Western Md Hospital Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records review and interviews, it was determined that the facility failed to develop a comprehensive care plan with measurable objectives and timeframe to meet the resident's medical needs. This was evident for 4 (Resident #6, #34, #9 and #24) out of of 24 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 a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) On 5/21/24 at 3:15 PM, a review of Resident #6's medical record revealed the resident resided in the facility for long term care since February 2020 and had multiple diagnosis which included a seizure disorder. Review of Resident #6's most recent quarterly assessment, with 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 observation, medical record review and staff interview, it was determined the facility failed to review and revise resident care plans after each assessment. This was evident for 2 (Resident #13 and #6) of 24 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 a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) Review of Resident #13's medical record, on 5/20/24, revealed the resident had resided at the facility for several years, was alert and oriented and able to verbally communicate. Resident #13 was currently receiving treatment for a UTI with intravenous antibiotics. On 05/20/24 at 02:16 PM, the surveyor conducted an interview with Resident #13. She/He explained that she/he gets recurring UTIs, one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a quality assurance committee which would include an Infection Preventionists at every committee meeting. The findings include: On 5/31/2024 at 1:15 PM, The Administrator provided the attendance sign in sheet for the facility QAPI committee meetings May 2023 through May 2024. Review of the attendance sign in sheets failed to reveal that the infection Preventionists attended the QAPI meetings for 6 consecutive months: The months that did not have a infections preventionist attend were as follows. 4/17/24, 3/20/24, 2/21/24, 1/17/24, 12/20/23, 11/15/23. On 6/04/24 at 12:02 PM, the Director of Quality was interviewed. During the interview she confirmed that the infection preventionists failed to attend the above-mentioned committee meetings. She reported that in 2023 the Infection preventionist was not required to attend every QAPI meeting, however beginning in January 2024 the Infection preventionists were required to attend every meeting.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide the resident or the resident's responsible party with written notice of a room change, including the reason for the change before the resident's room was changed. This was evident for 2 (Resident #31 and #9) out of 4 residents reviewed for choices during the survey. The findings include: 1) A record review on 5/20/24 at 11:00 AM revealed that Resident #31 was admitted to the facility in August 2022 with diagnoses including Dementia. Continued review showed an Minimum Data Set (MDS) assessment dated [DATE] that documented that Resident #31 had severe cognitive impairment with short- and long-term memory loss. 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 subsequent record review revealed that Resident #31 had a room change on 4/18/24. However, the…

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

Based on observation and interview it was determined that the facility failed to ensure areas in need of repair were identified and work orders were implemented. This was found to be evident for 2 out of 2 nursing units observed. The findings include: On 5/20/24 at 1:59 PM surveyor observed water stains on the ceiling above the foot of one of the residents' bed in room K on unit 1 East. On 5/20/24 at 2:34 PM surveyor observed a wall protector below the hand rail across from room E on unit 1 [NAME] was noted to be cracked. On 5/31/24 at 2:15 PM the Maintenance Director (Staff #55) reported that if problems are reported they can put in an e work order which is a program to request repairs. And if there is damage the nurse usually calls and puts an order in. He went on to report they do room checks every week and a walk thru every morning. On 5/31/24 a tour of the facility was conducted with the Maintenance Director between 2:27 - 2:42 PM. The areas identified on 5/20/24 of the cracked wall protector in the 1 [NAME] hallway and of the ceiling in room K on 1 East were still present.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility staff failed to report an allegation of abuse to the Office of Health Care Quality in a timely manner. This was evident for 1 (Resident #31) out of 6 residents reviewed for abuse during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A record review on 5/21/24 at 11:29 AM revealed that Resident #31 was admitted to the facility in August 2022 with diagnoses including Dementia. Continued review showed an MDS assessment dated [DATE] that documented that Resident #31 had severe cognitive impairment. Further review on the same day of a facility-reported incident related to Resident #31 with MD00202413 was conducted. The review showed that an allegation of abuse was reported to the Nursing Home Administrator (NHA) on 2/7/24 at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and interviews, it was determined that the facility failed to provide documentation that a thorough investigation of potential abuse was completed. This was evident for 3 (Resident #98, #15, and #9) out of 6 residents reviewed for abuse during the survey. The findings include: 1) On 5/22/24, review of facility report revealed that Resident # 98, a long-term resident of the facility, reported an allegation that he/she received abuse from a facility staff member. On 5/29/24 at 9:37 AM, review of social service progress notes dated 7/27/22, revealed that Resident #98 reported to social worker that he/she had received maltreatment by staff. Further review revealed that the resident was unable to provide any further identifying information and that the allegation was reported to nursing staff and administrator who was the abuse coordinator. The facility reported this allegation to the Office of Health Care Quality (OHCQ). On 5/22/24 at 12: 30 PM, the Administrator provided a 1-page document of the facility's findings in their investigations of…

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

Based on records review and interviews, it was determined that the facility failed to communicate the residents comprehensive care plan goals to the receiving healthcare institution to ensure safe and effective transition of care. This was evident for 2 (Resident #24, and #19) of 4 residents reviewed for hospitalizations. The findings include: 1) Resident #24 had been residing in the facility since 2020. On 5/21/24 at 10:46 AM, a review of the resident's medical record at this time indicated that the resident had been sent to the hospital 2 times in 2024. On 5/23/24 at 10:13 AM, a Registered Nurse (RN Staff #20) was interviewed about her process when a resident has an order to be transferred to the hospital. Staff #20 reported her process including the notifications and documentation she would prepare to facilitate the resident transfer. Staff #20 then proceeded to provide the surveyor with a sample of all the documents she would print out for Resident #24 if s/he was to be sent out to the hospital at that time. A review of the documents provided failed to reveal care plan goals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents in writing of a transfer, along with the reason for transfer, and failed to notify the Office of the State Long-Term Care Ombudsman of a transfer/discharges of residents. This was evident for 2 (Resident #19 and #24) of 4 residents reviewed for hospitalization. The findings include: 1) On 5/20/24 at 1:32 PM, a review of Resident #19's medical record revealed the resident had a change in condition on 3/26/24, was transferred to the hospital was readmitted several days later. Continued review of Resident #19's medical record failed to reveal documentation to indicate the resident received written notification of the transfer. On 5/23/24 at 11:00 AM, during an interview, Staff #6, Licensed Social Worker (SW), stated that when a resident was capable, nursing verbally informed the resident when s/he was being transferred to the hospital and verbally notified the resident's representative/family. The SW (Staff #6) stated that when a resident was sent to the hospital and remained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, records review and interviews, it was determined that the facility failed to provide a resident unable to carry out activities of daily living the necessary services to maintain good oral hygiene. This was evident in 1 (Resident #11) out of 2 residents reviewed for tube feeding. The findings include: Resident #11 had been residing in the facility since 2016. On 5/20/24 at 2:22 PM, the resident was observed in bed with white secretions in the mouth and surveyor noted concerns regarding oral care. On 5/21/24 at 9:29 AM, Resident #11's Minimum Data Set (MDS) assessment with a reference date of 3/16/24 was reviewed and indicated that the resident was severely impaired with cognitive skills and was dependent on staff for self-care including oral hygiene. Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 5/22/24 at 7:56 AM, a review of Resident #11 orders revealed that oral care was to be provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pertinent document review and interviews, it was determined that the facility failed to implement physician orders for 15-minute safety checks. This was evident for 1 (Resident #98) out of 1 resident reviewed for behavioral or emotional care during the survey. The findings include: On [DATE] review of medical record revealed that Resident #98 was a long-term resident of the facility with a history of depression and previous suicide attempts, while a resident at the facility. On [DATE] at 12:16 PM, review of a progress note dated [DATE], revealed nursing staff discovered Resident #98 in his/her room with a cord wrapped around his/her neck and the resident refused to surrender the cord when the nursing staff attempted to remove it. Further review revealed the resident was transferred to a local hospital for psychiatric evaluation. On [DATE] at 9:29 AM, review of physician's orders with a start date of [DATE], revealed an order, Every 15 minutes checks for safety document in three ring binder in Nurses…

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

Based on medical record review and interviews it was determined that the facility failed to provide services consistent with professional standards of practice to prevent the development of pressure ulcers and promote healing of existing pressure ulcers/injuries. This was evident for 1 (Resident #6) of 2 residents reviewed for pressure ulcers. The findings include: Pressure ulcers, also known as pressure sore or decubitus ulcer, is any lesion or injury caused by unrelieved pressure that results in damage to the underlying tissue and staged according the their severity from Stage 1 (area of persistent redness), Stage 2 (superficial loss of skin such as an abrasion, blister or shallow crater), Stage 3 (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage 4 (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 5/21/24 at 11:04 AM, a review of the facility's Matrix (used 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 medical record and other pertinent documentation review and interviews it was determined that the facility failed to ensure geriatric nursing assistants were competent to provide care to a resident dependent on mechanical ventilation. This was found to be evident for one (Resident #40) out of four residents reviewed for respiratory care. The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility in February of 2024 with a history of stroke and dependence on mechanical ventilation due to respiratory failure. The resident had severe cognitive impairment and was non-verbal. Review of the facility investigation documentation for MD00205708 revealed that on 5/14/24, in response to a ventilator alarm sounding, Respiratory Therapist (Staff #46) entered the resident's room and observed two agency GNAs (Staff #49 and #50) transferring the resident to a chair using a hoyer lift. The tubing used to provide mechanical ventilation to the resident was not attached at this time. The Respiratory Therapist re-connected the tubing to the…

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

Based on 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, and that the attending physician documented in the medical record that the review has been completed and what, if any, action has been taken to address it; and failed to develop policies and procedures that included time frames for the physicians to complete this review. This was evident for 2 (Resident #6 and #9) of 5 residents reviewed for unnecessary medication. The findings include: 1) On 5/24/24 at 9:00 AM, a review of Resident #6's electronic health record (EHR) reveal Medication Management - Medication Regimen Review (MM-MRR) notes that documented the pharmacist's results of the MRR and the pharmacist's recommendations for identified irregularities. 1a) On 9/14/23, in a MM-MRR note, the pharmacist wrote that on 8/18 and 9/11, under chronic pain syndrome, the physician documented that Resident #6 was on Oxycodone (narcotic) and Gabapentin (treats nerve pain) for pain. 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 interviews, it was determined that the facility failed to ensure a resident received medication according to an attending physician's orders. This was evident for 1 (Resident #32) out of 5 residents reviewed for unnecessary medications. The findings include: Medical record review on 5/28/24 at 11:52 AM found that Resident #32 was admitted to the facility in December 2022 with diagnoses including hypertension (high blood pressure). Further review on 5/31/24 at 10:30 AM showed an attending provider's order dated 12/20/22 for an antihypertensive medication to be administered twice daily to Resident #32. The order had parameters to hold (not to give) the medication for an SBP less than 100 mmHg (millimeters of mercury) and an apical pulse less than 55. Blood pressure (BP) is often written as an upper and lower number. Systolic blood pressure (SBP) is the upper number. It measures the pressure in the arteries during heart muscle contraction. A pulse is the heart rate. It's the number of times the heart beats in one minute. The apical pulse is the…

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

Based on medical record review and staff 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, side effects, or adverse consequences related to a resident's use of psychotropic medication. This was evident for 1 (Resident #6) of 5 residents reviewed for unnecessary medications. The findings include: On 5/21/24 at 3:15 PM, a review of Resident #6's medical record revealed the documentation that the resident resided in the facility for long term care since February 2020 and had diagnoses that included bipolar disorder (manic depression) (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident #6's May 2023 Electronic Medication Administration Summary (eMAR) revealed a 9/27/22 order for Mirtazapine (Remeron, an antidepressant) Tablet by mouth one time per day for bipolar disorder that was documented as given every day as ordered from 5/1/24 to 5/21/24. Continued review 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 observation, interview, and pertinent document review, it was determined that the facility failed to properly store medical devices and medications according to the manufacturer's guidelines to ensure their safe and effective use. This was evident for 2 out of 2 nursing units during the survey. The findings include: 1. On 5/29/24 at 1:15 PM, an observation was made of medication cart #1 with Nurse Supervisor Staff #13. Observation of the medication cart drawer revealed a box of approximately 20 safety lancets (a device that is used to measure blood glucose). The lancets were not in their original box and Staff #13 reported she could not report the expiration date of the devices. On 5/29/24 at 1:20 PM, during a brief interview with Staff #13, she reported that all the medication carts are designed for the safety lancets being placed in the cart and not in their original box with an expiration date. On 5/29/24 at 2:14 PM, an observation was made of the East Wing medication storage room with Nurse Supervisor Staff #13. Observation revealed a wall cabinet. Further review 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 review and staff interviews, it was determined that the facility failed to ensure an order was in place for a resident requiring and requesting dental services and failed to develop a care plan to address this issue as well. This was evident for 1 (Resident #9) of 2 Residents reviewed for dental. The findings include: Review of Resident #9's medical record on 5/20/24 revealed the resident had resided at the facility for several years, was alert and oriented and able to verbally communicate. Resident #9 is dependent on staff for transfers out of bed and mobility due to weakness. An interview with Resident #9 on 05/20/24 at 03:02 PM revealed that she/he has been experiencing frequent tooth pain. Review of medical record revealed that on 12/26/2023 the Nurse Practitioner (Staff #22) completed a progress note that included the resident reporting tooth pain. Staff #22 assessed the finding and prescribed Anbesol gel for the pain to be given as the resident needs. Anbesol gel is an oral topical gel used for temporary mouth discomfort. Review of the minimum data set (MDS)…

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

Based on record reviews and interviews, it was determined that the facility failed to maintain complete and accurate medical records for its residents. This was evident for 3(Resident #6, #21, and #96) of 24 residents reviewed during the survey. The findings include: 1a) On 5/20/24 at 11:24 AM Resident #6 was observed to have his/her hands in a cupped position indicating possible contractures (fixed resistance to passive stretch of a muscle). There was no splint or device in place in either of the resident's hands and soft palm protectors were observed on the resident's bedside table. On 5/21/24 at 3:15 PM, a review of Resident #6's medical record revealed the resident resided in the facility for long term care since February 2020 and had multiple diagnosis, including traumatic spinal cord dysfunction and contractures of muscle of his/her right lower leg, left lower leg, right upper arm and left upper arm. Resident #6's quarterly assessment with an assessment reference date (ARD) of 4/13/23 documented Resident #6 had a functional limitation in range of motion (ROM) in both upper…

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

Based on record review and interview it was determined that the facility failed to 1) conduct a root cause and analysis on the deficiencies cited during the recertification survey which resulted in reciting the same deficiencies and 2) ensure that they were in compliance by their alleged compliance date. This was evident throughout the revisit. The finding include: 1a. During the revisit survey it was determined that the facility was not sending the transfer notice to the resident's representative [F623]. An interview with the Social Work Supervisor Staff #7 on 9/12/24 at 1:30 PM, confirmed that if a resident had capacity the transfer notice was not being sent to the resident representative as required. They failed to ensure that the regulatory requirement was implemented. 1b. During the revisit it was determined that the facility was not incompliance with providing quality of care to the residents [F684] as staff continued to fail to follow physicians' orders. During a medication pass observation on 9/10/24 at 8:15 AM it was determined that the nurse failed to give a medication…

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

Based on review of 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. This was evident for 1 (#17) of 2 residents reviewed urinary tract infection/catheter, 2 (#15, #5) of 5 residents reviewed for unnecessary medications and 1 (#12) of 2 residents reviewed for pressure ulcers. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #17's medical record was reviewed on 5/22/19. The record revealed numerous Care Plan Progress Notes and Evaluations. Many indicated that the resident's goal was evaluated and continued to be appropriate. Resident #17 was reviewed for risk for infection related to suprapubic catheter. The goal was written as, Resident will remain free from infection. The resident was noted to have been sent out to an acute care hospital at least three times in the past quarter for urinary tract…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to develop care plans that were person-centered and had measurable goals. This was evident for 5 (#31, #17, #15, #5, #10), of 15 residents reviewed during the investigation stage of 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. 1) Review of Resident #31's medical record on 5/20/19 at 1:54 PM revealed that all goals for care plan problems were written as self-centered to the resident. A care plan problem indicated that Resident #31 was at risk related to a language barrier. The goal was not person/resident centered as it indicated that Resident #31 will have all needs met by staff. 2) Resident #17's medical record was reviewed on 5/22/19. Review of Resident #17's care plans revealed that some of the care plan goals were not resident centered. The resident was dependent on staff for total activities of daily living (ADL) care and the…

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

Based on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to a resident to ensure an orderly transfer to an acute care facility. This was evident for 2 (#17, #11) of 3 residents reviewed for hospitalization. The findings include: 1) On 5/22/19 at 10:57 AM, review of Resident #17's medical record revealed documentation that Resident #17 was sent to an acute care facility on 2/13/19. The progress note, written by a nurse on 2/13/19 timed for 2:09 AM, revealed that the resident had complained of chest pain, with complaints of generalized pain and that the resident was shivering. The note revealed that Resident #17 was sent to the ER (emergency room). There was no documentation found in the medical record that the resident had been prepared and oriented to the transfer. Documentation regarding Resident #17 for 3/31/19 at 6:31 PM revealed that Resident #17 was admitted to an acute care facility without any documentation related to preparation and orientation of the resident prior to being transferred…

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