Complete Care At Hyattsville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that Advance Directives were discussed with residents and/or responsible representatives. This was for 1 (Resident #2) of 8 residents reviewed for Advance Directives.The findings include:Resident # 2's clinical record revealed that the resident was admitted to the facility in [DATE] and their most recent re-admission was in [DATE]. The resident's diagnoses include Anoxic Brain Damage and End Stage Renal Disease.On [DATE] at 3:22 PM a review of Resident #2's clinical record revealed a MOLST (Maryland Orders for Life-Sustaining Treatment) form. The MOLST, which was dated [DATE], revealed verbal consent by the resident's Responsible Representative for CPR in the event of cardiac and/or pulmonary arrest (CPR). The clinical record failed to reveal the presence of an Advance Directive or that the Advance Directive was discussed with the Resident and/or Responsible Representative.Further, a review of the resident's Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and interviews it was determined that the facility failed to ensure the Ombudsman was notified of transfers and discharges. This was found to be evident for 2 (Resident #88 & #232) out of 2 Residents reviewed for hospitalization during the recertification survey.The findings include: During a review of Resident #88's medical record conducted on 09/18/2025 at 8:18 AM it was discovered that the Resident experienced a medical emergency and was transferred to a local hospital on [DATE]. During a review of Resident #232's medical record conducted on 09/18/25 at 8:47 AM it was discovered that the Resident was transferred to a local hospital on [DATE]. During an interview conducted on 09/18/25 at approximately 9:00 AM, this Surveyor asked the Nursing Home Administrator (NHA) to provide the Ombudsman notification for transfers and discharges.On 09/18/25 at approximately 11:45 AM the Nursing Home Administrator (NHA) provided this Surveyor with a printout of an email dated 09/18/25 at 11:26 AM from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately coded for residents. This was evident for 2 (Resident #123 and #168) out of 46 sampled residents reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a federally mandated comprehensive clinical assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. 1.On 09/19/2025 at 3:05 PM, a review of Resident #168's clinical record revealed the following physician order: Date 03/21/2025 for ADMIT to Hospice of the Chesapeake with a hospice diagnosis. Further review of Resident #168's clnical 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 clinical record review and interviews, it was determined the facility failed to provide residents and/or responsible representatives with summaries of their Baseline Care Plans. This was evident for 2 (Resident #3 and #14) of 46 residents reviewed during the annual /recertification survey.The findings include:A Baseline Care Plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident and/or their responsible representative.Resident #3 was admitted to the facility in June 2025 with diagnoses including Chronic Respiratory Failure and Anoxic Brain and is ventilator dependent.On 09/18/25 at 10:55 AM the surveyor reviewed Resident #3' clinical record. The record failed to reveal any evidence that the resident's Baseline Care Plan was discussed with the Resident and/or Responsible Representative and a copy…

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

Based on interviews and record reviews it was determined the facility failed to ensure Resident Care Plans were developed. This was found to be evident for 1 (Resident #6) out of 1 Resident reviewed for Care Plans during the recertification survey.The findings include: A Care Plan is a comprehensive document that outlines the specific healthcare needs, goals, and interventions for an individual patient. It serves as a roadmap for healthcare providers, ensuring coordinated and personalized care. During a record review conducted on 09/22/25 at 12:43 PM, it was discovered that Resident #6 had a diagnosis of schizoaffective disorder. During a review of Resident #6's Care Plan conducted on 09/22/2025 at 1:10 PM it was discovered that the Resident did not have a care plan for schizoaffective disorderDuring an interview conducted on 09/22/25 at approximately 1:30 PM, this Surveyor and Director of Nursing (DON) reviewed Resident #6's Care Plan with revisions. The DON confirmed that the Resident did not have a Care Plan for a schizoaffective disorder. The DON stated that he would add a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews it was determined that the facility failed to ensure staff provided services that met professional standards of practice. This was found to be evident for 1 (Resident #88) out of 1 Resident reviewed for services meet professional standards of practice during the recertification survey.The findings include: During a review of Resident #88's medical record conducted on 09/18/2025 at 8:18 AM it was discovered that the Resident experienced a medical emergency and was transferred to a local hospital on [DATE]. A review of Resident's #88 medical records conducted on 09/18/25 at 8:35 AM revealed a physician certification form dated 06/05/23. The form deemed the Resident unable to understand and sign admission documents and other information, unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risks, and benefits of the treatment, unable to effectively communicate 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, interview and record review, it was determined that the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident. This was found evident for 1 (Resident #20) out of 1 resident reviewed for ADL care. The findings include:According to the Centers for Medicare & Medicaid Services (CMS), the facility must provide care and services to assist residents with Activities of Daily Living (ADLs), including hygiene, mobility, elimination (toileting), dining, and communication. According to CMS, Oral care refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues. This involves not only activities such as brushing of teeth or oral appliances, but also maintenance of oral mucosa.According to CMS, a dependent resident is an individual who requires staff assistance to complete all or most Activities of Daily Living (ADLs) because they are unable to perform these tasks independently. This may include total dependence, where staff provide full physical assistance for care such as…

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

Based on interviews and record reviews it was determined that the facility failed to ensure a Resident received treatment as ordered for a pressure ulcer. This was found to be evident for 1 (Resident #126) out of 1 Resident reviewed for pressure ulcer during the recertification survey.The findings include:A pressure ulcer is damage to an area of the skin caused by constant pressure on the area for a long time. This pressure can lessen blood flow to the affected area, which may lead to tissue damage and tissue death. Pressure ulcers often form on the skin covering bony areas of the body, such as the back, tailbone, hips, buttocks, elbows, heels, and ankles. Patients who cannot get out of bed or change their position, or who always use a wheelchair have an increased risk of ulcers. Pressure ulcers often heal slowly and if not treated can damage tissues deep under the skin, including fat, muscle, and bone. Also called bedsore, decubitus ulcer, and pressure sore. Pressure ulcers are classified in stages by the depth of the tissue damage to the area. The stages range from 1 to 4.The four…

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

Based on observations, record reviews and interviews, it was determined that the facility failed to 1. date and label respiratory therapy equipment according to professional standards of practice and 2. ensure oxygen storage procedures were followed. This was evident for 2 (Resident #14 and #140) out of 5 residents reviewed for Respiratory Care during the annual survey.The findings include:1.On 09/15/25 at 9:31 AM during initial rounds the surveyor observed Resident #14 with oxygen in use via Nasal Cannula tubing. The oxygen tubing was not labeled as to when it was put in use or should be replaced. On 09/15/25 at 9:55 AM the Nurse Staff Educator was notified by the surveyor, and she observed and confirmed the findings. On 09/18/2025 at 8:03 AM a review of Resident #14's clinical record revealed that the resident was admitted with diagnoses including Chronic Respiratory Failure with Hypoxia and End Stage Renal Disease. Further review revealed a physician order written on 08/6/25 for Oxygen at 2 liters per minute via Nasal Cannula as needed for Shortness of Breath. The record failed…

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

Based on review of employees' files and interviews, it was determined that the facility failed to conduct Performance Reviews at least every 12 months for Geriatric Nursing Assistants (GNAs). This was evident for 1 (GNA #5) of 5 GNAs selected for reviews.The findings include:Performance Reviews are to be completed at least every 12 months to identify in-service education needed to address competencies of GNAs.On 09/23/25 at 10:15 AM the surveyor conducted a review of five GNAs files. The records revealed that GNA #5 was hired in the year 2022 and their annual Performance Review was due on 04/6/25. The most recent Performance Review on record was dated 04/5/24.A further review of the records revealed that the Performance Review was not completed on the due date, and it remained incomplete at the time of the surveyor's review on 09/23/25.On 09/24/25 at 7:26 AM in an interview the Director of Nursing (DON) stated that Performance Reviews for GNAs are conducted annually and as needed. The DON reviewed the records and confirmed the surveyor's findings.Later, on 09/24/25, the DON 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 observations and interviews it was determined that the facility failed to ensure medications were stored properly. This was found to be evident for 1 (Resident #229) out of 4 Residents observed for medication administration during the recertification survey.The findings include:An observation was conducted on 09/17/25 at 8:47 AM of Resident #229's medication administration. This Surveyor observed Registered Nurse (RN) #32 enter the Resident's room carrying 1 cup of water and 1 medication cup of crushed medications in apple sauce. The RN left 1 medication cup of lacosamide 10 MG/ML Oral Solution, 1 medication cup of valporate acid 250 mg/5 ml solution, and 1 medication cup of levETIRAcetam Oral Solution 100 MG/ML solution on top of the unattended medication cart.During an interview conducted on 09/17/25 at 8:57 AM, the RN acknowledged that he should not have left the medications unattended on top of the medication cart. The RN stated that the facility's policy is to store all medications inside of the medication cart when unattended.During an interview conducted on 09/18/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and review of a complaint, it was determined the facility staff failed to maintain accurate medical records in accordance with accepted professional standards This was evident for 2 (#3, #285) out of 46 sampled residents reviewed during the annual survey.The findings include:1.Resident #3 was admitted to the facility in June 2025 with diagnoses including Chronic Respiratory Failure and Anoxic Brain and is ventilator dependent. On 09/18/25 at 8:16 AM a review of Resident #3's clinical record revealed a physician order written on 06/10/25 stating NPO (nothing by mouth) diet, NPO texture, NPO consistency. The resident received nutrition and medications through a gastrostomy tube (G-tube). Further review of the resident's clinical record revealed a physician order as follows: Atorvastatin Calcium Oral Tablet 20mg. Give 1 tablet by mouth at bedtime for Hyperlipidemia Order Date 06/11/2025. The Medication Administration Record revealed the nurses signed off on the medication being administered by mouth from the date it was ordered to 09/17/25.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure residents had access to call bells. This was evident for 2 (#140 & #120) of 46 Residents observed for call bell access during the annual survey. The findings include: 1. During an observation of Resident #140 on 09/16/25 at 11:14 AM it was discovered that the resident's call bell cord was curled into a circle and lying on the floor behind the head of the bed. The Resident was lying in bed and the call bell was not within reach of the resident. During a repeat observation of Resident #140 on 09/17/25 at 12:33 PM it was revealed that he/she was sitting in a reclining chair and the resident's call bell was wrapped in a circle on the floor behind the head of the bed.During an interview and observation with the Director of Nursing (DON) on 09/17/25 at 12:50 PM. The DON advised residents are expected to be within reach of their call bell and agreed the call bell was not in reach of Resident #140. 2. During an observation on 09/17/25 at 9:32 AM Resident #120 was seen lying in bed and the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, it was determined that the facility failed to maintain a safe, functional and sanitary environment for residents, staff and visitors. This was evident for 1 of 1 administrative hallways observed during the annual survey.The findings include:On 9/15/25 at 8:05 AM, during the initial tour of the facility, surveyors observed two large bins covered with black plastic bags placed in the administrative hallway between the Director of Nursing's office and the Conference Room. Water was observed dripping from the ceiling into the bins. The black plastic bags contained visible holes, allowing water to collect at the bottom of the bins. Yellow caution tape was tied from a wet floor cone to the handrail, blocking access to that section of the hallway. An orange and white cone was also present. The ceiling tiles above the bins appeared loose and mismatched, and one ceiling tile had a large brown stain.On 9/15/25 at 1:28 PM, this surveyor observed the same bins, caution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employees' files and interviews, it was determined that the facility failed to provide continuing education training of no less than 12 hours per year for Geriatric Nursing Assistants (GNAs). This was evident for 2 (GNA #5 and GNA #22) of 5 GNAs selected for reviews.The findings include:On 09/23/25 at 10:15 AM the surveyor conducted a record review of five GNA files for the period January 1, 2024 to January 1, 2025. The records revealed that GNA #5 who was hired in the year 2022 and GNA #22 who was hired in the year 2015, did not complete their required 12 hours per year Inservice training. On 09/23/25 at 11:24 AM the surveyor interviewed Staff Development Nurse #23 who stated that the facility provides at least 12 hours of Inservice training to GNAs annually through Relias (online training). She further stated that she would check the Relias records to see if the employees completed the training. On 09/24/25 at 2:00 PM during an interview the Director of Nursing (DON) provided the surveyor with GNA #5's and GNA #22's Inservice training for the period January 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on tours of the facility and staff interview it was determined that the facility staff failed to ensure the facility environment was maintained in a homelike manner. This was evident for 5 out of 5 floors. The findings are: Tours of the facility by members of the survey team revealed: room [ROOM NUMBER] on 2/7/23 at 1:00 PM was observed to have water-stained ceiling tiles. A tour of the facility on 2/15/23 at 11:27 AM revealed 3 ceiling tiles outside of the room were water stained. The window in the room had two trapezoid windows that are part of the larger window. These trapezoids are 9.5 wide at the bottom, 8.5 at the top, and 4 tall. The trapezoid windows are designed to have screens to prevent insects, birds, etc. from entering the room. The left window was missing the screen. Tour on 2/6/23 at 2:18 PM revealed the Men's room window right trapezoid screen was missing. During the tour of the second floor pavilion the door to stairwell #2 was ajar. Licensed Practical Nurse (LPN) #10 was informed 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 medical record review and interview, the facility staff failed to offer and/or obtain advance directives for residents (Resident #1, #8, #19, #22, #63, #87, #115, #176, #553). This was evident for 9 of 16 residents reviewed during an annual survey. 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 because of illness or incapacity. A Maryland Medical Order for Life-Sustaining Treatment (MOLST) is a form that includes orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific resident or patient. 1. Review of the medical record for Resident #8 on 2/7/23 at 9:58 AM revealed the presence of a Maryland order for Life Sustaining Treatment (MOLST). Further review of the resident's medical record failed to reveal the presence of an actual Advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate an allegation for: 1) abuse (Resident #316) and 2) misappropriation of funds (Resident #540). This was evident for 2 out of 2 residents (Resident# 316 and # 540) reviewed for conducting a throrough investigation. The findings include: 1). A review of the facility investigation into the allegation of abuse made by Resident #22 on 12/13/2020 revealed staff interviewed other residents to determine their experiences with the alleged perpetrator and to determine if there are any unreported incidents of abuse. Resident #316 was interviewed on 12/13/20 (time not noted) and asked Has staff, a resident, or anyone else here abused you -- this includes verbal, physical, or sexual abuse? Resident answered yes but said they did not tell staff. The Director of Nursing (DON) was interviewed on 2/21/23 at 11:45 AM. The findings were explained. She did not have an immediate answer as to whether or not this new allegation was reported to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information (Residents #3, #22, #63, #94, #87, #107). This was found to be evident for 6 out of 13 residents reviewed for hospitalization during an annual survey. The findings include: 1. Review of Resident #3's medical record on 2/8/23 revealed the resident was admitted to the facility on [DATE]. The resident was transferred from the facility on 11/9/22 to the hospital. Further review of the resident's medical record failed to reveal any documentation that a written notice regarding the transfer had been provided to the resident and/or the resident's responsible party. Interview with the Director of Nursing (DON) on 2/14/23 at 10:40 AM confirmed neither Resident #3 nor their responsible party had been sent a letter that notified them of the transfer 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with resident and facility staff, it was determined that facility staff failed to 1.) appropriately code a resident's weight loss; and 2.) accurately code a resident's oral/dental status on the Minimum Data Set (MDS). This was evident for one out of one resident (#26) that was reviewed for both weight loss and oral/dental status. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Section K0300 of the quarterly MDS assessment dated [DATE] was reviewed on 2/15/23 at 2 PM. There are three available selections for coding this section of the MDS regarding weight loss of a resident. The three selections that are available for coding are: 0 (indicating no or unknown), 1 (indicating Yes, 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 interview with facility staff it was determined that the facility failed to revise Resident #26's plan of care accordingly after dental consults occurred. This was evident in 1 of 1 resident reviewed for dental problems. In addition, the facility staff failed to ensure care meetings were held for residents (#173 and #542). This was evident for 2 out of 53 residents reviewed during the annual survey. The findings include: A plan of care 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 #26's current care plan revealed the resident has an ADL (activities of daily living) self-care performance deficit. The intervention listed for personal hygiene/oral care states this resident requires set up assistance by one staff to maximize independence. Dental provider recommendations were made because of consults which occurred on 05/21/22 and 01/17/23. On 05/21/22, the following recommendations were made; action required by nursing home staff:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interview, it was determined the facility staff failed to administer medications (Resident #204 and #161), failed to provide treatments and services (Residents #541, #555, #8, #201) as ordered by the physician and This was evident for 6 out of 103 residents reviewed during an annual survey. The findings include: 1. During an interview with Resident #204's responsible party (RP) on 3/1/23 at 1:30 PM, the RP stated he/she believed the facility are not administering the resident's seizure medications as ordered. Review of Resident #204's medical record on 3/1/23 revealed the resident was admitted to the facility on [DATE] with a diagnosis to include seizures and had a physician order for Clonazepam 1 mg every 8 hours for seizure activity. Further review of Resident #204's medical record revealed the resident was transferred to the emergency room (ER) on 3/2/23 and returned to the facility on 3/3/23 at approximately 8:20 PM. Review of the resident's March 2023 MAR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, it was determined the facility staff failed to follow up on urology concerns for residents (Resident #140, #534, #537, #108). This was evident for 4 of 103 residents reviewed during an annual survey. In addition the facility failed to keep resident's # 534 and # 537 clean and dry, This was evident for 2 out of 2 residents. The findings include: 1. During an interview with Resident #140 on 2/6/23 at 1:21 PM, the resident stated he/she was supposed to be sent to the Urologist in October of 2022 but it still hasn't happened. Urologists diagnose and treat diseases of the urinary tract. Observation of the resident at that time revealed the resident has an indwelling urinary catheter. Review of Resident #140's medical record on 2/10/23 revealed the resident was admitted to the facility on [DATE] with diagnosis to include neuromuscular dysfunction of bladder. Further review of the resident's medical record revealed the resident went to a urology appointment 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 clinical record review and staff interview it was determined that facility staff failed to ensure that a resident received medication according to the physician's orders. This was evident for 1 out of 53 residents in the survey sample. The findings are: A review of Resident #22's clinical record on 3/2/23 revealed that the resident's primary physician ordered Oxycodone-Acetaminophen 5-325 mg 1 tab every 6 hours as needed for severe pain (8-10) on 12/26/22. A review of the Medication Administration Record (MAR) revealed the resident rated pain as a 7 on 12/28 and 12/31 but was administered the medication. During the month of January the resident rated pain as a 6 on 1/1/23 at 5:45 AM, 1/2/23 at 6 AM, 1/6/23 at 6 AM, and on 1/21/23 at 6 AM. Also, during January the resident rated pain as a 7 on 1/2/23 at 11:40 PM, 1/4/23 at 5:40 AM, 1/11/23 at 5:30 AM and 11:15 PM, 1/13/23 at 5:55 AM, 1/18/23 at 5:35 AM, 1/19/23 at 6 AM, 1/28/23 at 5:30 AM, and 1/29/23 at 5 AM. The February MAR was reviewed and the resident rated pain as a 7 but was administered the medication during 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, observation and interview with resident and facility staff, it was determined that the facility failed to address and implement interventions for a resident with verbalized history of trauma. This was evident for 1 of 11 residents reviewed for trauma informed care (#242). The findings include: Surveyor met Resident #242 during an initial tour and screening on 2/6/23 at 10:40 AM. Resident #242 was very teary and visibly and verbally anxious and stated that s/he is now on antianxiety medications because staff does not come and care for him/her. Resident #242 was started on an antidepressant on 11/27/22, this was increased on 12/25/22 and then s/he was started on a sedative 1/10/23 related to his/her anxiety. Record review on 2/9/23 at 8:27 AM revealed that on 11/4/22 a trauma screen was completed. This revealed that Resident #242 has a history of sexual abuse in adolescence, sexual assault in the hospital and has a history of childhood trauma, on top of this new diagnosis of amyotrophic lateral sclerosis (ALS) a fatal debilitating disease, as of 2022.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to document an accurate overview of the resident during a physician visit. This was evident during 2 of 65 resident record reviews. (#242, #247) The findings include: 1. Review of the medical record on 2/9/23 for Resident #242 revealed a physician history and physical completed on 11/6/22. The attending physician #42 documented active diagnosis for Resident #242 including amyotrophic lateral sclerosis. However, under #22 for cranial nerves 'c.' moves all extremities was selected. Surveyor had met with Resident #242 previously on 2/6 and 2/8 where s/he verbalized not being able to move any extremity secondary to their diagnosis and being completely dependent on staff. Staff #42 was interviewed on 3/1/23. He stated that he was familiar with Resident #242 and that due to his/her diagnosis that 'no' s/he would not be able to move their extremities. He went on to explain the form that he has to fill out and that there are click buttons and he must have just 'selected 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 Based on medical record review, observation and interview with resident and facility staff, it was determined that the facility failed to provide appropriate interventions for a resident with identified history of trauma. This was evident for 3 of 11 residents reviewed for behavioral and emotional concerns. (Resident # 242, #1 and # 109) The findings include: 1. Record review on 2/9/23 at 8:27 AM revealed that on 11/4/22 a trauma screen was completed. This revealed that Resident #242 has a history of sexual abuse in adolescence, sexual assault in the hospital and has a history of childhood trauma, on top of this new diagnosis of amyotrophic lateral sclerosis (ALS) a fatal debilitating disease, as of 2022. According to the 11/10/22, 5-day Minimum Data Set (MDS) assessment section 'D' for mood, the severity was documented as a '3' for minimal depression. A review of the baseline care plan noted that under section 'C' completed by social services the goals for care documented that 'trauma history was discussed 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 clinical record review and staff interview it was determined that facility staff failed to ensure a resident received medication according to physician's orders. This was evident for 3 out of 53 residents in the survey sample. Resident (# 22, 242, 201). The findings are: 1. A review of Resident #22's clinical record on 3/2/23 revealed that the resident's primary physician ordered Oxycodone-Acetaminophen 5-325 mg 1 tab every 6 hours as needed for severe pain (8-10) on 12/26/22. A review of the Medication Administration Record (MAR) revealed the resident rated pain as a 7 on 12/28 and 12/31 but was administered the medication. During the month of January the resident rated pain as a 6 on 1/1/23 at 5:45 AM, 1/2/23 at 6 AM, 1/6/23 at 6 AM, and on 1/21/23 at 6 AM. Also during January the resident rated pain as a 7 on 1/2/23 at 11:40 PM, 1/4/23 at 5:40 AM, 1/11/23 at 5:30 AM and 11:15 PM, 1/13/23 at 5:55 AM, 1/18/23 at 5:35 AM, 1/19/23 at 6 AM, 1/28/23 at 5:30 AM, and 1/29/23 at 5 AM. The February MAR was reviewed and the resident rated pain as a 7 but was administered 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 clinical record review it was determined that the facility staff failed to ensure that residents received needed dental care (#22, #8, #210). This was evident for 3 out of the 53 residents in the survey sample. The findings include: 1. Resident #22 was observed on 2/6/23 at 9:43 AM. The resident did not have teeth and was not wearing dentures. A review of the resident's clinical record revealed that Resident #22 had a dental exam on 1/30/20 and the Dentist recommended that the resident's dentures be replaced. The resident had a dental exam scheduled for 9/8/20. The exam was not done because family could not visit secondary to Coronavirus disease 2019 (COVID-19) restrictions. There was no indication as to why staff were not able to transport. Resident #22 had another dental appointment rescheduled for 10/21/20. The resident was not treated because the resident was not due for treatment and family was not present. It was noted that dental services would continue once family is able to return to the facility. No evidence of the resident having dental consults…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 multiple random observations and interviews with facility staff, it was determined that the facility staff failed to maintain proper infection control practices while providing care to residents. The findings include: Review of Maryland Department of Health (MDH) Amended Directive and Order Regarding Nursing Home Matters, dated 9/8/21, revealed the following: All personnel who are in close contact with residents of nursing homes shall use appropriate Standard and Transmission-based Precautions, as recommended by MDH and the Centers for Disease Control and Prevention (CDC), based on the procedures being performed and the availability of specific forms of PPE. Facilities shall use good faith efforts to maintain adequate supplies of all types of Personal Protective Equipment (PPE). During tour of the facility and observations of residents on 2/13/23 staff GNA #33 was observed in a resident room that was designated for contact precautions, including gown in gloves for contact with the resident. At 12:50 PM, staff #33 was observed in Resident #201's room holding an open packaged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 tour of the facility and staff interview it was determined that the facility staff failed to ensure that handrails were secured to the walls. The findings include: During tour of the facility on 02/07/23 at 09:22 AM the handrails in the 5th floor hallway across from room [ROOM NUMBER] were observed to be loosely fitting to the wall. A handrail should be secure with no movement but these handrails moved. This surveyor toured with Staff #21 on 3/3/23 from 1:00 PM to 2:00 PM. Staff #21 was made aware of the handrails and stated that he would ensure they were secure.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and medical record review it was determined that the facility failed to notify a resident's Responsible Party of 1) an injury and 2) change in treatment. This was found evident of 9 (Residents #19, #22, #63, #87, #115, #176, #551, #553 and #556) of 10 residents reviewed for notifications during the facility's annual and complaint survey. The findings include: 1. On 2/28/23 at approximately 1 PM, the surveyor reviewed Resident #551's medical records and reviewed documentation from a lower extremity arterial doppler preformed by the Vascular Specialist, dated 12/9/20. On the top of the document the facility's name was handwritten and Resident #551's name was typed in the upper right corner. Further review of the chart revealed no documentation that Resident #551's Responsible Party (RP) was informed prior to the test being performed or after the test was performed. On 3/1/23 at 12:11 PM, the surveyor interviewed the [NAME] President of the contractor/vender, Staff #15. The surveyor asked Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and interviews it was determined the facility failed to provide a bed hold for a resident transferred to the hospital. This was found to be evident for 1 (resident #94) out of 1 residents reviewed for transfer and discharge. The findings include: During an interview conducted on 02/07/2023 at approximately 1:28 PM, Resident #94 stated he recently was hospitalized for bleeding. On 02/07/2023 at approximately 1:45 PM a review of Resident #94's medical records revealed the resident was transferred to the hospital on [DATE] due to profuse bleeding. Further review of the medical records did not reveal documentation of a bed hold for the transfer to the hospital on [DATE]. On 02/13/2023 at approximately 11:15 AM the surveyor advised the Director of Nursing (DON) the s/he was unable to locate a bed hold for Resident # 94 hospitalization on 09/05/2022. On 02/13/2023 at approximately 1:00 PM the DON provided the surveyor a notice of transfer/discharge. The notice included Resident #94's name,…

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

Based on medical record review, interview with resident, and facility staff and observations, it was determined that the facility staff failed to appropriately code a residents mobility ability on admission Minimum Data Set (MDS). This was evident during the review of 1 of 9 (Resident #242) residents reviewed for positioning/mobility. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment. The triggered MDS items target care areas for additional assessment and review, as warranted by MDS item responses. During initial tour and screening, Resident #242 was interviewed on 2/06/23 at 10:40 AM. Resident #242 was very teary and visibly and verbally anxious and stated that she is now on antianxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and/or implement a resident's interdisciplinary care plan (Residents #1, #22 and #201). This was evident for 3 of 4 residents reviewed for care planning during an annual 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 Minimum Data Set (MDS) is a federally-mandated assessment of all residents in Medicare and Medicaid certified nursing homes. Information collected drives resident care planning decisions. 1. The facility staff failed to develop a care plan to manage depression for Resident #1. During interview of Resident #1 on 2/7/23 at 8:28 AM, Resident #1 stated he/she would like to see a counselor for his/her depression and he/she can't remember the last time he/she talked to one. Review of Resident #1's medical record on 2/8/23 revealed the resident was admitted 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 observation and staff interview it was determined that the facility staff failed to ensure nursing staff followed professional standards of practice. This was evident during 1 out of 2 medication administrations that were observed as part of the survey. The findings are: During observation of the medication administration on 2/22/23 at 9:28 AM, Staff #57 left Resident #451's medications in a cup on the bedside table while she went back to the medication cart to get the resident's nasal spray. The medications that were left unattended were: carvedilol 3.125 mg (treats high blood pressure), Lasix 40 mg (diuretic), Potassium Chloride (supplement), isosorbide 5mg (treats angina), senna 8.6 mg (treats constipation), and vitamin D3 (supplement). Staff #57 was preparing medications for Resident #107 on 02/22/23 at 10:17 AM. She left a bottle of aspirin on the top of the medication cart unattended while she entered the resident's room to find out if the resident needed lactulose (helps with bowel movements). Staff #57 asked on 02/22/23 at 10:39 AM if she made any errors during 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 Based on medical record review, observation and interview, it was determined the facility staff failed to provide grooming and personal hygiene services for a resident (Resident #3). This was evident for 1 out of 8 residents reviewed for activities of daily living (ADL) during an annual survey. The findings include: Observation of Resident #3 on 2/6/23 at 11:16 AM revealed the resident to have elongated and dirty fingernails, elongated toenails and unshaven facial hair. Interview with the resident at that time revealed the resident would like to have his/her fingernails and toenails trimmed and have face shaven. The Surveyor had Staff #25 come to the resident's room at that time and confirmed the surveyor's observations. Review of Resident #3's medical record on 2/8/23 revealed the resident was admitted to the facility on [DATE] is dependent on the facility staff for his/her care, comfort and safety. The facility staff conducted a MDS (Minimum Data Set) assessment on 1/25/23 and coded the resident in Section G…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with staff and resident, and review of facility records, it was determined that the facility failed to have an activities program designed to meet the interests and needs of residents from both facility sponsored and individual activities based on the resident's comprehensive assessment and care plan. This was found evident of 1 of 2 residents reviewed for activities (Resident #114) during an annual survey. The findings include: On 2/7/23 at approximately 8 AM, the surveyor reviewed Resident #114's medical record. The review revealed that Resident #114 was admitted to the facility in late 2018. On 2/7/23 at 10:04 AM, the surveyor interviewed Resident #114. During this interview Resident #114 express he/she was one for the youngest residents in the facility and that the activities that were offered were not very age appropriate. On 2/13/23 at 12:15 PM, the surveyor conducted an interview with the Activities Director Staff #14. Staff #14 reported Resident #114 participates in resident council and (specific gender) club but prefers to socialize with friends outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow up and ensure ophthalmology services were obtained for Resident #140. This is evident for 1 of 4 residents reviewed for vision and hearing during an annual survey. The findings include: During an interview with Resident #140 on 2/6/23 at 1:21 PM, the resident stated he/she was supposed to be sent to an eye specialist in 2022 but it still hasn't happened. Review of Resident #140's medical record on 2/10/23 revealed the resident was admitted to the facility on [DATE] and was seen by an Ophthalmologist on 3/1/22. An Ophthalmologist is a specialist in medical and surgical eye problems. Review of the Ophthalmologist's assessment on 3/1/22 revealed the Ophthalmologist documented the plan was a consult with a Retina Specialist due to visual disturbance. Further review of the resident's medical record revealed the resident was seen again by an Ophthalmologist on 9/2/22 where again the Ophthalmologist again documented 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 Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #1 and #554, 551). This is evident for 3 of 15 residents reviewed for pressure ulcers during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (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). A deep tissue injury (DTI) is a unique form of pressure ulcer. 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, record review, and observation it was determined that the facility failed to ensure Resident #201 was receiving proper foot care treatment. This was evident for one of one resident (#201) reviewed for foot care. The findings include: Upon initial tour Resident #201 reported to the surveyor on 2/6/23 at 1:37 PM that s/he was performing foot soaks with epsom salt every day and did not require betadine or other wound care anymore. Resident #201 with diagnoses of gangrene of foot required surgical amputation (removal) on 12/14/22 of right digits (toes) 1-5, and left digits (toes) 1, 2, and 5. During surveyor record review on 2/6/23 subsequent to initial tour, hospital discharge instructions dated 12/14/22 did not reveal recommendation for epsom salt soaks. The most recent recommendation made by the foot surgeon prior to 2/6/23, was on 1/23/23 and included instructions to the facility for care of the wounds: wash with soap and water, apply betadine to incisions, and cover daily with dry gauze and wrap with rolled gauze. Notes from the wound healing center on 1/4/23…

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 interview with facility staff, it was determined that the facility failed to follow up and implement interventions for a residents #231 and #57 with an identified impaired nutritional status. This was for 2 out of 53 residents reviewed within the survey sample. The findings include: 1. Review of the medical record for Resident #231 on 2/21/23 at 8:56 AM revealed diagnoses including chronic respiratory failure with dependence on mechanical ventilation, percutaneous endoscopic gastrostomy (the placement of a feeding tube through the skin and the stomach wall and is needed when you are unable to eat or drink) feeding for nutrition and hemodialysis. Review of the weight/change note completed on 12/16/22 noted Resident #231 had a significant weight loss. Per facility admission weights, Resident #231 was due for 1 more weekly weight as well as the following month of Januarys weight. A nutrition/dietary note was completed on 1/12/23 noting abnormal labs and that the monthly weight was not yet available for review. On 1/30/23 a 'weight change note' 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 observations, interviews, and record review it was determined that the facility failed to provide post dialysis care consistent with professional standards of practice. This was evident of 1 of 4 Residents reviewed for dialysis during the annual survey (Resident #616). The findings include: On 2/13/23 at 7:52 AM, the surveyor reviewed Resident #616's medical record. This review revealed Resident #616 was admitted in May 2022. Resident #616' past medical diagnoses history includes, but not limited to, memory deficit following cerebral infarction, end stage renal disease, and dependance on renal (kidney) dialysis. On 2/10/23 at 9:50 AM, the surveyor observed Resident #616 with a white dressing over right his/her dialysis access site. On 2/10/23 at 9:51 AM, the surveyor interviewed Resident #616. Resident #616 stated he/she had dialysis yesterday and indicated the dressing on his right arm was from dialysis treatment preformed yesterday. On 2/10/23 at 11:32 AM, the surveyor reviewed Resident's # 616's medical orders. The review revealed that Resident #616 had an order 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, resident interview, and staff interview it was determined that the facility failed to ensure properly working bedrails (#3). This was evident for 1 out of 53 residents in the survey sample. The findings are: Resident #3 was interviewed on 2/22/23 at 9:32 AM. The resident said that the left upper rail of the bed was broken. This surveyor held onto the rail and was able to move it towards the resident and back towards the wall. A bed rail should not move as it is to provide stability. Staff #21 was shown the bed rail on March 3, 2023, at 1:30 PM. This surveyor showed him how the rail moved and told him what the resident said. He looked at the rail and attempted some adjustments by hand. After a couple of attempts he said he would adjust later in the evening after we were done touring.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and observation and interview with resident and facility staff, it was determined that the facility failed to implement interventions to prevent potential trauma triggers as identified in the trauma screen in order to limit or prevent the exacerbation of a residents anxiety. This was evident during the review of 2 of 11 residents (#242, #1) reviewed for behavioral health services. The findings include: 1. Record review on 2/9/23 at 8:27 AM revealed that on 11/4/22 a trauma screen was completed. This revealed that Resident #242 had a history of sexual abuse in adolescence, sexual assault in the hospital and had a history of childhood trauma, on top of this new diagnosis of amyotrophic lateral sclerosis (ALS) a fatal debilitating disease, as of 2022. The trauma screen includes a post-traumatic stress disorder (PTSD) checklist. There were two areas identified as 'a little bit' that bothered the resident within the past month; #2 feeling upset when something reminded you of a stressful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with resident and facility staff, it was determined that the facility failed to have non-pharmacologic interventions in place to address a resident's psychosocial well-being. This was evident for 2 of 11 residents reviewed for behavioral health. (residents # 1 and # 242). The findings include: 1. Surveyor met Resident #242 during initial tour and screening on 2/6/23 at 10:40 AM. Resident #242 was very teary and visibly and verbally anxious and stated that he/she is now on antianxiety medications because staff does not come and care for him/her. A care plan was noted in place related to the residents 'behavior problems' of: refusing treatment, 'socially inappropriate behavior' of: demanding excessive use of staff time when needs are met and depression related to poor prognosis with an intervention only to administer medication as ordered and monitor for reactions to the medications. According to the medication administration record, the targeted behaviors that were 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 interviews, observation, and review of the facility's documentation, it was determined that the facility failed to accurately provide a meal based on the facility's established menu. This was evident of 1 of 2 residents (Resident #149) reviewed for accuracy of meals during an annual survey. The findings include: On 2/22/23 at 7:38 AM, the surveyor observed Resident #149 eating breakfast in his/her room. The food on the tray consisted of eggs, toast, oatmeal, apple juice, and a coffee. On the tray was a printed meal ticket requesting regular ground meats. No meat was observed on Resident #149's tray, however sausage was on the daily menu for that morning's breakfast. The surveyor conducted an interview with Resident #149 during the observation. In this interview Resident #149 stated the food was okay and that he/she prefers to have meat in the morning but does not normally receive meat on his/her breakfast tray. On 2/22/23 at 7:42 AM the surveyor interviewed the facility's Certified Dietary Manager (CDM) Staff #58. During the interview staff #58 stated, if the kitchen has…

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

Based on observation and interview with facility staff it was determined that the facility failed to serve food at appetizing temperatures. This was evident on 2 of 2 meal tray delivery observations reviewed during an annual survey. The finding include: On 2/9/23 at 11:46 AM, the surveyor observed the facility's kitchen staff assemble food trays for the lunch mealtime. The surveyor requested a sample tray to be placed on the food cart scheduled to be delivered to the 5th floor. On 2/9/23 at 12:48 PM, the surveyor observed the food cart delivered to the 5th floor. On 2/9/23 at 12:57 PM, the surveyor observed all the lunch meal trays, from the 5th floor meal cart, had been delivered with the exception of the sample tray. At this time the surveyor asked the facility's Certified Dietary Manager (CDM) Staff #58, and the Food Service Manager, Staff #4 to use their kitchen thermometer to monitor the temperatures of the foods on the sample tray. The results were as follows: Stew- 127 degrees Beans- 126 degrees Vegetable blend- 133 degrees Puree meat- 128 degrees Puree vegetable- 138 degrees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with facility staff it was determined that the facility failed to store food in accordance with professional standards. This was evident of 2 of 5 kitchen observations done during the annual survey. The findings include: On 2/6/23 at 9:16 AM, the surveyor conducted an initial tour of the facility's kitchen. The surveyor noted pots and pans piled up on a shelf adjacent to the pots and pan washing area. Further inspection of the pots and pans revealed moisture noted between both pots and pans and after turning the pots and pans the surveyor observed water dripping out. The facility's Certified Dietary Manager (CDM) Staff #58 was present during the tour and stated that pots and pans should be fanned out not allowing moisture to accumulate and he would get an additional shelf to help in this process. The surveyor continued the observation of the kitchen and observed one bag of elbow macaroni and one bag of spaghetti pasta opened with no opened date marked on the bags. Additionally, a grape drink mix was opened without an open date and a pan of what…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure the provision of rehabilitation services for a resident who had surgery and was recommended to begin physical therapy by their surgeon. This was evident in one of one resident (#201) reviewed for rehabilitation services. The findings include: Upon initial tour occurring on 2/6/23 at 1:38 PM, Resident #201 expressed to the surveyor that s/he was told that therapy was needed and then s/he can go home. Additionally, the resident had questions about when therapy was going to work with her/him. The resident reported s/he currently had the ability to do some walking. During an interview on 2/13/23 at 12:50 PM, Resident #201 further reported to the surveyors' that therapy had still not begun and that s/he has been able to ambulate in the room and has been doing her/his own therapy by walking down the hallways holding the railing because s/he was ready to get back home, and family life was very important to her/him. On 3/2/23 at 9:26…

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

Based on record review and interviews it was determined that the facility failed to ensure that a resident was scheduled for a necessary outside specialist provider appointment. This was evident for one out of one resident (#201) reviewed for wound care. The findings include: Upon the surveyor's review of Resident 201's medical record on 3/9/23 at 10:22 AM, the resident had toe amputations (removals) in December 2022, and required a necessary vascular specialist appointment for after surgery care of their lower extremities. Resident #201 had an outside consultation on 1/4/23 for wound healing with instructions documented for the resident to have a follow up evaluation with vascular surgery, and additionally included was a referral dated 1/4/23 to the specified vascular specialist. On 1/23/23 there was another consult for wound healing with documented instructions: keep the follow up appointment with vascular surgery. Another ambulatory clinical summary, dated 2/27/23, instructed the facility to ensure the scheduling of a follow up appointment with a podiatrist/vascular surgeon prior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review and staff interview it was determined that the facility staff failed to ensure that clinical records were maintained in a complete manner (#553, #262, #551, #56, #201). This was evident for 5 out of the 53 residents in the survey sample. The findings are: 1. A review of Resident #553's clinical record revealed that there was no indication that the resident's family was able to Facetime with the resident as they requested upon admission. The Social Worker (#32) was interviewed on [DATE] at 12:38 AM. He confirmed that he remembered the resident's name. He said he did not keep the records the facility had to show they contacted family during the pandemic. He said the records of family notification and Facetime visits were shredded. He stated that if family had requested Facetime then he would have made sure it happened. He suggested that he might have notes supporting the use of Facetime on behalf of the resident. He, also, recalled making contact with another nursing home for 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 tour of the facility, observation, and staff interview it was determined that the facility staff failed to maintain patient care equipment. This was evident for 1 out of 5 floors toured. The findings are: During tour of the facility on 2/7/23 at 10:02 AM a survey team member observed on the 4th floor a Hoyer lift with wheels that could do not rotate so the lift must be dragged to moved. This surveyor toured with Staff #21 on 3/3/23 at 1:00 PM. At 2:05 PM Staff #21 left the Conference Room at the end of the tour and he said he would request logs from the outside company that is contracted to maintain the Hoyer lifts on Monday. Staff #21 stated that he thinks they were serviced by the company back in November 2022 and that he may only have an email receipt and/or an acknowledgement of service. Staff #21 returned to the Conference Room at 2:15 PM and said he thought that he gave a list of 14 Hoyer lifts that were inspected to the survey team. The list of Hoyer lifts that were inspected and maintained, according to Staff #21, was not in the possession of the survey team as 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 while touring the facility it was determined that the facility failed to ensure the facility was maintained in a safe manner. The findings are: During tour of the facility on 2/15/23 at 11:44 AM the second floor pavilion stairwell #2 door was observed to be ajar. No residents were currently in the hallway. Staff #10 was informed and she secured the door.