975 revealed that, on 10/25/22 at approximately 2:30 PM, concerns were brought to the Director of Nursing (Staff #47, who at the time of the report was the Director of Nursing) about possible narcotic diversion by nurse (Staff #58). The nurse (Staff #58) was suspended and an investigation was initiated by the facility. On 8/04/23 at 1:43 PM, review of the narcotic audit the facility completed as part of their investigation revealed that from May until October 2022 multiple discrepencies were noted between scheduled and PRN (as needed) narcotic administrations that the nurse (Staff #58) had signed off. Many of these examples were for PRN narcotics that were signed out on the Controlled Medication Utilization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility documentation, resident records, and interviews, It was determined the facility failed to ensure that the residents had an environment that was free from involuntary seclusion. This was evident for 1 (Resident #25) of 19 residents reviewed for abuse. The findings include: Involuntary seclusion - is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative. Minimum Data Set (MDS) - 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. On 7/13/23 at 7:29 AM, a medical record review for Resident #25 revealed a progress note for the attending physicians visit on 4/26/23 where he documented the resident had the following, but were not limited to, diagnoses:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for one (Resident #7) of two residents reviewed for hospitalization and one (Resident #25) of four residents reviewed for discharge. The findings include: 1) On 7/31/23 at 1:15 PM, a review of the medical record revealed Resident #7 was transferred to an acute care facility on 3/15/23. On 3/15/23 at 1:59 PM, in a progress note, the nurse documented that Resident #7 was transferred to the hospital for evaluation of the resident's complaint of severe abdominal pain and the resident's representative was notified of the transfer. Further review of the resident's medical record failed to reveal any documentation that the resident and/or the resident's representative (RR) was notified in writing of the resident's transfer along with the reason for the transfer. The above concerns were reviewed with the Director of Nurses on 7/31/23 at 2:10 PM. 2) 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 facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #7) of 2 residents reviewed for hospitalization. The findings include: On 7/31/23 at 1:15 PM, a review of the medical record revealed that Resident #7 was transferred to an acute care facility on 3/15/23. On 3/15/23 at 1:59 PM, in a progress note, the nurse documented that Resident #7 was transferred to the hospital for evaluation of the resident's complaint of severe abdominal pain and the resident's representative was notified of the transfer. Continued review of the medical record failed to reveal any documentation that Resident #7 was oriented and prepared for the transfer in a manner the resident could understand and there was no documentation of the resident's potential understanding of the transfer. On 7/31/23 at 2:10 PM, during an interview, the above concerns were reviewed with the Director of Nurses (DON), and the DON offered no explanation or additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for one (Resident #7) of two residents reviewed for hospitalization and one (Resident #25) of four residents reviewed for discharge. The findings include: 1) On 7/31/23 at 1:15 PM, a review of the medical record revealed that Resident #7 was transferred to an acute care facility on 3/15/23. On 3/15/23 at 1:59 PM, in a progress note, the nurse documented that Resident #7 was transferred to the hospital for evaluation of the resident's complaint of severe abdominal pain and the resident's representative was notified of the transfer. There was no documentation to indicate a copy of the facility's bed hold policy was provided to the resident upon transfer to the hospital, and further review of the medical record failed to produce written…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with facility staff, it was determined that the facility staff failed to develop and implement resident-centered care plans as evidenced by the failure to implement interventions to prevent injury related to wandering behavior and failure to address a resident's visual needs related to being legally blind. This was evident for 2 (#66, and #102) of 84 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument, 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 scheduled to meet the needs of each Resident. 1) On 7/11/23…

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 staff interview, it was determined that the facility staff failed to evaluate and update resident's plan of care after each assessment and have an effective system in place to ensure interdisciplinary team care plan meetings were scheduled to conduct the needed reviews and revisions. This was evident for 2 (Resident #84 and #8) of 84 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of 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. 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 7/19/23 at 10:45 AM, a review of the medical record…

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

Based on medical record review and interview, it was determined that the facility failed to ensure geriatric nursing assistants (GNA) provided activity of daily living care to dependent residents as needed. This was found to be evident for 2 (Resident #116, #106) out of 17 residents reviewed in relation to complaint investigations. The findings include: Activities of Daily Living (ADL) include, but iare not limited to, bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed); transfers (how resident moves between surfaces such as from bed to chair); dressing; toilet use (how resident uses the toilet room, commode, bedpan or urinal; cleanses self after elimination; changes pad); personal hygeine (how resident maintains personal hygeine including combing hair and brushing teeth) and bathing (full body bath/shower, sponge bath and transfers in/out of tub or shower). Minimum Data Set (MDS) - The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs.…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that interventions for the prevention of pressure ulcers were implemented. This was found to be evident for 1 (Resident #106) out of 9 residents reviewed for facility reported pressure ulcers during the survey. The findings include: Review of Resident #106's medical record on 8/1/23 revealed the resident was admitted in February of 2023 with diagnoses that included, but not limited to, diabetes and dysphasia (difficulty swallowing). Review of the Braden Scale for Predicting Pressure Sore Risk, completed by the registered nurse #71 on 2/22/23 revealed the resident was at High Risk for pressure sore development. Review of facility report MD00189649 revealed the facility reported a newly identified pressure ulcer on 3/3/23. Review of the progress notes revealed a note written by nurse #46 on 2/23/23 at 9:53 PM which includes: .Resident requires an air mattress. Mattress was delivered and set up, but did not inflate to proper pressure. Message left to unit manager to make arrangement for…

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

Based on record review, interviews, and observation, it was determined that the facility failed to review the dialysis book to monitor for complications after dialysis treatments. This was evident for (Resident # 41) 1 out of 1 resident reviewed for dialysis. The findings include: Resident #41 was a long-term resident at the facility that received dialysis at an outside dialysis center every Monday, Wednesday, and Friday. Review of Resident #41's orders on 7/17/23 at 2:41 PM, revealed an order that the resident's vital signs and dialysis book were to be checked for updates and recommendations when the resident returned to the facility. On 7/18/23 at 9:11 AM, review of Resident # 41 care plan revealed that nursing staff were to maintain communication with the dialysis treatment center through the communication book. The nursing staff were to check the communication book when the resident returned from dialysis for any orders, instructions, updates, or recommendations, additionally obtain weights after the resident was treated with dialysis. On 07/18/23 at 10:55 AM, during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that all residents received informed trauma care. This was evident for 1 (#43) of 8 residents reviewed for behavioral/emotional care needs. The findings include: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. A trigger is a psychological stimulus that prompts a recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. A care plan is a guide 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, medical record review and interview, it was determined the facility failed to accurately assess a resident for the use of side rails, failed to explain the risks and benefits to the resident's representative and obtain a signed consent for the use of side rails, failed to obtain a physician's order and failed to create and implement a care plan for the use of side rails. This was evident for 1 (#7) of 16 resident(s) reviewed for accidents: The findings include: A review of the physician orders failed to reveal an order for Resident # 7's use of side rails, nor were there any orders to monitor Resident # 7 while using the side rails. 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. On 7/10/23 at…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that residents were seen by an attending provider every 60 days at a minimum. This was evident for 1 (Resident #25) of 5 residents reviewed for unnecessary medication review; and 1 (Resident #117) of 16 residents reviewed for accidents. The findings include: 1)On 7/13/23 at 7:29 AM, a medical record review noted that Resident #25's medical conditions included but were not limited to Uncontrolled Diabetes, Hypertension, and Anxiety per an attending provider's note dated 6/7/23. A medical record review revealed attending provider visit notes, dated 2/14/22 and 3/24/22. However, no visits by an attending provider were recorded for April 2022 and May 2022 until the following visit notes, dated 6/20/22, indicating that Resident #25 was not seen by an attending provider for 80 days between visits. On 7/14/23 at 12:57 PM, an interview was conducted with the DON (Director Of Nursing). During the interview, she stated that residents needed to be visited by an attending provider at…

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

Based on facility document review and interviews, it was determined that the facility failed to assess and monitor a residents psychological well-being following a resident to resident alleged sexual assault. This was evident for (Resident #7)1 out of 19 residents reviewed for abuse during a survey. The findings include: Resident # 7 was a long-term resident at the facility with severe cognitive decline and was dependent on the facility for their daily care. Review of the facility investigative report revealed that the resident was the victim of alleged sexual abuse by another resident, which occurred in March 2022. Further review of the facility investigative report revealed that the facility's investigation recommended that the resident have a psychological evaluation, behavior monitoring, updates to their care plan and notification provided to his/her physician. On 8/02/23 at 11:43 AM, review of Resident #7's physician orders failed to reveal an order for a psychological consult or behavior monitoring. On 8/7/23 at 12:00 PM, review of medication administration and 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.

Based on observation, record review, and staff interview, it was determined that the facility staff failed to develop and implement a resident - centered dementia care plan with achievable care plan goals for residents with dementia. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications. 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 care. 07/17/23 11:06 AM, a review of Resident #58's electronic medical record (EMR) was conducted. Review of Resident #58's census revealed that Resident #58 was admitted to the facility in mid-April 2020 for long term care. On 4/17/202, in a History and Physical note, the physician documented that one of the resident's chief complaints was s/p (status post) delirium with dementia, and the resident had diagnoses which included. unspecified dementia. Review of Resident #58's quarterly assessment with an ARD (assessment reference date) of 1/10/23 documented Resident #58's BIMS (brief interview for mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records and other pertinent documentation and interviews, it was determined that the facility failed to have an effective system in place to identify potential diversion of controlled medications; and failed to ensure at least two nurses completed the narcotic count at each change of shift. This was found to be evident for two (Resident #43, and #67 ) out of four residents reviewed in relation to a facility self report of drug diversion and one out of three medication carts reviewed. The findings include: 1. On 8/4/23, review of facility report MD00184975 revealed that, in October 2022, based on interviews and narcotic drug audits, the facility substantiated narcotic diversion. On 8/04/23 at 1:43 PM, review of the narcotic audit the facility completed as part of their investigation, revealed that from May until October 2022, multiple discrepancies were noted between scheduled and PRN (as needed) narcotic administrations that Nurse Staff #58 had signed off. Many of these examples were for PRN narcotics that were signed out on the Controlled 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 medical record review and interview with staff, it was determined that the facility failed to ensure that irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon, and documented in the resident's medical record. This was evident for 3 (Resident #58, #9 and #28) of 5 residents reviewed for unnecessary medications. The findings include: 1) On 7/12/23 at 2:34 PM, a review of Resident #58's EMR (electronic medical record) was conducted and revealed documentation that Resident #58 was admitted to the facility April 2020, transferred to an acute care facility at the end of September 2022 and readmitted to the facility in mid-October 2022, for long term care. Review of Resident #58's EMR revealed that Resident #58's July 2023 medication administration record (MAR) revealed physician orders which included the following psychotropic medications: a) Depakote (Divalproex) ER extended release by mouth daily at bedtime for diagnosis of delusional disorders, start date 10/12/22. b) Divalproex (Depakote) DR (delayed release) 250 mg…

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

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to adequately monitor a resident for behavior related to psychotropic medication use. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications The findings include: Behavioral interventions are individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. On 7/12/23 at 2:34 PM, Resident #58's electronic medical record (EMR) was reviewed. Resident #58's July 2023 medication administration record (MAR) documented the resident received the psychotropic medications: Mirtazapine (Remeron) (antidepressant) by mouth at bedtime for depression with poor appetite, with a start date of 4/20/23,…

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 observation, interview, and pertinent documentation, it was determined that the facility failed to ensure medications were stored according to acceptable professional standards. This was evident for one medication storage refrigerator out of 2 storage refrigerators, reviewed during the survey. The findings include: On 7/14/23 at 8:10 AM, an observation of the second-floor medication storage room refrigerator revealed that insulin was stored inside the refrigerator. An additional observation was made of the Medication Storage Monthly Temperature Log located on the front of the refrigerator. Review of the temperature log revealed the acceptable temperature range for the medication refrigerator were 36 degrees F to 46 degrees Fahrenheit (F). The temperature log had a space to document AM and PM temperatures. Further observation of the documented temperatures revealed the following temperature readings: On 7/10/23 AM, the temperature documented was 33 degrees F. and there was no temperature documentation for the PM temperature documentation. On 7/11/23 AM, the temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store and prepare food in accordance with professional standards for food service safety as evidenced by failure to enure staff wore hair nets in the food preparation area and failure to ensure potentially hazardous food items were cooled according to acceptable standards. This was evident during 2 out of 3 kitchen observations. The findings include: 1) On 7/09/23 at 09:17 AM, a cook (Staff #4) was observed during the initial tour of the kitchen and verified at the time of the observation with an interview that she was not wearing a hairnet. On 7/21/23 at 11:10 AM, on another tour of the kitchen, a cook (Staff #25) was observed walking around the food prep area without wearing a hair restraint. 2) On 7/12/23 at 11:48 AM, an observation was made of cooked food in the refrigerator. The items were labeled as: a) Chicken gravy dated 7/11 use by 7/14 b) Puree for crab cake Wednesday dinner 7/11 c) medium steak 7/11/23 Thursday lunch use by 7/13/23 d) puree steak 7/11/23 Thursday lunch use by 7/13/23 e)…

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

Based on interview and record review, it was determined that the facility employed staff in positions that were outside their scope of practice in accordance with state laws. This was evident for 1 (Staff #14) of 2 Unit Managers. The findings include: The Annotated Code of Maryland Health Occupations Article, Title 8 is the Nurse Practice Act and contains the laws and regulations in which licensed nurses must follow and defines their scope of practice. Licensed nurses are governed by the Maryland Board of Nursing. According to the Nurse Practice Act Title 10 Maryland Department of Health Subtitle 27: Board of Nursing Chapter 10: Standards of Practice for Licensed Practical Nurses (LPN): .01 Definitions - 6. a. Comprehensive nursing assessment means an assessment performed by a registered nurse which is the foundation for the analysis of the assessment data to determine the nursing diagnosis, expected client outcomes and the client's plan of care. .04 Prohibited Acts. The LPN may not: C. Perform the comprehensive nursing assessment, D. serve as a case manager for client care, E.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 as evidenced by failing to ensure that physician visit progress notes were in a resident's electronic medical record and failure to ensure that staff documented the type of g-tube feeding that was being administered to a resident who had diabetes. This was evident for 6 (Residents #58, #117, #8, #107 and #106) out of 84 residents reviewed during the survey. The findings include: 1) On 7/12/23 at 10:51 AM, a review of Resident #58's medical record revealed that the resident was admitted to the facility in April 2020 and resided in the facility for long term care. Further review of Resident #58's electronic medical record (EMR) failed to reveal evidence of physician visit progress notes for Resident #58 in the resident's EMR. On 7/12/23 at 2:20 PM, Staff #41, Clinical Service Director was informed that no physician visit progress notes and no nurse practitioner (NP) visit notes for Resident #58 were found in the medical record. On 7/17/23…

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 observation and interview, it was determined that the facility failed to maintain the unit floors in a safe and sanitary condition. This was evident for two nursing unit floors out of two nursing units observed during a survey. On 8/4/23 at 12:16 PM, surveyors observed deep cracks in the floor tile on several of the nursing unit hallways. Observations of the second-floor nursing unit revealed deep cracks in the tile at the threshold area to entrance of the East wing, entrance to the South wing and at the threshold entrance to the dining room. In addition, there were deep cracks in the floor tile in front of the nursing station, near the elevator. On 8/4/23 at 12:33 PM, observations of the third-floor nursing unit revealed deep cracks in the tile at the threshold area to entrance of East wing, entrance to the South wing and at the entrance to the dining room. In addition, there were deep cracks in the floor tile in front of the nursing station, near the elevator. On 8/8/23 at 8:19 AM, a second observation to these areas was made with the Maintenance Director present. The…

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

Based on record review and staff interview, it was determined that the facility failed to ensure that all staff were provided education regarding resident abuse. This was evident for 2 (Staff #88 and #89) of 7 staff reviewed for abuse training. The findings include: 1) A review of Geriatric Nursing Assistant GNA Staff #88's employee file on 8/3/23 at 9:45 AM revealed that she was hired in May 2023 and had no abuse training. An interview on 8/3/23 at 10:07 AM with the Human Resource Director, Director of Nursing (DON), and Assistant Director of Nursing (ADON) revealed that the facility utilized a computer training program, and the trainings were preset for each employee based on their job title. They were not aware that Staff #88 had not completed the abuse training and could not provide an explanation as to why it had been missed. 2) On 8/3/23 at 9:18 AM, a review of GNA Staff #89's employee file revealed she was hired in May 2023 and had not completed abuse training. An interview on 8/3/23 at 10:07 AM with the Human Resource Director, Director of Nursing (DON), and Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, it was determined that the facility staff failed to ensure that the caulk around the base of the resident's toilets was maintained in a manner to facilitate cleaning and sanitizing. This was evident in 9 of 19 bathrooms located in resident bedrooms on the third floor of the facility. The findings include: On 6/6/19 at 9:50 AM, the surveyor observed the bathroom located within room [ROOM NUMBER]. The caulk around the base of the toilet was rippled and uneven with numerous lumps, grooves and recessed areas. Sections of the caulk appeared to be detached from the floor and the toilet base. The gaps, groves, crevices and recessed areas contained dark brown material and appeared dirty. On 6/13/19 at 12:06 PM, the surveyor observed the toilet in room [ROOM NUMBER], and on 6/13/19 at 2:15 PM, the bathrooms shared by the resident's residing in rooms 318/319, 320/321, 322/323, 325/326, 327/328, 329/330 and 331/332. The caulk around the base of these toilets was found to be in the same…

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

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to develop comprehensive person-centered care plans for each resident including measurable objectives. This was evident for 5 of 52 residents (Resident #7, #96, #6, #23 and #30) reviewed during the investigative 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) During an interview on 6/5/19 at 2:44 PM, the surveyor observed dark purple bruising on Resident #7's left and right forearms. The resident explained it was from bumping them on the edge of the dining room table and that he/she takes a blood thinner, causing him/her to bruise more easily. Resident #7's medical record was reviewed on 6/11/19 at 3:04 PM. A plan of care for anticoagulant use identified the resident's goal as will not experience excessive bleeding or bruising through the review period. The plan of care did not identify measurable objectives and 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 record review and staff interview, it was determined that the facility failed to provide written notice that Medicare coverage was ending. This was evident for 1 of 3 residents (Resident #311) reviewed for beneficiary protection notification. The findings include: Notification to residents and or their representative regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that the coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. A review conducted on 6/7/19 at 10:07 AM, of the beneficiary notification for Resident #311 indicated that resident's therapy was discontinued on 12/26/18 and was discharged home from the facility on 12/27/18. Further review indicated that notification had not been provided to the resident/or their representative. An interview with the Director of Nursing (DON) on 6/7/19 at 10:15 AM indicated that since the resident had self-initiated a discharge home, the facility did not need to give the resident the notice. The Director…

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

Based on review of facility investigation of facility reported incidents and staff interviews, it was determined that the facility staff failed to protect residents from abuse. This was found to be evident for 2 of 15 residents (Resident #359 and #21) reviewed for possible abuse during the survey. The findings include: 1) A review of the facility staff's investigation for (MD00133164) revealed that, on 10/28/18, Resident #359 reported to the facility staff LPN (Charge Nurse) nurse #17, that GNA (Geriatric Nursing Assistant) # 16 violated his/her HIPPA (Health Insurance Portability and Accountability Act) rights by commenting on his/her medical diagnosis in the hallway. The resident had a BIMs of 15 and was cognitively intact. The resident was interviewed by the DON (Director of Nursing) on 10/30/18, and during the interview, Resident #359 stated, s/he was sitting near the nurse's station when GNA # 16 was trying to go through with the Hoyer lift and 'ran into his/her chair on purpose'. The resident stated, that s/he told the GNA to 'watch where s/he was going.' The resident stated…

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

Based on review of the facility's investigation of a facility reported incident MD00133164 and staff interview, it was determined the facility failed to report an allegation of abuse to the appropriate agency. This was true for 1 out of 15 residents (Resident #359) reviewed for possible abuse during the investigative portion of the survey. The findings include: The facility failed to notify the Maryland Board of Nursing of an alleged incident of abuse. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, unusual occurrences and misappropriation of resident property are reported immediately to officials in accordance with state laws. A review of the facility staff's investigation for (MD00133164) revealed that, on 10/28/18, Resident #359 reported to facility staff LPN (Charge Nurse) nurse #17, that GNA (Geriatric Nursing Assistant) #16 violated his/her HIPPA (Health Insurance Portability and Accountability Act) rights by commenting on his/her medical diagnosis in the hallway. The resident had a BIMs of…

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

Based on record review and interview with staff, it was determined the facility staff failed to ensure resident MDS assessments were accurate and complete. This was evident for 1 of 16 residents (Resident #30) reviewed for Accidents. 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. The findings include: On 6/14/19 at 8:54 AM, the surveyor reviewed Resident #30's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 4/2/19. Section C - Cognitive Status indicated that a brief interview of mental status was conducted however, the assessment contained no interview responses. A staff assessment should have been completed when the resident was unable to complete the assessment interview. The staff assessment also contained no assessment findings. On 6/14/19 at 9:14 AM, an interview was conducted with MDS Nurse #27 who confirmed but was unable to explain why…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time as evidenced by failure to update interventions on a behavioral care plan and failure to update a change in a resident's Cardio Pulmonary Resuscitation (CPR) status. This was evident for 1 of 15 residents (Resident #92) reviewed for abuse and for 1 out of 1 resident (Resident #96) reviewed for Hospice and End of Life services. 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 #92's medical record was reviewed on [DATE]. The medical record review revealed that the latest quarterly comprehensive assessment was dated [DATE]. A care plan developed for the category behavior symptoms had a written goal that this resident would not have inappropriate interactions with other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, review of the medical record and surveyor observation, it was determined that the facility staff failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidenced by failure to identify and monitor resident bruises; failure to properly administer medication, and failure to inform the physician when the resident repeatedly refused or was unable to take a thyroid medication. This was evident for 3 out of the 52 residents (Resident #7, #6 and #57) with investigations completed during the survey. The findings include: 1) During an interview on 6/5/19 at 2:44 PM, the surveyor observed dark purple bruising on Resident #7's left and right forearms. The resident explained it was from bumping them on the edge of the dining room table and that he/she takes a blood thinner causing him/her to bruise more easily. Resident #7's medical record was reviewed on 6/11/19 at 3:04 PM. A Weekly skin observation sheet completed 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 surveyor observation and interview with facility staff, it was determined the facility staff failed to ensure that the resident's environment remained as free of accident hazards as was possible by failing to ensure the resident's swing away bed rail was latched securely in place. This was evident for 1 of 16 residents (Resident #16) reviewed for accidents. The findings include: The surveyor observed Resident #16 in his/her room on 6/6/19 at 9:47 AM. The resident was lying fully dressed on top of his/her neatly made bed resting. ¼ bed rails were on each side of the bed, near the head of the bed. The rail attached to the bed on the resident's right hand side was firmly affixed to the bed frame. The rail on the resident's left hand side, however, swung outward, away from the bed when the surveyor grabbed it. The nurse #3 confirmed on 6/6/19 at 10:00 AM, that the bed rail was not properly latched into place and indicated that it must not have been latched after the resident's bed was made earlier that morning. Review of the resident's record on 6/6/19 at 11:07 AM revealed 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 medical record review, it was determined that the facility failed to keep accurate medical records as evidenced by nursing staff signing off that the resident was assisted with restorative walking with assistance prior to being walked; and failed to clarify a medication order for a medication that was listed as an allergy. This was evident for 2 of 52 residents (Resident #61 and #359) reviewed during the survey. The findings include: 1) Resident #61 was interviewed on 6/6/19 at 9:24 AM. Resident #61 was sitting in a wheel chair at the time of the interview and the resident indicated that s/he was to be walked everyday as part of a restorative program. Resident #61 indicated that s/he was not always walked. Review of Resident #61's care plans in the medical record, on 6/11/19 at 9:38 AM, revealed a problem category for Rehabilitation potential. The care plan indicated that the resident was receiving restorative ambulation care. One of the interventions/approaches of care indicated; Resident will ambulate up to 500 ft with assistance of rolling walker and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to follow The Centers for Disease Control (CDC) and The Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations of residents. This was evident for 2 of the 5 residents (Residents #309 and #6) reviewed for immunizations under the facility task for infection control. The findings include: The CDC and ACIP require that each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. The CDC and ACIP recommends that both the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent pneumococcal conjugate vaccine (PCV13) to be administered routinely in a series to all adults [AGE] years old or older. 1) On 6/10/19 at 1:21 PM, a review of Resident # 309's medical chart failed to reveal evidence that the 2nd dose of the PNA (Pneumonia) vaccine either the PPSV23 or the PCV13 was offered or administered. The first dose of the PNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff, it was determined the facility failed to ensure a functioning call bell system for all residents. This was evident for 1 of 24 resident call bells observed during initial observations. The findings include: An observation was made of room [ROOM NUMBER]-A on 6/6/19 at 9:50 AM. The resident was lying on the bed with the call bell cord beside him/her on the bed. The surveyor pressed the call bell button, however, the light in the hallway above the residents doorway did not light. A second attempt to activate the light also failed. Geriatric Nursing Assistant (GNA #6) was in the hallway and was asked at that time how staff know when a call bell is activated? She shrugged and said the only way you know is if you're in the hallway and see the light on above the door. The call bell for 333-B was tested and the hallway light activated. Unit Nurse Manager #3 was made aware on 6/6/19 at 10:00 AM and confirmed that the call bell was not working. The above concerns…

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