White Oak Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to meet professional standards of care by ensuring a resident's cardiology follow up appointment was scheduled as ordered by physician. This was evident for 1 (Resident #303) out of 33 facility residents reviewed during the investigative phase of the survey. The findings include: On 4/18/2025 at 10:21, a review of Resident #303's electronic medical record revealed a physician order, dated 2/15/2025, for the resident to follow up with his/her cardiologist in 12 weeks. During further review, the Surveyor discovered that the resident was admitted to the facility on [DATE] after being hospitalized for a stroke. On 4/22/2025 at 9:50AM, the Surveyor requested documentation of Resident #303's follow up appointment with his/her cardiologist as ordered on 2/15/2025. During an interview conducted with the Assistant Director of Nursing (ADON) #11 on 4/23/2025 at 9:30AM, the Surveyor was informed that when a resident is admitted to…

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

Based on medical record review, observation, and staff interview it was determined the facility failed to administer medication to a resident as ordered by the physician. This was evident for 1 resident #106 out of 7 residents reviewed for orders during the survey. The findings include: Review of Resident #106's medical record on 04/18/2025 at 6:30 AM revealed a physician's order stating that Resident #106 was to receive a controlled substance medication Lacosamide 150mg 1 tablet by mouth twice daily. During observation rounds and review of Resident #106's medical records on 04/18/2025 at 6:32 AM on the [NAME] wing medication cart #1 with staff #5, a controlled substance count of Resident #106's medication Lacosamide 150mg tablet blister pack was counted to have a total of 8 tablets. A review of the facility medication-controlled substance count sheet revealed that on 04/17/2025 at 9:00 PM staff #6 signed that Resident #106 received 1 tablet of medication Lacosamide 150mg and there was a total of 7 tablets left. During an interview on 04/18/2025 at 6:35 AM staff #5 stated that…

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

Based on medical record review, observation and staff interview, it was determined that the facility failed to perform accurate reconciliation of resident controlled substance medications. This was evident for 1 resident (#106) out of 7 residents reviewed for medications during survey. The findings include the following: Review of Resident #106 medical's record on 04/18/2025 at 6:30 AM revealed a physician's order stating that Resident #106 was to receive controlled substance medication Lacosamide 150mg 1 tablet by mouth twice daily. During observation rounds, review Resident #106's medical records and facility medical records on 04/18/2025 at 6:32 AM on the [NAME] wing medication cart #1 with staff #5, revealed a controlled substance count of Resident #106's medication Lacosamide 150mg tablet blister pack was counted to have a total of 8 tablets. A review of the facility medication controlled substance count sheet revealed that on 04/17/2025 at 9:00 PM staff #6 signed that Resident #106 received 1 tablet of medication Lacosamide 150mg and there was a total of 7 tablets left. 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 interviews it was determined that the facility staff failed to ensure a resident received dental care. This deficient practice was evidenced in 1 (#39) of 2 residents assessed for dental care during the survey. The findings include: On 4/16/25 at 9am while speaking with Resident #39, s/he stated, I was seen by the dentist and would like these teeth pulled. I can only eat soft foods. On 4/16/25 at 9:30am the unit manager (staff #18) was made aware of the resident request. She stated the resident was seen by the dentist and she would follow up on it. Review of Resident #39's medical record on 4/22/25 at 11am revealed a dental consult dated 4/2/25 from a Prosthodontist which read please evaluate and treat for full mouth rehabilitation; resident strongly wants implants. A Prosthodontist is a dental specialist who focuses on tooth restoration and replacement, including the design and fitting of prosthetics. They are trained in areas like dental implants, crowns bridges and dentures. The referral indicated resident #39 needed several surgical extractions. During…

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

3. A Brief Interview for Mental Status (BIMS) is a standardized cognitive screening tool used in long-term care facilities to quickly assess a resident's cognitive function. The score ranges from 0 to 15, and different ranges suggest varying levels of cognitive impairment. A score of 13-15 generally indicates intact cognition, 8-12 suggests moderate impairment, and 0-7 indicates severe impairment. A smoking screen and/or assessments in long-term care facilities focus on evaluating residents' ability to safely smoke without posing a risk to themselves or others. These assessments typically consider cognitive ability, judgement, manual dexterity, mobility, and physical diagnoses that could impact smoking safety. During review of Resident #54's medical record on 04/17/2025 at 1:30 PM revealed on 03/03/2025 Resident (#54) had a Brief Interview for Mental Status (BIMS) assessment score of (99). A score of (99) is entered when a resident is unable to complete the interview, but the assessment revealed answers that a resident was able to complete the interview with answers that showed the…

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

Based on observation and interview with staff, it was determined that the facility failed to ensure a resident's tracheostomy extension tubing and drainage bag were not touching the floor. This was evident for 1 (Resident #88) out of 2 residents observed with tracheostomy's during the survey. The findings include: On 4/16/2025 at 8:38AM during a tour of the east wing nursing unit, the Surveyor observed Resident #88 in his/her room. The Surveyor observed the oxygen delivery system located along the wall to the right of the door. The tracheostomy extension tubing, with drainage bag, stretched across the floor and connected to the resident's trach collar. On 4/17/2025 at 9:00AM, the Surveyor observed Resident #88 's tracheostomy extension tubing and drainage bag stretched across the floor and connected to the resident's trach collar. On 4/24/2025 at 12:00PM, during an interview with Unit Manager #25 of the west wing nursing unit in Resident #88's room, the Surveyor was informed that the tracheostomy extension tubing and drainage bag should not be touching the floor, however, the east…

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 staff interviews, it was determined that the facility failed to maintain a safe, comfortable environment for residents. This was evident for 2 resident bathrooms observed during the survey. The findings include: On 04/16/25 at 08:33 AM during observation rounds, room [ROOM NUMBER]'s bathroom was observed to have a missing cove base at the bottom of the wall. On 04/16/25 at 08:47 AM during observation rounds, room [ROOM NUMBER]'s bathroom was observed to have peeling paint on the floor. On 04/16/2025 at 01:25 PM, the Nursing Home Administrator staff #1 and the Assistant Director of Nursing staff #11 were interviewed. During the interview, the surveyor informed staff #1 and staff #11 about the missing cove base on the wall in room [ROOM NUMBER]'s bathroom and the peeling paint on the floor in room [ROOM NUMBER]'s bathroom.

Based on staff interviews and review of facility records, it was determined that the facility failed to disseminate mail delivered to the facility for the residents. This was evident for 1 (Residents #167) out of 4 residents reviewed during the survey. The findings are: On 04/23/2025 at 10:58 AM, complaint MD00208416 was reviewed. Complaint MD00208416 indicated that Resident #167 mentioned that the facility's Business Office is holding resident mail longer than they should. On 04/23/2025 at 11:31 AM, the surveyor attempted to contact Resident #167 via telephone for an interview. Resident #167 did not answer the telephone call; therefore, the surveyor left a voicemail message on 4/23/2025 at 11:33 AM. As of 4/29/25, Resident #167 had not returned the surveyor's phone call. On 04/24/2025 at 9:25 AM, the Nursing Home Administrator staff #1 was interviewed. During the interview, the surveyor informed staff #1 of the complaint about the Business Office holding residents' mail. On 04/24/2025 at 9:32 AM, the Business Office Manager staff #17 was interviewed. During the interview, staff #17…

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

Based on resident interviews and staff interviews and review of facility documentation, it was determined that the facility failed to protect the resident's property from loss. This was evident for 2 (Resident #161 and #203) out of 6 residents reviewed during the survey. The findings include: A controlled drug log is delivered with the controlled medication. The log is completed as the medication is administered and once the medication is completed the form goes into the resident's medical record. Each form is designated to the packet of medications that it was delivered with. On a controlled drug log, the date the medication is delivered, the resident name, medication, amount that is delivered, dosage, and administration orders are all noted at the top of the form. As medication is administered, staff are to document date/time, dose, amount wasted if applicable, administered by, and amount remaining. Once a medication has been administered in its entirety, staff need to reorder the medication, and a new Controlled drug log will also be delivered with the corresponding medication.…

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

Based on medical record review and staff interviews, it was determined the facility failed to ensure that resident or resident's representative received in writing the facility bed-hold policy before a resident was transferred to the hospital. This was evident for 1 resident (#156) out of 6 residents, reviewed during the survey. The findings include the following: Review of Resident #156's medical record on 04/21/25 at 10:51 AM revealed that resident was transferred to the hospital in August 2024 and before the transfer, there was no documentation found that resident or representative was notified of the facility bed-hold policy. During an interview on 04/22/25 at 8:34 AM with staff #1 stated there was no bed hold policy paperwork or documentation given to the resident or resident representative by the facility before the resident was transferred to the hospital.

Based on observation and staff interview, it was determined that the facility nursing staff failed to ensure that all medications were stored in a locked compartment or room. This was observed during a tour of the facility. The findings include: During a tour of the facility on 01/12/24 at 10:40 am on the Terrace Unit, with the facility maintenance director and the facility administrator, the nurse survey observed the bottom of what appeared to be a black jacket hanging out of the medication rooms door exactly at the height of the door handle. The nurse surveyor was able to easily push the door to an open position. A woman's black winter coat and black purse were observed on the right-hand side of the sink. Further observation of the medication room's door handle revealed that someone had stuffed brown colored hand tissues into the area that would house the door latch bolt. Placing the brown colored hand tissues into the door latch bolt area prevented the door from locking properly. Inside the medication room the surveyor observed 2 large, fully filled, gray colored pharmacy bags…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to 1) complete the daily assessments and documentation accurately, 2) have dental consults readily available on the chart, and 3) address a documented 41-pound weight gain discrepancy in one month, and 4) accurately document a resident observed skin assessment after admission. This was evident during the review of 4 of 55 (Residents #8, #45, #36 and #55) residents reviewed during a complaint survey. The findings include: 1) Review of the medical record for Resident #8 on 1/4/24 at 10:49 AM revealed admission for rehabilitation following multiple injuries from a motor vehicular collision including a sub-arachnoid hemorrhage (bleeding around the brain), rib fracture, left elbow dislocation, right knee dislocation, tracheostomy placement, percutaneous endoscopic gastrostomy (a tube placed in the abdomen for feeding). The resident arrived at the facility assessed as non-verbal. Further review noted that 23 of 29…

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 complaint and observation, it was determined that the facility failed to maintain all patient care equipment in proper working function by 1) not having enough batteries available for resident lifts, 2) not having enough battery charging receptacles available for the resident lifts, and 3) the rest room fan in room [ROOM NUMBER] is in disrepair by making loud grinding noises. This was observed on the Terrace and [NAME] nursing units during an observation tour of the facility. The findings include: Review of complaint MD00186774 on 01/03/24 revealed an allegation the nursing hoyer lifts have been broken before Thanksgiving 2023. 1) During a tour of the facility on 01/12/24 at 10:40 am on the terrace unit, with the facility maintenance director and the facility administrator, the nurse survey observed an Arjo-Sara lift that was nonfunctioning. In an interview with the facility maintenance director at the time, the facility maintenance director stated that the lift needed a charged battery to function 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 observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 1 of 4 nursing units observed during a revisit survey. The findings include: During an observation of the facility on 01/12/24 at 10:40 AM with Director of Maintenance and the facility Administrator, the nurse surveyor observed the following resident room call bells missing or in disrepair: 1) No resident call bell, wall mounted or handheld, was observed in the shared rest room between rooms [ROOM NUMBERS]. The facility administrator was immediately made aware of the observation. 2) The rest room cables in rooms: a) #70 was observed in disrepair. The cable had been cut and did not reach all the way to the floor. b) #72 is totally missing a cable. c) #7 is totally missing a cable.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of an active and closed medical record, and staff interviews, it was determined that the facility failed to 1) to report an allegation of sexual abuse (Resident # 18), 2) create a facility reported incident for a resident (Resident # 19) who fell outside on the facility grounds, and 3) report an injury of unknown source to the State survey agency. This was evident for 3 (Residents #18, #19, #30) of 55 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #18 medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after…

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 failed to thoroughly investigate allegation of resident abuse (resident #5 and #18). This was evident in 2 of 18 residents reviewed during a complaint survey. Findings includes: 1. The State of Maryland's Office of Health Care Quality received a facility report which reported resident #5 alleged resident #52 committed sexual abuse toward resident #5. Review of resident #5's medical records on 1/10/24 at 12:30 pm revealed the resident was admitted to the facility on [DATE] for long-term care related to a diagnosis of multiple sclerosis. Review of resident #52's medical record revealed the resident was admitted to the facility on [DATE] for long-term care related to Parkinson's disease and stroke. Additional review of both resident #5 and resident #52's medical records on 1/10/24 at 1:00 pm revealed the resident's rooms were not on the same unit. No other information was found in the electronic record regarding an allegation of sexual abuse in either…

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 failed to provide written notice to the resident or resident representative of bed hold policy. (Resident # 18). This was evident in 1 of 18 residents reviewed during a complaint survey. Findings includes: Review of Resident #18's medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility. Further review of resident's #18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 and voluntarily…

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 failed to complete the discharge process when the resident (Resident # 18) failed to reside in the facility for more than 30 days. This was evident in 1 of 18 residents reviewed during a complaint survey. Findings includes: Review of Resident #18's medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility. Further review of resident's #18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 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, it was determined that the facility failed to 1. update care plans based on medication use, and 2. initiate identified concerns for a resident after they were sent to the hospital for an extended admission, 3) initiate a care plan for a resident with a history of opiod disorder. This was evident for 3 of 4 residents (#14, #39 and # 41) reviewed during a complaint survey. The findings include: 1. Review of the medical record for Resident # 14 on 1/4/24 at 9:24 AM revealed diagnosis including schizophrenia and neuromuscular dysfunction of the bladder. Further review of Resident #14's medical record and physician orders noted no medications in place or order related to the resident's psychiatric diagnosis. Medical records indicate that s/he is followed by psychiatry and that the medication s/he was on was discontinued on 11/5/2021. However, review of the care plans in place on 1/4/24 at 12:43 PM noted active care plans in place to monitor behaviors related to…

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

Based on medical record review and interview, it was determined that that facility failed to hold care plan meetings every quarter and include the resident and or the representative. This was evident for 1 of 3 reviewed (Resident #1) for care plan meetings during the complaint process. The findings include: Review on 1/10/24 at 12:12 PM of the medical record for Resident # 1 secondary to a complaint, revealed admission to the facility for diagnosis including peripheral vascular disease, dystonia (movement disorder that causes the muscles to contract involuntarily) and disc degeneration. Further review of the complaint revealed concerns related to care plan meetings and the scheduling and holding of the care plan meetings. Interview on 1/10/24 at 10:02 AM with Resident #1 revealed that [the facility] never schedules care plan meetings .' and that s/he 'has never had one.' Interview on 1/10/24 with staff #23 the facility Director of Social work was interviewed regarding Resident #1's concerns. She stated that the resident only likes to have the meetings if everyone on the list 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview with Director of Nursing and review of the GNA [NAME], it was determined that resident # 12 did not receive toileting care on the following dates. This was evident for 1 out of 5 residents reviewed for toileting. Findings include: The GNA [NAME] is a record the GNA (Geriatric Nursing Assistant) fills out on the care provided to residents. The following dates were discovered on the GNA [NAME] in which the GNA did not provide toileting care to resident # 12. [NAME] for toileting indicated on Oct. 2021 No toileting documented for the night shift. 10/24/21 day shift 10/15-19, and 10/22/21- 26. Nov. 2021 No toileting documented for: 11/6, 11, 15, 18, 20, 21, and 26-day shift 11/13, 16, 19, 22, and 27-night shift Dec. 2021 no toileting documented for: 12/1, 2, 9, 10, 22, 26, and 27-day shift 12/3, 7, 11, 14, 17- night shift Jan. 2022 no toileting documented for: 1/4/22 and 5-day shift 1/28/22 night shift DON (Director Of Nursing) made aware and said nothing, but that there…

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 complaint, reviews of a closed medical record, and staff interview, it was determined that the facility nursing staff failed to administer an intravenous antibiotic timely. This was evident for 1 (Resident #30) of 55 residents reviewed during a complaint survey. The findings include: Review of complaint MD00194081 on 01/10/24 revealed an allegation Resident #30 did not receive quality of care. Review of Resident #30's closed medical record on 01/10/24 revealed that Resident #30 was sent to the hospital on [DATE] due to a change in condition. Nursing progress notes, dated 07/28/23 at 10:05 AM, indicated that Resident #30 was observed coughing and became short of breath. Resident #30 was also noted with difficulty swallowing. The nurse notified Resident #30's physician and obtained the following orders: obtain a chest x-ray, obtain blood and urine laboratory specimens for encephalopathy, do not give anything by mouth, obtain a speech and language consult for dysphagia, start and IV and administer IV…

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 failed to provide psychiatric evaluation for a resident (resident #26) who had a history of Post Traumatic Stress Disorder (PTSD) and Schizophrenia. This is evident in 1 of 18 residents reviewed during a complaint survey. Findings includes: Review of Resident #26's medical records on 1/9/24 at 10:00 am revealed the resident was admitted to the facility on [DATE] for rehabilitation after a stroke. Review of the care plan records revealed the facility placed the interventions of providing psychiatric services and providing psychiatric medication as ordered as a remedy for behaviors related to the resident's diagnosis of Schizophrenia and PTSD. Review of the resident's medical record found no evidence that the resident received psychiatric services during his/her stay in the facility. An interview with the Director of Nursing (DON) on 1/9/24 at 1:18 pm revealed the facility failed to provide a psychiatric evaluation as written as an intervention in 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 record review and staff interview, it was determined that facility staff failed to offer and provide the influenza vaccine to a resident (resident #3) during his/her stay. This deficient practice was evident for 1 of 18 residents reviewed during a complaint survey. The findings include: A review of resident #3 medical records on 1/18/24 at 9:30 am revealed the resident was admitted to the facility on [DATE] for rehabilitation after a stroke. Review of resident #3's vaccination records revealed the resident received only tuberculosis vaccines when admitted to the facility. Review of orders revealed the resident was ordered to be offered the influenza vaccine on 7/23/21. Further review of medical records found no evidence that the resident was offered the influenza vaccine. An interview with the Director of Nursing (DON) on 1/18/24 at 11:30 am revealed all residents are supposed to be offered the influenza vaccine when admitted . The DON admitted that he/she was unable to locate evidence that resident #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe and sanitary environment for a resident through failing ensure an electrical outlet was safe (resident #1). This deficient practice affected 1 of 1 resident reviewed during a complaint survey. The findings include: On 8/10/23, the State of Maryland's Office of Health Care Quality received a complaint (MD00195366) alleging the facility failed to maintain a clean environment for its residents, failed to have working air conditioning, and resident #1 failed to have a fall mat on his/her floor when it was ordered. On 8/11/23 at 12:00 PM, the surveyor with the Administrator and Maintenance Assistant #3 toured the facility. Resident #1's room was visited. The surveyor observed the electrical outlet with the TV plugged into it was exposed and did not have a cover over the outlet. Maintenance Assistant [NAME] acknowledged that the outlet should have a cover. On 8/11/23 at 1:45 PM, the surveyor expressed concern that Resident #1 room had a outlet…

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 laundry staff and the Director of housekeeping and laundry, the facility failed to replace, fix, or have another system in place for 1 out of 2 washing machines that were not in working order. This has affected all residents who have their laundry done by the facility. The findings include: During interviews with the residents held between 5/18/21 and 5/20/21 and at the Residents Council Meeting held on 5/25/21 at 1 PM, residents had complained about not having their laundry done and wanted to know the laundry schedule. On 5/24/21 at 11:45 AM the surveyor spoke with staff (#'s 34 and 35) who informed the surveyor that there was a laundry schedule but right now it is not in effect due to a broken washing machine. Staff # 35 said the washing machine has been broken since April 2021 and that the Director (staff 37) is aware. Staff # 37 said, this issue is creating a problem because they are trying to keep up with the linen for everyday use and when linen is not in the machine they try to do some resident's clothing. Staff # 34 stated that there…

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

Based on review of facility and resident records and interview with staff it was determined the facility failed to thoroughly investigate and report the investigation findings to the Office of Health Care Quality (OHCQ). This was evident for 2 (#433, #28) of 43 residents reviewed for Abuse. The findings include: 1) On 5/24/2021 at 9:00 AM complaint MD00158325 was reviewed. This complaint alleged that Resident #433 was assaulted by another resident. Review of Resident #433's medical record revealed that on 8/4/2020 Resident #433 was punched on the side of the head by another resident in the hallway but sustained no injuries. At 9:40 AM the Administrator provided the facility's investigation into the incident on 8/4/2020. The facility's investigation included the Comprehensive & Extended Care Facilities Self-Report Form, Resident #433's face sheet, Resident #433's Brief Interview for Mental Status (BIMS) Assessment and a statement from the Social Services Director at that time which said the Social Service Department also conducted a safe survey which consisted of asking qualitative…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#53,430, 431, 432 ) of 5 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #53 on 5/20/21 revealed that on 2/12/21 and 3/9/21 Resident #53 was transferred to an acute care facility due to a change in mental status. There was no evidence found in the medical record that written notification was made to the responsible party regarding the reason for the transfer and the location of the transfer. During the interview with (staff # 3) on 5/20/21, he stated the resident and or resident representative is made aware verbally and documented in the medical record. 2. A review of Resident #430's clinical record on 5/26/21 revealed that the resident on 1/10/21 was sent to the hospital. There was no mention of the resident or the Responsible Party (RP) receiving, in writing, the reason(s) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) The facility staff failed to ensure the (MDS) assessments were accurately coded for (#39). Review of Resident #39's medical record on 5/20/2021 at 11:40 AM revealed a quarterly assessment MDS from 9/20/2021 which documented in Section I, Active Diagnoses, that the resident had no Multi-drug Resistant Organism (MDRO) infections. Further review of Resident #39's medical record revealed an order for Contact precautions every shift for MDRO of unknown organism with KPC gene starting 8/22/2019 and ending 10/22/2019 when the resident was discharged . 4) The facility staff failed to ensure the (MDS) assessments were accurately coded for Resident #116. Review of Resident #116's medical record on 5/26/2021 at 9:35 AM revealed orders for Humalog Solution 100 UNIT/ML, inject 8 units subcutaneously three times a day for DM (diabetes mellitus) as well as Humalog solution cartridge 100 UNIT/ML, inject as per sliding scale .subcutaneously before meals for Diabetes. Further review of Resident #116's Quarterly MDS assessment…

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

Based on medical record review and staff interview, it was determined the facility failed to have a system in place to complete an interim care plan and to provide a written summary of the interim plan of care to the resident or responsible party. This was found to be evident for 1 out of 16 residents (Resident #4) reviewed for care planning during the 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. A review of Resident #4's medical record on 5/19/21 at 10:15 AM revealed Resident #4 was admitted to the facility in September 2018 for rehabilitation and with a diagnosis that included impaired mobility. Further review of the medical record and care plans failed to reveal a care plan for Heparin and/or documentation that a copy of the baseline care plan was provided to Resident #4 or Resident #4's responsible party within 48 hours after admission. An interview with the facility (staff #3) on 5/20/21 at 11:00 AM confirmed the findings. All…

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 a medical record review and staff interview, it was determined that facility staff failed to initiate a care plan for a resident receiving anticoagulant therapy. This was evident for two residents out of 56 selected for review during the annual survey, residents (#4, 98). The findings include: A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) The facility failed to initiate a care plan for a resident (#4) receiving Heparin for Deep venous Thrombosis. A review of the medical records on 5/18/21 at 11:00 AM, revealed that Resident # 4 was admitted to the facility in September 2020 for long-term care and with a diagnosis that included impaired immobility. A review of Resident # 4's medical record on 5/20/21 at 10 AM revealed a physician order dated 9/16/20 to administer Heparin Sodium Solution 5000 units/ml (milliliter) subcutaneously (under the skin) three times a day for DVT (Deep vein thrombosis) starting 9/17/20. Heparin injection is an anticoagulant. It is used to…

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

Based on observation and interview with residents and facility staff, it was determined that the facility failed to 1) provide sufficient supervision of residents' smoking as evidenced by failing to follow their smoking policy and failing to complete smoking assessments accurately and 2) failed to protect a resident, who was dependent on staff for turning and positioning, from falling out of bed during care. This was evident of 2 (Resident #116, #113)) of 3 residents reviewed for smoking. The findings include: 1) The facility failed to 1) provide sufficient supervision of residents' smoking as evidenced by failing to follow their smoking policy and failing to complete smoking assessments accurately During the initial tour of the facility that took place on 5/18/21, the surveyor made an observation of Resident #116's room at 11:07 AM. During the observation, the surveyor noted that Resident #116 had a cigarette lighter on his/her windowsill. When the surveyor asked if s/he keeps his/her own smoking supplies, Resident #116 said, yes. The resident also stated that s/he smokes multiple…

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 staff competencies conducted on 5/24/21 at 1:14 PM, the facility failed to provide competency training services for 4 out of 5 staff members. The findings include: On 5/24/21 at 1:14 PM a review of 5 staff personnel records were reviewed. This included staff records for staff # 16, 17, 18, 19, and 20. New Hire education was provided to all new staff hired after 3/2020, however there were no competencies or skills checklist in the files. The Administrator was notified of this on May 24, 2001, at approximately 1pm. Staff # 17 was the only staff person who had a skills competency in her record. The Administrator stated that the previous facility sold the building on 3/2020 and took with them all training provided to staff and all background checks. The Administrator stated that she no longer has access to their files.

Based on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to develop a comprehensive plan to manage Heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments in one (Resident #4) of 16 residents reviewed during the annual survey. The findings included: Heparin injection is a blood-thinning medication used to treat and prevent blood clots. Heparin has a risk of increased bleeding and is monitored by a blood test called a PTT (Partial thromboplastin time). PTT is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. The therapeutic PTT range for heparin is 60 to 100 seconds, with lower intensity dosing in the range of 60-80. Elevated levels indicate an increased risk of bleeding. According to the EMR(electronic medical record), Resident #4 was admitted to the facility in September 2020, for Long Term Care with the diagnosis that included severe head trauma, craniectomy, diabetes, impaired immobility…

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

Based on medical record review and staff interview it was determined the facility staff failed to; 1) accurately reflect what was in Resident's #4 medical record; 2.) ensure that documentation of Residents' #97'showers was accurate. 3.) respond to Resident #8's medication regimen review in a timely manner. The findings include: The facility documentation in the resident's progress notes, did not accurately reflect what was in Resident #4's medical records. 1a. Review of Resident #4 medical record on 5/20/21 at 11 AM, revealed two (NP) Nurse Practitioner (staff#27) progress notes dated 4/6/21 and 5/20/21. Both Nurse Practitioner progress notes documented the resident was receiving hemoglobin A1C every three months and Humalog per sliding scale. Further review of the medical record failed to reveal an order to obtain resident (#4's) hemoglobin A1C every three months, however, the medical record revealed a physician order dated 2/3/21 to discontinue the Humalog per sliding scale per pharmacy recommendation. Interview with the Nurse Practitioner on 5/20/19 at 1:30 PM he stated, 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 observation, it was determined that the facility failed to ensure that residents outside of their rooms wore masks and that hand sanitizer dispensers were available and kept from going empty. Failure to apply resident masks was evident for 1 of 9 days the survey took place. Failure to keep hand sanitizer readily accessible at the check-in station was evident for 2 of 9 days the survey took place. Failure to keep hand sanitizer dispensers filled was evident for 3 of 13 sampled hallway dispensers and 5 of 20 sampled room dispensers. The findings include: During an initial tour of the facility that took place on 5/18/21 and beginning at 8:00 AM, the survey team observed two residents who were not wearing masks while in the hallways outside their rooms. Staff who were present in the hallways at that time did not make an attempt to assist either resident in applying a mask. Also, during the initial tour of the facility, the survey team sampled hand sanitizer dispensers to determine if any were empty. The…

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

Based on observations, medical record reviews, and interviews during a tour of the facility, it was determined that the facility failed to maintain and enhance the dignity of the residents: 1) by failing to provide privacy and rendering care to resident (#4) , 2) failed to provide clean clothes and or linen for resident (#37) due to broken equipment and, 3 ) failed to provide proper bedding for resident (#99). This occurred in three of three sampled residents for dignity. The findings include: The facility failed to maintain and enhance dignity for resident #4 by failing to provide privacy after rendering am care. 1a) On 5/18/21 at 9:00 AM during a tour of the facility this surveyor observed resident (# 4) lying in bed on the left side uncovered with brief exposed. The bed was in the highest position. The resident's feeding tube tubing was lying over his/her left arm attached to the feeding pump. The resident had a crème-colored dried substance on the left side of the sheets. The feeding pump was off, and the total volume infused from the feeding pump was1350 (ml) milliliters.…

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 the facility failed to: 1) ensure that Resident (#68) was provided proper storage for personal belongings, and 2) ensure that (residents #69, #114, #116) have access to the facility's communication system (call bell). This was found to be evident for 4 out of 56 residents reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities. 1) On 05/18/21 at 1:40 PM, the surveyor observed that Resident # 68's clothing was piled on the floor next to his/her bedside. The resident stated that he/she did not have an armoire closet for storage of his clothing. The resident stated that the dresser in his room had wound…

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 discussions with the residents during the Resident Council Meeting held on 5/25/21 at 1 PM, the facility staff do not respond to all the concerns the residents had. This was evident for all residents who attended the resident council meetings. The findings include: On 5/24/21 at 9:15 AM this surveyor reviewed the minutes prior to attending the Resident Council Meeting held on 5/25/21 at 1 PM. The Activity Director, staff # 8, stated that the facility just recently started the resident council meeting in March and April 2021. Record review indicated that during the March 3/30/21 meeting residents wanted to know if they will have to sign a new admissions package because the company was sold in March 2020. They, also, wanted to know what the new laundry schedule is. The residents would also like to know what the policies and procedures are for the new company, Vita. Those items were not documented as addressed to the Resident Council. Further review of the resident council notes for the April 27,2021 meeting, it was revealed that residents wanted to know why some residents can…

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 staff interviews it was determined the facility failed to: 1) provide housekeeping and maintenance services to keep the resident's environment clean and in good repair on the first floor nursing unit, and . 2) failed to ensure that equipment involved in a resident's artificial feeding was maintained in a clean, sanitary, and homelike manner for Resident #84. The findings include: The following environmental concerns were observed during the survey: On May 18, 2021, at 9 AM during observation rounds: room [ROOM NUMBER]B: There were multiple brown and black stains on the privacy curtain. The base molding by the radiator had approximately 8 inches pulled away from the wall by the radiator. There was a dried crème bottom sheet on the left side. room [ROOM NUMBER]: the bathroom had rust around the toilet bolts that hold the toilet seat down. There were several tiles cracked in front of the bathroom sink. room [ROOM NUMBER] B: The window blind on the left was covered with dark brown and black…

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

Based on review of facility staff records and interview with the administrator, the facility failed to present background checks for employees that have been employed by the facility prior to March 2020. This was evident for 2 out of 5 staff checked for background checks (Staff # 16 and 17). The findings include: On 5/25/21 at 9 AM Surveyor # 375867 requested the employee records for 5 staff members, that included staff # 16, # 17, # 18, #19, and # 20. A review of the records indicated that there was no background check information documents available for staff #16 and staff #17. The Administrator was called at 12:10 PM on 5/25/21 and asked where the staff background check information was. The Administrator stated that when the old company left, in March 2020, they took with them all the employee records, including the background checks and the skills competency check list. The Administrator stated that she does not know where they are and will accept a deficiency tag for this.

Based on medical record review, review of facility statements, and interviews, it was determined the facility staff failed to report an incident to the Office of Health Care Quality (OHCQ) and local law enforcement as required in a timely manner. This was evident for 2 (Resident #433 and #8 ) out of 43 residents reviewed during a complaint survey. The findings include: 1) On 5/24/2021 at 9:00 AM complaint MD00158325 was reviewed. This complaint alleged that Resident #433 was assaulted by another resident. Review of Resident #433's medical record revealed that on 8/4/2020 Resident #433 was punched on the side of the head by another resident in the hallway but sustained no injuries. At 9:40 AM the Administrator provided the facility's investigation into the incident on 8/4/2020. The facility's investigation included the Comprehensive & Extended Care Facilities Self-Report Form which must be filed with OHCQ within 2 hours if serious bodily harm resulted and within 24 hours for all other incidents, as stated on the bottom of the form. According to the Self-Report form the facility did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #1) of 2 residents reviewed for resident assessment. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments are completed at differing intervals but never further than 92 days apart as long as a resident remains at a facility. Each assessment must be encoded within seven days and transmitted within fourteen days of the assessment being performed. On 5/20/21 at 12:50 PM, the surveyor reviewed information from the Centers for Medicare and Medicaid (CMS) regarding transmission of Minimum Data Set (MDS) Assessments. The review revealed that no assessment information had been transferred for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that a resident whose stay at the facility exceeded 30 days had a new Preadmission Screening and Resident Review (PASARR) Level 1 screening completed within 40 days of admission. This was evident for 1 (Resident #116) of 4 residents reviewed for PASARR. The findings include: The PASARR level 1 screening is federally mandated and must be completed for all applicants to nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. The screening form only needs to be partly completed if a resident is expected to remain in a nursing facility for fewer than 30…

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

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #116) of 4 residents reviewed for Bladder and Bowel Incontinence. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). The surveyor reviewed Resident #116's medical record on 5/18/21 at 11:37 AM. The review revealed that Resident #116 had a quarterly MDS assessment completed on…

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

Based on medical record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #432) of 43 residents reviewed during an annual recertification survey. The findings include: Review of Resident #432's closed medical record on 5/25/2021 revealed that Resident #432 was discharged from the facility on 11/28/2019. Resident #432's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #432's attending physician that included: a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. The Administrator and Director of Nursing were made aware of this issue during the exit conference on 5/28/2021.

Based on medical record review and staff interview it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 2 (#432, #430) of 43 residents reviewed during the survey The findings include: 1. On 5/25/2021 complaint MD00148458, which alleged that Resident #432 was not receiving their Acetaminophen as ordered, was reviewed. Review of Resident #432's medical record at 12:00 PM revealed physicians orders for Acetaminophen Liquid, give 10.15 mL by mouth every 6 hours as needed for pain scale of 1-3 and Acetaminophen Tablet, give 650 mg by mouth every 7 hours as needed for pain of 1-3. Further review of Resident #432's pain level documentation revealed a pain level of 3 on 11/26/2019 at 4:56 PM, however, no pain medication was given according to the facility's medication administration report. 2. On 5/24/2021 at 12:08 PM, Resident #430's medical record was reviewed in regards to complaint MD00146201. Review of Resident #430's medical record revealed an order for Carbohydrate controlled, low sodium…

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 record review on 5/19/21 at 11:54 AM, resident interview on 5/18/21 at 9:16 AM, and complaint # MD00160765, staff failed to put hearing aids in Resident # 98's ears on a routine basis. This was evident for 1 out of 3 residents with hearing loss. The findings include: On 5/18/21 at 9:16 AM an interview was conducted with Resident # 98. The resident had trouble answering the questions the surveyor asked her because she stated the she was hard of hearing. Resident # 98 stated that she wears hearing aids and they were not in. Resident # 98 proceeded to say that her hearing aids are located in her dresser drawer which was located behind her bed, which the resident could not reach. The resident, also, stated that she had a stroke which makes her hands shaky so it was impossible for Resident # 98 to place her own hearing aid in the right ear. Resident #98 was observed multiple times during this survey to make sure that her hearing aids were placed in her ear. The hearing aids were not placed in her ear on 5/18/21, 5/27/21 and 5/28/21. On 5/28/2021 the surveyor spoke 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 medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to supervise Resident #4's care as evidenced by their failure to develop a comprehensive plan to manage heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments. This was evident for one (Resident #4) of 16 residents reviewed during the annual survey. The findings included: Heparin injection is a blood-thinning medication used to treat and prevent blood clots. Heparin has a risk of increased bleeding and is monitored by a blood test called a PTT (Partial thromboplastin time). PTT is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. The therapeutic PTT range for heparin is 60 to 100 seconds, with lower intensity dosing in the range of 60-80. Elevated levels indicate an increased risk of bleeding. According to the EMR(electronic medical record), Resident #4 was admitted to the facility in September 2020 [deleted comma] for Long Term Care 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 medical record review and staff interview it was determined that what the Nurse Practitioner documented in the resident's progress notes, did not accurately reflect what was in the resident's medical records. This was evident for 1 (#4) of 16 residents. The findings include: 1.Review of Resident #4 medical record on 5/20/21 at 11 AM, revealed two (NP) Nurse Practitioner (staff#27) progress notes dated 4/6/21 and 5/20/21. Both Nurse Practitioner progress notes documented the resident was receiving hemoglobin A1C every three months and Humalog per sliding scale. Further review of the medical record failed to reveal an order to obtain Resident (#4's) hemoglobin A1C every three months, however, the medical record revealed a physician order dated 2/3/21 to discontinue the Humalog per sliding scale per pharmacy recommendation. Interview with the Nurse Practitioner on 5/20/19 at 1:30 PM he stated, the progress notes are incorrect, clearly no labs are being done. 2. Review of Resident #4 medical record on 5/22/21 at 1 PM revealed a Podiatrist (staff # 45) progress note dated…

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

Based on resident interviews during the resident council meeting, the facility failed to answer the call lights in a timely manner. This had the potential to affect all residents at the facility. The findings include: During the resident council meeting on 5/25/21 at 1PM resident #'s 105, 145, 129, 36, and 97 expressed having to wait for long periods of time for staff to answer the call bells, timely. They are met with responses such as, Go ask your nurse, I am not your nurse today or I am too busy now. This issue was addressed by the Administrator who provided an in-service to staff on 4/16/21. However, the residents stated that the staff were not educated properly, as they continued to act the same way. In addition, the resident council meeting attendees stated that the call bells are being answered now because the state is in the building. The residents stated as soon as the state leaves, staff will go back to their old ways.

Based on review of staff hire documents and training programs, 1out of 1 staff members did not have 12 hours of documented dementia training in their records. The findings include: On May 24, 2021 at approximately 12:30 PM, a review of 5 employee records were reviewed. One out of 5 staff members, staff # 20, did not receive the dementia training of 12 hours.

Based on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that posted nursing staff information was accurate. This was true for 1 of 4 units in the facility. The findings include: On 5/19/21 at 11:50 AM, the surveyor interviewed Resident #97 who stated that the resident's assigned nurse was not administering time-sensitive medication to him/her. On 5/19/21 at 12:00 PM, the surveyor made an observation of the nursing assignment board which indicated that Licensed Practical Nurse (LPN, Staff #60) was assigned to Resident #97. LPN #60 was interviewed at that time and stated that a change in the assignment had been made. Now, LPN #21 was assigned to Resident #97. LPN #21 was also interviewed at that time and confirmed that she was now assigned to Resident #97 but that the assignment board was not updated. LPN #21 stated that she would administer Resident #97's medication then. The surveyor interviewed the Assistant Director of Nursing (ADON) on 5/19/21 at 12:29 PM. The ADON stated that the assignment had been changed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked. This was evident for 2 out of the 8 medication carts. The findings are: This surveyor observed on 5/25/21 at 7:58 AM two unlocked medication carts between rooms [ROOM NUMBERS]. This surveyor was able to open two drawers. Staff #42 walked through the fire doors and upon seeing this surveyor asked what was wrong. She was told that the carts were unlocked. Staff #42 said she would find the nurse and walked to the first room past the intersection. She found the nurse (Staff #21) and told her. Staff #42 then came back and locked the carts. This surveyor observed a medication cart located outside of room [ROOM NUMBER] unlocked on 5/26/21 at 8:37 AM. Two drawers were pulled open by this surveyor and the nurse (Staff #21) came out of room [ROOM NUMBER] within a few seconds of the drawers being opened. She immediately locked the medication cart. The Administrator was informed 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 resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 1 (Resident #97) of 43 residents reviewed during the survey. The findings include: On 5/19/2021 at 10:47 AM an interview with Resident #97 revealed concerns with the facility's food service. A test tray was ordered on 5/26/2021 for the lunchtime meal service. Observation of Resident #97's meal tray on 5/26/2021 at 12:40 PM revealed 3 packets of pure cane sugar, a cup of orange juice and a piece of white cake. The test tray brought to surveyors also contained 3 packets of pure cane sugar, a cup of orange juice and a piece of white cake. The tray ticket on Resident #97's tray did not specify what type of diet the resident is ordered, nor did it state which specific food items should be on the tray. Review of Resident #97's medical record on 5/26/2021 revealed a diagnoses of Type 1 diabetes and an order for CHO (carbohydrate) Controlled Low Sodium Cardiac Diet, Regular texture.…

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, it was determined that the facility failed to ensure that the facility stored food in accordance with professional standards for food service safety. This was evident for 1 of 2 observaitons of the kitchen. The findings include: During the initial tour of the kitchen that took place on 5/18/21 at 8:14 AM, it was observed that the facility had stored an unmarked, unlabeled salad in the refrigerator that contained sliced lunch meat. It was also observed that, in the dried foods storage area, dried foods were being stored in boxes directly on the floor without being stored on dunnage crates at least six inches off the floor.

Based on observation it was determined the facility staff failed to dispose of garbage and refuse properly. The findings include: On 5/20/2021 at 9:12 AM the facility's dumpster area was observed with discarded gloves, plastic litter and debris on the ground. Plastic wrappers and trash was also observed on the side of the building near the kitchen exit. These findings were reviewed with the Administrator and Director of Nursing during the exit conference on 5/28/2021.

Based on record review and staff interview it was determined the facility failed to provide specialized rehabilitative services. This was evident for 1 (Resident #435) of 43 residents in the final sample. The findings include: On 5/21/2021 at 9:10 AM a review of complaint MD00157036 was started which alleged that Resident #435 was not receiving specialized rehabilitative services while at the facility. Review of Resident #435's electronic medical record revealed orders for PT (physical therapy) EVAL AND TREAT AS INDICATED and OT (occupational therapy) EVAL AND TREAT AS INDICATED created on 7/17/2020, the day Resident #435 was admitted . No record of physical or occupational therapy was found in the resident's electronic medical record. During an interview on 5/25/2021 at 12:25 PM the Administrator stated that she spoke with her Physical Therapy team and the facility did not screen the resident upon admission. The facility was unable to provide any evidence that Resident #435 was provided with rehabilitative services.

Based on a review of the Quality Assurance Program and interview, the Quality Assurance Committee failed to identify issues related to quality assessment activities, failed to recognize gaps in systems or processes, monitor and ensure implementation of plans of action to correct deficiencies. The findings are: Although the facility's Quality Assurance Committee is required to meet monthly, there is no evidence that the current deficiencies had been identified and appropriate plans of action had been implemented. Refer to: F550, F558, F565, F 584, F 606, F609, F610, F623, F640, F641, F645, F655, F656, F657, F661, F684, F685, F689, F711, F725, F726, F730, F732, F775, F761, F800, F812, F814, F825, F842 and F867. Interview with the Director of Nursing and Nursing Home Administrator confirmed the findings on 5/28/21 at 1 PM.

Based on a review of the Quality Assurance (QA) attendance records and staff interviews it was revealed that the required facility staff is not attending the QA meetings. The findings include: A review of the monthly QA attendance sheets revealed that the GNA (geriatric nursing assistant) only attended 1 of the 12 monthly meetings. Further review of the monthly attendance sheets failed to reveal that in August 2020, September 2020, December 2020, and January 2021, the required QA meeting was not held. During an interview with the DON (Director of Nursing) on 5/28/21 at 1:00 PM, she revealed that she is new to the facility and the QA committee. The DON acknowledged that the GNA did not attend the required meetings, and the sign-in sheets for August 2020, September 2020, December 2020, and January 2021 could not be located. She stated, moving forward the meetings would be conducted as required. She also revealed that the QA is a work in progress and more staff will be involved.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This was evident for 1 out of 15 handrails observed during the annual survey. The findings include: During a tour of the facility conducted on 05/18/21 at 8:32 AM, the surveyor observed a handrail hanging in a downward position away from the wall located in the hallway between resident rooms [ROOM NUMBERS] of the [NAME] Wing. During an interview on 05/18/2021 at 9:23 AM, the surveyor advised the Administrator of the observation of the loose hanging handrail. On 05/18/2021 at 9:47 AM, the surveyor observed (Staff #5) the Maintenance Director repair the handrail located between resident rooms [ROOM NUMBERS] of the [NAME] Wing. On 05/18/2021 at 11:30 AM, the Surveyor confirmed that the handrail was secured to the wall.

Based on medication cart observations and staff interviews it was determined that facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out of 8 medication carts with Informed Consent /Declination Forms involving Resident's #48 and Resident #363. The finding includes: On 8/8/18 at 10:28 A.M. on the third floor long term care unit, the surveyor observed on top of a standing unattended medication cart for Team#1, on the 1st floor west wing, the nursing shift to shift report dated 07/11/2018. The document was not kept in a confidential manner for residents in rooms; 29A, 29B, 30A, 10B, 31A, 32A, 32B, 33A, 33B, 34A, 35A, 35B, 36A, 36B, 37A, 37B, 38A,38B, 39A, 40A, 41B, 42A, 42B, 43A, 44A, 45A, 45B, 46A, 48A, 48B,49A, 50A,52B, 53, 54A and 54B. The nursing shift to shift document is used by the facilities nursing staff for assigned nursing task preformed during the nurses shift on assigned residents. The surveyor was able to view the listed resident's names, room numbers, vital signs, medications, lab results, new medical orders…

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 the facility failed to ensure a staff restroom was kept locked or was included in the resident call system. This was evident for 1 of 3 staff restrooms observed during the survey. The findings include: On 10/22/18 at 12:10 PM the restroom door across from the therapy room was found open. Observation of the inside of the restroom revealed there was not a device connected to the resident call system for a resident to call staff if needed. Although the door is equipped with a lock that requires a code to unlock the door, when employees leave the door open there is a potential for a resident to go in, shut the door, and be unable to contact staff in case of a fall. The door was also found open by surveyors on at 1:45 PM and 2:25 PM. On 10 /23/18 at 10:06 AM the door was found open again. The Administrator was then made aware. On 10/24/18 at 9:30 AM, the staff restroom door for the restroom closest to the front door of the facility was found open. Observation of the inside of the restroom revealed there was no device connecting…

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.