Citizens Care Center

Based on clinical record review, resident interview, and staff interview, it was determined that facility staff failed to ensure a resident received routine dental services. This was evident for one (Resident #5) out of three residents reviewed for dental services during the recertification/complaint survey. The findings include: This surveyor interviewed Resident #5 on 1/22/26 at 9:41 AM. This surveyor asked if the resident has seen a dentist in the past 12 months and if the resident was having any mouth pain. The resident stated that they have not been to the dentist or had a dentist come to see them at the facility for over a year. The resident also reported no mouth or tooth pain. This surveyor interviewed the Unit Manager (#26) for Bay Lane unit on 1/22/26 at 12:05 PM. She said they assess residents for pain, discomfort, chewing and/or swallowing issues and will call the dentist when appropriate. She was unaware that the resident needed to go to the dentist since the resident has not been complaining or has stated a need to see a dentist. A review of the clinical record on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the investigation of complaints, medical record review, and staff interviews, it was determined that the facility failed to update residents' (and/or responsible parties') wishes related to life-sustaining treatment and assess residents' capacity to make decisions in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.The findings include:A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient.As a portion of the investigation into complaint #361874, the surveyor reviewed Resident #8's medical records on [DATE] at 8:30 AM. The review revealed that the resident was their own Responsible Party (RP) 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 the investigation of complaints, medical record review, and interviews with facility staff, it was determined that the facility failed to ensure that changes in residents' condition were notified to the physician in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.The findings include: As part of the investigation into complaint #361874, the surveyor reviewed Resident #8's medical records on 11/05/25 at 8:30 AM. The review revealed the following: -Staff #11 (Registered Nurse) documented in a progress note on 5/12/25 at 12:38 PM that Resident #8 was tearful with increased confusion.-Staff #4 (Social Worker) recorded Resident #8's confusion on 5/12/25 at 1:26 PM in a progress note, stating: [Resident's name] was tearful during our exchange. Unable to provide year, month stating 'I'm confused.'However, there was no documentation indicating that Resident #8's change in mental status was notified to the provider.In an interview with the Assistant Director of Nursing (ADON) on 11/05/25 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 an investigation of intakes, reviewing medical records, and interviewing facility staff, it was determined that the facility failed to ensure that a resident's Treatment Administration Records (TAR) were correctly documented. This was evident for one (Resident #8) of eight residents reviewed for care during this complaint survey.The findings include:During the investigation of complaint #361874, on 11/05/25 at 8:30 AM, it was noted that Staff #8 ( Licensed Practical Nurse) wrote a progress note on 5/14/25 at 7:14 PM as returned from hospital without boots.Further review of Resident #8's progress notes revealed that multiple staff documentation about the resident's boots, which could not be found. Specifically: A note dated 5/15/25 by Staff #4 wrote, Resident #8 reported that he/she don't know where his/her blue boots were he/she was supposed to wear them. The nurse clarified that there were no boots. A note dated 5/16/25 by Staff #4 wrote, Resident asked for his/her blue boots. Nursing to follow up. A note dated 5/17/25 by Staff #9 (Registered Nurse) wrote that they were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with facility staff it was determined the facility failed to: (1) to ensure that a resident followed up with the Urologist for management of the foley catheter; (2) transcribe physician pain scale orders for resident #1. (3) follow a treatment order as ordered by the physician for resident #59. (4) follow physician orders as evidenced by a resident not being properly positioned to receive enteral nutrition, enteral nutrition not being administered during the ordered times, medications were not administered the times ordered, and the ordered amount of oxygen was not delivered for several days. This deficient practice was evident in 5, (Resident #1 # 18, #33, #59, #100) of 38 resident records reviewed during the Survey Findings include: 1. The facility failed to ensure that resident #18 followed up with the Urologist for management of the foley catheter. A medical record review was done on 5/2/24 at 10:00 AM and it revealed resident # 18 was admitted to the facility with the following but not limited to diagnosis: Multiple Sclerosis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to ensure that water temperatures remained within acceptable range. This was found to be evident during 11 room observations made of the Harbor View Unit and 2 residents (#31,#32) during the facility's survey. Findings include: 1. On 4/30/24 at 10:39 AM the surveyor made observations of water temperatures in resident rooms located on the Harbor View Unit. Bathroom temperatures for the following rooms were observed: Room# 148 had a temperature of 122 degrees Fahrenheit (F) Room # 149 had a temperature of 122 degrees F Observations were made on the same date at 11:05 AM of the water temperatures of the sink located inside the resident rooms as follows: Room # 149 sink temperature was 120 degrees F Room # 150 sink temperature was 120 degrees F After the surveyor identified elevated temperatures on the above unit, the Director Maintenance of (DOM), Staff # 21 was notified and arrived on the unit at 11:30 AM to obtain…

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

Based on observations and interviews it was determined that the facility staff failed to get a resident out of bed for four out of five days and failed to dress the resident in his/her own clothing. This deficient practice was evident in 1(#59) of 2 residents observed for dignity during the survey. The findings include: On 04/29/24 at 1:14 pm The surveyor entered Resident #59's room and observed him/her in bed wearing a soiled hospital gown, and tube feed infusing. On 05/01/24 at 10:35am The surveyor observed Resident #59 in bed wearing a hospital gown, and his/her hair was not combed. On 05/02/24 at 10:35am The surveyor observed Resident #59 in bed wearing a hospital gown, uncombed hair, and the blinds closed. During an interview with Geriatric Nursing Assist (GNA)#30 on 05/02/24 at 1:46 pm, the GNA reported being assigned to Resident #59 the previous day (05/01/24) and the resident prefers to wear a hospital gown while in bed. GNA#30 did not get Resident # 59 out of bed (OOB) on 05/01/24 or 05/02/24. Resident #59 did not get out of bed Monday (4/29/24) and had on a gown because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 issue the bed hold notice. This was evident for 1 out of 1 resident (#109) reviewed for hospitalization during the facility's recertification survey. The findings include: Review of the medical record by the surveyor on 5/3/24 at 11:16AM revealed a nursing progress note dated 9/24/21 that Resident #109 was transferred to the hospital on 9/24/21, however, no documentation could be found in the medical record to indicate the facility issued the bed hold notice. On 5/3/24 at 11:32AM the surveyor made a request to the Director of Nursing (DON) for any documentation of the bed hold notice having been provided to Resident #109 and/or their representative. During an interview on 5/3/24 at 12:15PM the DON informed the surveyor that the facility did not have any documentation that the bed hold policy was issued to the resident.

Based on a review of the medical record and interviews with the facility staff it was determined the facility failed to follow the resident care plan for the management of a resident with a foley catheter. This was found to be evident for 1 (Resident # 18) of 39 residents reviewed during the facility's survey. 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. A medical record review was done on 5/2/24 at 10:00 AM and it revealed resident # 18 was admitted to the facility with the following but not limited to diagnosis: Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), and Benign Prostatic Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Review of the facility resident matrix indicated the resident currently had an indwelling catheter in place. The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, and record review, it was determined that the nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident room. This was evident for 1 (Resident #89) of 4 residents observed for professional standards. The findings include: On 04/30/24 at 11:39 AM, the surveyor observed Licensed Practical Nurse (LPN) #22 administer medications to Resident #89. LPN #22 placed a dark amber colored liquid in a small cup at the resident's bedside table. The LPN left the room. The cup was untouched, and no directions were given to the resident on what to do with the cup. On 04/30/24 at 11:41 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) #25 and LPN #22. GNA #25 stated that's the protein when asked about what was in the cup on Resident #89's bedside table. When the surveyor asked LPN #22 about what the standard of practice is when administering medications, the LPN confirmed it is the standard of practice to ensure the resident completes the medication before leaving the…

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

Based on interviews and record review the facility failed to demonstrate that annual performance reviews were conducted for geriatric nursing assistants (GNAs)annually based on the employee's hire date. This was determined and evidenced to be true for 4 out of 4 GNAs, (GNA #40, 41,42, and 44) during the review of facility human resource and staff education files while performing the staffing facility task during the survey. The findings include: On 05.06.24 at 1:52 PM the surveyor requested the director of nursing (DON) to provide seven human resources records and seven staff education records. On 05.06.24 at 2:30 PM the surveyor received seven staff education records which included two registered nurses, one LPN and four geriatric nursing assistants. On 05.07.24 at 08:30 AM the surveyor reviewed the staff education records of four certified GNAs. The surveyor was not able to find any evidence of performance evaluations completed for four GNAs (#40,41, 42,44) for the years of 2022 or 2023. During an interview on 05.07.24 at approximately 10:07 AM, with the director of nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff, it was determined that the facility failed to address a pharmacy recommendation in a timely manner. This was evident for 1 (Resident #3) of 5 residents reviewed for unnecessary medications. The findings include: The medical abbreviation PRN stands for 'pro re nata,' which means that the administration of medication is not scheduled at prescribed times, but instead, the medication is taken on an as needed basis. On 5/3/24 at 9:48 AM review of the medical record revealed a document titled Letter to Physician from the pharmacist, Staff #37, with a medication regimen review (MRR) dated 3/8/24 that stated: Resident has an order for PRN lorazepam. Please note all PRN psychotropic drugs require a stop date, regardless if resident is hospice. Please specify a stop date of 14 days or, in order to extend a PRN order past 14 days: 1) The prescriber must document their rationale in the medical record (such as end of life) and 2) Indicate the duration for the PRN order (consider 3 or 6 months and then reevaluate). In the section, titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to monitor a resident for side effects who was prescribed psychotropic medication. This deficient practice was evident for 1 (#33) of 2 medical records reviewed for side effects of medications during the Survey. The findings include: On 4/29/24 at 9:49 AM the surveyor reviewed Resident #33 medication administration record (MAR) and treatment administration record (TAR) revealed on 08/05/22 at 10 am the resident was ordered Zyprexa 2.5 mg by mouth every am and on 06/05/23 at 9 pm the resident was ordered Zyprexa 7.5 mg by mouth at bedtime. On 5/7/24 at 10:00 AM on further review of Resident #33 MAR/TAR revealed there was no documentation to verify the resident was being monitored for psychotropic medication side effects. On 05/07/24 at 11:21 am during an interview with License Practical Nurse (LPN) #22, the surveyor asked what the process is for monitoring a resident on psychotropic medications for side effects. Nurse #22 reported that if he/she noticed a change in behavior, it will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of facility staff it was determined the facility failed to ensure a medication was not left unattended and failed to: (1) ensure a medication cart was locked evident for one medication cart observed : (2) discard expired medications, properly store medical supplies, and check the refrigerator temperatures for biologicals and supplements. This deficient practice was evident in 2 out of 2 medication storage rooms assessed during the survey. The findings include: 1. On 5/6/24 at 12:49PM, the surveyor observed one medication cart on the Bay Lane Unit unattended with the lock mechanism protruding, indicating the cart was unlocked. Upon further observation of the cart, the surveyor observed one labeled Baclofen (muscle relaxant) medication blister packet containing a pill sitting on the work surface of the cart with a pair of scissors next to it. Upon sliding each drawer mechanism, the surveyor was able to open all drawers of the cart which contained various medications and supplies. On 5/6/24 at approximately 1:00PM Staff #36, Registered 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 record review, interview and observation it was determined the facility failed to: 1.) date and sign inventory sheets for resident personal effects, and 2.) failed to ensure accuracy of a medical order. This was evident for 2 out of 2 resident's inventory sheets (#39, #42) reviewed and 1 out of 3 residents reviewed for pressure ulcers during the facility's recertification survey. The findings include: 1.) On 4/30/24 at 10:04AM Resident #39 reported to the surveyor that their bottom dentures had broke in half and they preferred to have them. On 5/3/24 at 11:53AM the surveyor conducted a review of the medical record and observed the inventory sheet in the paper chart which listed personal effects for the resident, however, it did not include any denture(s) listed. Upon further review of the inventory form, there was no signature of anyone confirming the personal effects listed or date on the form to determine when the inventory occurred. On 5/3/24 the surveyor conducted an interview with Staff #30, Geriatric Nursing Assistant, who reported to the surveyor that they were 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 interviews and record review the facility failed to ensure that four geriatric nursing received and completed a total of 12-hours of clinical training annually. This was determined and evidenced to be true for four out of four GNAs, (GNA #40, 41,42, and 44) human resource and staff education files reviewed during the survey. The findings include: On 05.06.24 at 1:52 PM the surveyor requested the director of nursing (DON) to provide seven employee human resources records and seven employee staff education records. These files included 4 geriatric nursing assistants (GNAs), one licensed practical nurse (LPN#39), and two registered nurses (RN #43 and # 45). On 05.06.24 at 2:30 PM the surveyor received seven staff education records which included two registered nurses, one LPN and four geriatric nursing assistants. The DON was unable to provide written documentation that the four GNAs completed a total of twelve hours of clinical education training annually during 2022 and 2023. On 05.07.24 at 2:30 PM the surveyor interviewed staff #9, staff educator who stated that she that…

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

Based on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident (#4) to reflect accurate and current interventions. This was evident for 1 of 1 residents reviewed for care plans during the survey process and 1 of 49 residents reviewed during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reviews of a medical record and staff interview, it was determined the facility staff failed to follow a physician's order and apply had splints to a resident daily, to take steps to address skin discolorations on a resident's legs, to address and notify the physician of results of an abnormal blood sugar level. This was evident for 3 (Resident #3, #52, and #77) of 49 residents reviewed during an annual recertification survey. The findings include: 1) During an observation of Resident #3 on 04/29/19 at 1:21 PM, the surveyor observed Resident #3 to have bilateral hand contractures and there were no splints applied to Resident #3's hands at that time. A review of Resident #3's medical record revealed a physician order, dated 04/16/19, instructing the nursing staff to apply bilateral palm protectors to Resident #3's hands from 9 AM to 9 PM. The 04/16/19 physician order also instructed the nursing staff to remove Resident #3's for washing, to keep Resident #3's hands clean and dry, as well as perform daily stretching. A review of Resident #3's April 2019 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 reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on the entire nursing assistant staff for the year of 2018, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year. The findings include: 1) In an interview with the Director of Nursing (DON) on 05/02/19 at 10:27 AM, the facility DON stated that none of the geriatric nursing assistant staff received a performance evaluation for 2018. 2) On 05/02/19, a review of 5 random (GNA) staff members, educational records for 2018, revealed that 5/5 GNA's (staff member #9, #10, #11, #12, and #13) failed to complete at a minimum of 12 hours of education for the year of 2018.

Based on dining observation and interview, it was determined the facility staff failed to provide Residents (#6 and #103) with the most dignified existence with dining. This was evident for 2 of 9 residents observed for dining in the first-floor dining room. The findings include: Surveyor observation of lunch in the first-floor dining room on 4/30/19 revealed residents #29 and #59 at a table eating lunch at 12:20 PM. Further observation revealed the facility staff brought Residents #6 and #103 into the dining room and sat them at the same table with Residents #29 and #59 who was currently eating. Residents #6 and #103 were alert and observing Residents #29 and #59 eating to the point of Resident #103 questioning the other resident about eating and did they have their food yet. Further observation revealed the facility staff failed to provide lunch to Residents #103 and #6 until 12:40 PM, 20 minutes after initial placement at a table with Resident #29 and #59 eating. Interview with the Director of Nursing on 5/1/19 at 1:30 PM confirmed the facility staff failed to provide Residents…

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

Based on medical record review and interview it was determined the facility staff failed to provide showers to Resident (#4). This was evident for 1 of 49 reviewed for choices during the annual survey process. The findings include: Medical record review for Resident #4 revealed the resident was to have showers on Tuesday and Friday day shift. Interview with the resident on 4/29/19 at 10:19 AM revealed the resident stating he/she is always the last resident to be showered, after 12:00 PM and Resident #4 wanted showers to be early. Further record review revealed the facility staff documented showers for Resident on: 4/2/19 at 2:20 PM, 4/16/19 at 3:39 PM, 4/19/19 at 2:32 PM and 4/30/19 at 2:19 PM. Further record review revealed the facility staff failed to provide a shower to Resident #4 on 4/5/19, 4/9/19, 4/12/19, 4/16/19, 4/23/19 and 4/26/19 and there is no evidence of the resident refusing shower on those days. Interview with the Director of Nursing on 5/1/19 at 10:00 AM revealed the resident does like showers early and in talking with the resident will change shower times to night…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility staff failed to ensure an advance directive was in place for Resident (#33). This was evident for 1 of 6 residents selected for review of advance directives and 1 of 49 residents selected for review during the annual survey process. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The (Medical Orders for Life-Sustaining Treatment) MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). DNR order, is a medical order written by 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 observation, medical record review and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Resident #75). This is evident for 1 of 3 residents selected for review for ADL care and 1 of 49 reviewed during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. Surveyor observation of Resident #75 on 5/1/19 at 1:30 PM revealed the resident's finger nails on left hand, ring finger of left hand extremely long and jagged, it was…

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

Based on clinical record review, observation and staff interview it was determined the facility staff failed to ensure Resident (#75) was being turned and repositioned as ordered. This was true for 1 out of 49 residents selected to be reviewed for pressure ulcers. A nursing care plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in patient care would be lost. Pressure ulcers are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. One preventative measure to in the development of pressure ulcers is: change positions frequently. When you change positions often, there will be less pressure on your skin, reducing your risk of developing pressure…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#53) with the physician ordered nutritional services and failed to document the amount of supplement consumed. This was evident of 1 of 4 residents selected for review of nutrition during the annual survey process and 1 of 49 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to provide Resident #53 with the physician ordered nutritional services. Medical record review for Resident #53 revealed on 9/12/18 the physician ordered: resident to have distant supervision for all meals. resident to go to dining room for lunch on days that are provided, in day room on unit for all other meals. resident to have 2-3 items in front of her/him instead of whole tray to help reduce distraction. Surveyor observation of Resident #53's breakfast on 4/30/19 at 8:40 AM revealed Resident #53 eating breakfast in the room and the facility staff failed to provide the resident with 2-3 items in front of him/her. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct AIMs testing on Residents (#74). This was evident for 1 of 49 resident selected for review during the survey process. The findings include: The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970's to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. Tardive dyskinesia is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs, which affects 20%-30% of patients who have been treated for months or years with neuroleptic medications. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance. 1. The facility staff failed to conduct an AIMS on Resident #74. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, reviews of a medical record, and staff interview, it was determined that the facility staff failed to take steps to obtain dental services for a resident. This was evident for 1 (Resident #112) of 3 residents reviewed for dental services during an annual recertification survey. The findings include: In an interview with Resident #112 on 04/29/19 at 11:14 AM, Resident #112 stated that s/he had not seen a dentist since being admitted to the facility. A review of Resident #112 medical record failed to reveal any documentation Resident #112 was offered the opportunity to be seen by the facility dentist. A review of Resident #112's resident fund account on 05/02/19 revealed Resident #112 had monies that could be used for a dental consultation. In an interview with staff member #14 on 05/02/19 at 9:19 AM, staff member #14 stated that s/he could not locate any documentation about Resident #112 receiving dental services, but s/he would continue to look. Review of Resident #112 annual 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 observation of medication pass, it was determined the facility staff failed to administer medications without using bare hand contact. This was evident for 1 of 5 residents observed for medication observation and 2 out of 37 opportunities. The findings include: Medical record review for Resident #14 revealed on 7/1/14 the physician ordered: Lyrica 75 milligrams by mouth and on 10/13/17 ordered Zantac 150 mgs by mouth every morning for reflux-acid indigestion. Lyrica is used to treat pain caused by nerve damage due to diabetes, shingles (herpes zoster) infection, or spinal cord injury. Zantac is used to treat ulcers of the stomach and intestines and prevent them from coming back after they have healed. This medication is also used to treat certain stomach and throat (esophagus) problems such as gastroesophageal reflux disease-GERD- acid indigestion. It works by decreasing the amount of acid the stomach makes. Observation of medication pass on 5/1/19 at 8:40 AM revealed the facility staff nurse #8 dropped the Lyrica and the Zantac on top of the medication cart. At that time,…

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