Turtle Creek Rehabilitation and Wellness Center

Based on record reviews, interviews, and observations, it was determined that the facility failed to provide activities based on the resident's comprehensive assessment. This was evident for 1 (Resident #51) of 4 residents reviewed for neglect. The findings include:The concerns related to Complaint2795585 included a report that staff was mistreating Resident #51 by showing other residents more attention. On 4/14/26 at 10:08 AM, Resident #51 was observed in room, watching TV.On 4/17/26 at 12:10 PM, a review of Resident #51's most recent comprehensive assessment with a reference date of 7/15/25 section F, indicated that it was very important for the resident to do things with groups of people and to go outside to get fresh air when the weather is good.On 4/17/26 at 12:15 PM, Resident #51's care plan for activities included interventions such as, encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities; and invite resident to scheduled activities.A review of April 2026 activities and activity participation…

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

Based on medical record review and interview it was determined that the facility failed to ensure lab tests that were required to determine if a specific medication needed to be administered were obtained. This was found to be evident for one (Resident #40) out of five residents reviewed for unnecessary medications.The findings include:Review of Resident #40's medical record revealed the resident has leukopenia, which is a lower than normal white blood cell (WBC) count. A low white blood cell count leaves a resident vulnerable to infections.The resident had an order, in effect from 11/20/25 through 2/21/26 for Zarxio to be administered once every 14 days for leukopenia when the WBC (white blood count) is less than 4. The resident had an order from 9/26/25 until 4/17/26 for a CBC (complete blood count - which includes WBC) every two weeks on Tuesdays and to fax the results to the pharmacy for neupogen delivery. Neupogen and Zarxio have the same active ingredients. Review of the lab results revealed the resident had a WBC of 2.7 on 2/12/26 and the Zarxio was administered. On 2/22/26…

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 observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #45) of 4 residents reviewed for pressure injuries. The findings include:Resident #45 had been a resident of the facility since early 2018. On 4/13/26 at 11:10 AM, the resident was observed in bed equipped with an air mattress. The control unit for the air mattress was located at the foot of the bed and was observed to be set at 550 lbs.A review of Resident #45's medical record was conducted on 4/13/26 at 1:32 PM. The review revealed the resident's most recent weight was 252.4 lbs. taken on 4/3/26. Current orders included for nursing to check air mattress to be set per manufacturers guidelines and check for proper placement and function every shift.The Braden Scale is a widely used healthcare tool to assess a patient's risk of developing pressure injuries/ulcers. Scores range from 6 to 23, with lower scores indicating higher risk.…

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

Based on medical record review and interview it was determined that the facility failed to ensure urology appointments for monthly suprapubic catheter changes were scheduled in a timely manner. This was found to be evident for one (Resident #40) out of two residents reviewed for urinary catheter care.The findings include:Supra pubic catheters require a surgical procedure in which a small incision is cut through the abdomen to allow for insertion of a tube into the bladder. The tube remains in place to allow for continuous drainage of urine into a drainage bag. Review of Resident #40's medical record revealed the resident was admitted to the facility in 2025. The resident has a suprapubic catheter, with orders in effect from 9/3/25, to change the supra pubic catheter monthly at the urologist office. Review of the medical record revealed documentation that the resident was seen by the urologist for a supra pubic catheter change on 10/9/25 with a recommendation to follow up in 4 weeks for a catheter change. Review of a 10/9/25 nursing progress note revealed the resident's next…

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

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to a resident requiring such services according to professional standards of practice. This was evident for 1 (Resident #6) of 2 residents reviewed for pain management. The findings include:Resident #6 had been a resident of the facility since mid-2019. The medical record indicated that the resident was cognitively intact.Resident #6 was interviewed on 4/13/26 at 11:52 AM. During the interview, the resident reported that s/he was in severe pain and that the facility had run out of his/her pain medication. The resident stated, they have a box upstairs for emergency if you run out but they won't do that for me.A review of Resident #6's medication orders was conducted on 4/16/26 at 1:37 PM. The review revealed that the resident was on a routine narcotic pain medication (Oxycodone 5 MG capsule every 6 hours) for chronic pain scheduled at 12 AM, 6 AM, 12 PM and 6 PM. The administration record for April 2026 revealed that the resident missed doses on 4/12/26 at 6 AM,…

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

Based on observation, record review, and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice. This deficient practice resulted in a medication error rate of 17.24% (5 errors out of 29 opportunities), exceeding the allowable 5% error rate.The findings include:On 4/15/26, a medication pass observation identified 5 medication errors out of 29 opportunities (17.24%).On 4/15/26 at 2:25 AM, a Licensed Practical Nurse (LPN) #3 was observed to have partially dispensed medications for Resident #38 prior to completing the administration for another resident. The medications included: Levetiracetam 750 mg, Divalproex sodium DR 500 mg, and Lactulose 30 mL. These medications were unlabeled and placed in a non-resident-specific drawer within the medication cart. LPN #3 then proceeded to administer medications to Resident #3, leaving three of Resident #38's medications unsecured and not identifiable for the intended resident. Constituting three errors.On 4/15/26 at 9:50 AM, LPN…

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 reviews, it was determined that the facility failed to ensure complete and accurate hospice documentation was maintained and readily accessible for 1 (Resident #9) of 1 Residents reviewed for Hospice Care.The findings include:Resident #9 had a medical history that included, but was not limited to, a terminal diagnosis of cerebral atherosclerosis and had been receiving hospice care services since 7/4/2025 from Heartland Hospice.On 4/15/26 at 1:13 PM, a record review revealed that Resident #9's electronic medical record contained hospice-related documentation limited to a care plan conference dated 10/7/25, covering benefit period dates 10/2/25 through 12/20/25. There was no evidence of additional hospice care documentation in the medical record, in the two available electronic formats, or on a hard copy.On 4/16/26 at 11:30 AM, during an interview with the Director of Social Services, SSD #4 stated that Heartland provided the facility with handwritten documentation of visits to the resident and that it was maintained in 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.

Based on review of facility documentation of employee education records and interview, it was determined that the facility failed to ensure all staff received mandatory Quality Assessment and Performance (QAPI) training (Staff #20). This was evident for 1 of 5 employees reviewed during a complaint survey. The findings include:On 2/9/26 a review of 5 random employees' education records provided by the facility was conducted for QAPI training.Review of Staff #20's education records with a hire date of 7/31/24 revealed no QAPI training has been completed.Interview with the Administrator on 2/9/26 at 2:13 PM confirmed there is no evidence Staff #20 has received QAPI training.

Based on review of facility documentation of employee education records and interview, it was determined that the facility failed to ensure all staff received mandatory Compliance and Ethics training annually (Staff #20). This was evident for 1 of 5 employees reviewed during a complaint survey.The findings include:On 2/9/26 a review of 5 random employees' education records provided by the facility was conducted for annual Compliance and Ethics training.Review of Staff #20's education records with a hire date of 7/31/24 from January 2025 until February 2026 revealed no Compliance and Ethics training has been completed.Interview with the Administrator on 2/9/26 at 2:13 PM confirmed there is no evidence Staff #20 has received annual Compliance and Ethics training.

Based on review of facility documentation of employee education records and interview, it was determined the facility failed to ensure all nurse aides received 12 hours of training annually that included dementia management and abuse prevention (Staff #20). This was evident for 1 of 5 nurse aides reviewed during a complaint survey. The findings include:On 2/9/26 a review of 5 random nurse aides' education records provided by the facility was conducted for annual training.Review of Staff #20's education records with a hire date of 7/31/24 from January 2025 until February 2026 revealed no evidence Staff #20 received 12 hours of training that included dementia management and abuse prevention.Interview with the Administrator on 2/9/26 at 2:13 PM confirmed there is no evidence Staff #20 received 12 hours of training from January 2025 until February 2026 that included dementia management and abuse prevention.

Based on record review, observation and interview, the facility failed to provide residents with an adequate supply of linens. This has the potential to affect all residents residing in the facility. The findings include: During a review of Intake #MD00164452 on 2/19/25 at 08:30 AM the complainant stated that the facility did not have enough towels and washcloths. On 2/20/25 at 09:30 AM, 2/20/25 at 12:30 PM and 2/21/25 at 8:00 AM, the surveyors observed that the linen carts in the hall contained only one or two towels and washcloths in the cart. During those observations Geriatric Nursing Assistants #7, #11, #12 and #13 were interviewed about the amount of linen they have to provide for resident care. They stated they have enough linen to provide care, but they often have to go down to the laundry to get extra linens. During an interview on 02/21/2025 at 8:06 AM, laundry staff #9 stated she never has enough laundry to give staff when they come down and request it because they are very short on all laundry but especially washcloths, towels, and gowns. During an interview 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 observations and interviews it was determined that the facility staff failed to properly store food in accordance with professional standards for food service and safety. This was found evident in 1 of 3 kitchen observations and 2 out of 2 unit storage refrigerators during the survey. This has the potential to affect all residents. The findings include: On 2/18/25 at 8:18 AM, the surveyor conducted initial observation of the facility kitchen. During the observation the facility's Dietitian and interim-Dietary Manager Staff #17 was present. On 2/18/25 at 8:20 AM, the surveyor along with Staff #17 observed the dry storage room. Staff #17 stated that dietary staff are expected to date the food items when they are received. The surveyor noted one can of sliced peaches without a labeled received date. The surveyor also noted that one can of mandarin oranges that did not have a receive date. The can also did not have an expiration date. On a different row 6 cans of the same product, mandarin oranges, we noted all to have recently received dates. The surveyor asked Staff #17 how…

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 staff interviews, it was determined that the facility failed to provide adequate privacy in resident bathrooms. This was found to be evident throughout the facility during the recertification survey. The findings include: On 2/18/2025 at 9:10 AM, surveyors conducted on interview with Resident #442's family member who addressed concerns about bathroom privacy for the resident due to lack of blinds in the resident bathroom. On 2/18/2025, surveyors observed multiple bathrooms located in resident rooms on the ground floor with no blinds or curtains covering the windows. Brackets were observed hung in resident window frames in bathrooms without blinds or curtains. Windows in resident bathrooms were also observed not to be frosted. On 2/20/2025 at 2:30 PM, surveyors toured outside the facility. During this tour, surveyors were able to see inside residents' bathrooms from outside on the ground level. The Maintenance Director (MD) was interviewed on 2/25/2025 at 11:10 AM. The MD stated that he had worked at the facility for 8 years and was not aware at any time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to recognize the rights of a Resident. This was found evident of 1 (Resident #56) of 46 residents reviewed during the survey. The findings include: On [DATE] at 11:20 AM, the surveyor reviewed Resident #56's medical record. The record revealed that Resident #56 had a Maryland Order for Life Sustaining Treatment (MOLST) form dated [DATE] that indicated Resident #56 decided for him/herself that he/she wanted Cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. On further review the surveyor reviewed a psychologist note dated [DATE]. In the note Psychologist Staff #29 documented that Resident #56 was non-verbal in that he/she cannot clearly speak. She further documented that Resident #56 could however, communicate using a flip phone and text. She wrote; Resident #56's writing suggests he/she is bright with good vocabulary and faster than expected speed of processing, based on the speed in which he/she types/texts. 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 resident interview, medical record review, and staff interviews, it was determined that the facility failed to adjust the care plan to reflect the resident's preferences. This was evident for 1 (Resident #22) of 8 residents reviewed during the annual survey. The findings include: On 2/18/25 at 11:46 AM, during an interview with Resident #22, the resident reported that the facility failed to honor his/her preference for female healthcare providers. On 2/21/25 at 10:34 AM, a review of Resident #22's medical record failed to reveal documentation of Resident #22's healthcare provider preference. On 2/21/25 at 11:00 AM, an interview with Staff #26 was conducted. Staff #26 stated that Resident #22 only requested female healthcare providers to care for him/her. Staff #26 also reported that all staff members and the facility management were aware of Resident #22's preferences. On 2/21/25 at 12:09 PM, an interview with the Director of Nursing (DON) was conducted. The DON confirmed that the facility failed to update Resident's #22 care plan to reflect his/her preferences.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility staff failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) order. This was found to be evident for 1 (Resident #24) out of 5 residents reviewed for MOLST orders and advance directives during an annual survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. An incapacitated person cannot sign a Medical Orders for Life-Sustaining Treatment (MOLST) form. Instead, a health care agent or surrogate can sign the form on their behalf. Record Review, on 02/18/25 at 03:33 PM, found that MOLST was from year 2020 with Resident #24 as the decision maker for his medical treatments. However, a legal court Gaudian Appointed Order was issued on 6/16/2022. Further record review, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility's policy and interview, it was determined that the facility staff failed to document ongoing re-assessments that would help determine the necessity of restraints for a resident who utilized a restraint. This was evident for 1 (Resident #10) of 1 resident reviewed for restraints during the survey. The findings include: Physical restraint includes all devices and practices used by the facility that restrict freedom of movement or normal access to one's body. On 2/18/25 at 9:13 AM, the surveyor observed a half gate across Resident #10's doorway. Resident #10 was noted walking up to the door and resting his/her hands on the top of the gate. When the surveyor approached the door Resident #10 smiled and walked back to his/her bed and sat down. On 2/25/25 at 1:46 PM, the surveyor reviewed the restraint order dated 11/17/17. The order stated, may apply a gate at the resident's door for safety every shift. Next the surveyor reviewed Resident #10's care plan. 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 the facility's investigation on report, staff record review, the facility's policy and procedures for abuse prevention, and facility staff interview, it was determined the facility failed to prevent further potential abuse during an active investigation of abuse. This was evident for 1 resident (#143) of 7 residents reviewed for abuse during the annual survey. The findings include: On 2/19/25 at 1PM, the surveyor reviewed the facility's investigation report (FRI) MD00164084. The report revealed that on 2/18/21 around 8:20 PM Resident #143 reported to county police that Geriatric Nursing Assistant (GNA), Staff #35, punched him/her in the face four times. The facility began their investigation on 2/18/21 and concluded the allegation of abuse on 2/24/21 as allegation not verified. Review of the facility's initial report to the Office of Health Care Quality (OHCQ) revealed a statement from Staff #35 that he/she worked with the resident on 2/18/21 3p-11p shift; denied touching resident- said resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, it was determined the facility failed to notify the Ombudsman of resident's transfers. This was found evident of 3 (Resident #27, #4, & #40) of 6 residents reviewed for hospitalization during the survey. The findings include: The facility ombudsman was contacted on 2/18/2025 at 12:34 PM by surveyors during the recertification survey. The ombudsman addressed concern to surveyors that she was not receiving consistent transfer and discharge notifications monthly from the facility. 1) On 2/19/25 at 9:19 AM, the surveyor reviewed Resident #27's medical record. The review revealed that Resident #27 had to be transferred to the hospital on [DATE]. On 2/24/25 at 1:33 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON was asked if the facility updates and informs the Ombudsman of resident's transfers and discharges. The DON stated that he informs the Ombudsman when she comes into the facility but stated that he was not sending or providing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to code the resident's discharge status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #141) of 1 resident reviewed during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 2/25/25 at 8:41 AM, a review of Resident #141's medical record revealed an order to discharge Resident #141 to home on 1/15/25. Further review of the record revealed a Discharge summary dated [DATE] that indicated Resident #141 was discharged to home. On 2/25/25 at 9:08 AM, a review of Resident #141's MDS Section A -2105 assessment completed on 1/16/25 and signed 1/17/25, indicated that Resident #141 was discharged to a…

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

Based on record review and interview, it was determined that the facility staff failed to prepare all relevant resident information incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's transfer request to another nursing facility. This was evident for 1 (Resident #54) out of 2 residents reviewed for timely safe discharge during an annual survey. The findings include: Interview, on 02/19/25 at 12:38 PM, Resident #54's family by phone revealed that, we have requested this facility to move Resident #54 to another facility since 2/5/25 and we were okay the next facility's location in different counties if it cannot be near by the family. During an interview, on 02/19/25 at 01:00 PM, Social Services Assistant Staff #23 and Director of Nursing (DoN) stated that they were aware of the transfer request but needed to get back due to Social Services Staff #22 having discussions with Resident #54 and the family. Record review, on 02/20/25 at 11:15 AM, found that Resident # 54 was admitted to this facility on 12/3/23, 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 record reviews and interviews it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 2 (Resident #56, #51) out of 5 residents reviewed for pressure ulcers. The findings include: 1a) On 2/20/25 at 11:13 AM, the surveyor reviewed Resident #56's medical record which revealed that Resident #56 was being seen by a wound team for two wounds in February of 2025. The surveyor reviewed the February 2025 Treatment Administration Record (TAR). An order was written for the left buttock wound treatment to start on 2/6/25. This treatment was discontinued on 2/11/25. A new order was written for treatment to start on 2/14/25. The order stated, to cleanse wound with normal saline, pat dry, and apply Medihoney to the wound and cover with a dressing. A new order was written to start on 2/20/25 that stated, cleanse wound with normal saline, pat dry and apply calcium alginate to wound can cover dressing with a border dressing daily and as needed. The older order was not discontinued and both treatments were documented…

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 staffing information, medical records and interviews, it was determined that the facility failed to ensure sufficient weekend staffing on each type of personnel on a 24-hour basis to provide nursing care and answering call lights. This was found to be evident weekends during the period of 12/29 to 2/1/25 of an annual survey. The findings include: Interviewed Residents #55, #102 and #292 during the tour of the facility on 2/11/25, revealed that the unit staff did not answer or late answering the call lights on weekends. During an interview, on 02/24/25 at 11:26 AM, Director of Nursing (DoN) stated that the staffing scheduling was managed by Bridgeway Staffing, Monday through Friday from 8AM to 5PM only and including finding replacements for call outs. And the facility's Administration staff managed the staffing, after-hours including weekends' call outs. Record review, on 02/24/25 at 12:31 PM, found that the staffing reports (from 12/29/24 to 02/1/25) weekends staff hours fell consistently below 3.0 hours per resident per day (HPPD): 12/29/24 required 422.98 hr.…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #51) out 6 residents reviewed for medication regimen review. The findings include: On 2/18/25 at 10:33 AM, the surveyor interviewed Resident #51. During the interview Resident #51 stated that on multiple occasions he/she was not able to get his/her prescribed Pregabalin (a medication used to treat seizures and nerve pain). On 2/25/25 at 8:53 AM, the surveyor reviewed Resident #51's November 2024, December 2024 and January 2025 Medication Administration Record (MAR) for Pregabalin. The order was for Resident #51 to get Pregabalin 200 mg every 8 hours for neuropathic pain. The review revealed on 11/4/24, 9 was coded, as other/see progress notes. In November on 12/6/24, the 2 PM dose, and 10 PM doses were coded with a 9, as well as the 6 AM dose on 12/7/24. On 1/6/25 the 6 AM and 2 PM doses were coded as 9 and the 10 PM dose was coded as 5, Held/see progress notes. On 1/7/25 the 6 AM and 10 AM doses…

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 1) act upon recommendations made by consulting the Pharmacist in a timely manner; and 2) the attending Physician failed to document that he reviewed and addressed the Pharmacist's identified irregularities in the resident's medical record. This was found evident of 2 (Resident #56 & #92) of 5 residents reviewed for unnecessary medication during the annual survey. The findings include: 1.) On 2/26/25 at 9:50 AM, a review of Resident #92's medical record revealed four medical regimen reviews were conducted from November 2024 to February 2025. During these reviews, irregularities were identified on 1/28/25 and 2/14/25. Further review of Resident #92's record failed to show the details of the irregularities. The Director of Nursing (DON) was asked to provide details of the Pharmacist's identified irregularities. On 2/26/25 at 10:23 AM, the surveyor received the identified irregularities details for Resident #92. A review of the medication irregularities details revealed: On 1/28/25- The pharmacy…

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 failed to ensure a medication error rate of less than 5% during the medication administration observation. This was evident for 3 medication errors out of 25 opportunities which resulted in a medication error rate of 12%. The findings include: On 2/21/25 at 8:05 AM, a Licensed Practical Nurse (LPN) #24 was observed preparing medications for Resident #106. LPN #24 administered 1 tablet of Ibuprofen 600mg, and 2 tablets of Tizanidine 4 mg to the resident. (Ibuprofen is a non-inflammatory medication used to treat pain and Tizanidine is used to help relax tight muscles and reduce muscle spasms). On 2/21/25 at 9:30 AM, a review of Resident #106's medical record revealed Ibuprofen 600mg 1 tab order was discontinued on 2/16/25. Further review of the Physician's order revealed that the correct ordered dose to be given for Tizanidine was 6mg. On 2/21/25 at 9:46 AM, an interview with LPN #24 was conducted. The LPN confirmed that s/he gave Resident #106 a discontinued medication (ibuprofen 600mg), and an incorrect…

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: 1) properly store medications and 2) ensure medications were properly labeled with expiration date. This was evident for 2 of 3 medication carts observed during the annual survey. The findings include: 1.) On 2/21/25 at 8:05 AM, during medication administration observation, a Licensed Practical Nurse (LPN) #24 was observed administering medications to Resident #106 (Ibuprofen 600mg, pain relief medication) and Resident #25 (Vitron C, an iron supplement with Vitamin C). On 2/21/25 at 9:30 AM, a record review for Resident #106 and Resident #25 was conducted, The review of record revealed that Ibuprofen 600mg was discontinued for Resident #106. A review of Resident #25's medication orders revealed that Vitron C was discontinued. On 2/21/25 at 9:46 AM, an interview with LPN #24 was conducted. The LPN confirmed that the discontinued medications were stored in the medication cart. On 2/24/25 at 8:10 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON…

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

Based on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harboring pests. The findings include: On 2/25/25 at 10:37 AM, the surveyor took a tour of the outdoor dumpster that the kitchen utilized for waste removal. The surveyor noted that four mattresses were piled up next to the dumpsters with other materials surrounding the mattresses. On 2/25/25 at 10:40 AM, the surveyor conducted an interview with Maintenance Director Staff #6. During the interview the Staff #6 confirmed that the wooded area surrounding the building was a habitat for multiple types of potential vermin. The surveyor asked how long the mattresses were left there and why the mattresses and other material were not put into the dumpster. Staff #6 stated he did not now know long the mattresses had been there and that the garbage removal company would not take mattresses. He further stated that he had another dumpster he could move the mattresses to. On 2/25/25 at approximately 2 PM, the surveyor conducted a follow-up…

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

Based on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 1 (Resident #50) of 46 residents reviewed during the survey. The findings include: Preadmission Screening and Resident Review (PASARR): is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. A preliminary assessment is done to determine whether a resident might have a Severe Mental Illness (SMI) or Intellectual Disability (ID). This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. On 2/29/25 at 8:38 AM, the surveyor reviewed Resident #50's medical record. The review revealed on 11/10/22 a level one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide maintenance services necessary to maintain a clean, comfortable, and homelike environment in the kitchen and resident rooms. This was found evident on: 1) one exterior door leading to the garbage disposal area, and 2) 2 resident rooms (#113 and #117) and one resident shower room during the recertification survey. The findings include: 1) On 2/25/25 at 10:37 AM, the surveyor observed the door that the kitchen staff utilizes to remove the garbage to the outdoor dumpsters. The surveyor noted light coming in from the outside from an opening at the junction where the wall and the right corner of the door met. On 2/25/25 at 10:44 AM, the surveyor conducted an interview with the Director of Maintenance Staff #6. During the interview the surveyor was able to show Staff #6 the concern, the open area on the exterior door. Staff #6 stated that the hole had been concreted before but due to rough handling at the door the concrete had…

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 written and verbal complaints, documentation review and staff interview, it was determined the facility failed to obtain a full-time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 140 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents. The findings include: On 9/24/24 at 1:44 PM a review of complaint MD00209234 revealed Resident #4's responsible party (RP) complained that communication from the social work department dropped off in early 2024 after the social worker left and issues that the RP had pertaining to Resident #4's care went unanswered. On 9/25/24 at 12:33 PM an interview with Resident #4's RP was conducted. Resident #4's RP stated that he has not had a care plan meeting with the facility regarding Resident #4. The RP stated he used to talk to the previous SW but has not had any resolution to his issues. The RP stated it has been very frustrating trying to get things done for his sibling. On 9/24/24 a review of complaint MD00209271…

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 review, environmental observations, and interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 2 of 2 nursing units observed during a complaint survey. The findings include: 1) Review of complaint MD00201103 on 9/25/24 at 10:00 AM revealed allegations that Resident #17's room was unsanitary, the toilet seat was in disrepair, the room was malodorous, and the floor around the resident's bed was soiled and sticky. The following environmental concerns were observed during the survey: The surveyor observed room [ROOM NUMBER] on 9/25/24 at 9:30 AM. The bathroom inspection revealed that the toilet seat had 2 metal bolt covers that appeared covered with a dark substance and rust. The porcelain toilet bowel was soiled with dirt also. room [ROOM NUMBER] restroom lacked toilet tissue and hand towels. On the floor, in front of Resident #17's bed was observed…

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 facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 5 (#11, #6, #2, #20) of 22 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 9/23/24 at 11:15 PM a review of facility reported incident MD00203077 was conducted and revealed Resident #11 was at the hospital and reported to the hospital social worker that he/she had been hit in the head by a staff member at the nursing facility. On 2/28/24 at 12:30 PM the facility became aware of the incident from the hospital social worker. The facility reported incident initial report form typed in that the Director of Nursing (DON) filled out the form and submitted it to OHCQ on 2/28/24 at approximately 1:30 PM, however the DON was unable to provide the surveyor with an email confirmation of when the form was sent to OHCQ. Review of the ASE Complaint/Incident Investigation Report…

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 have quarterly care plan meetings for residents and responsible parties). This was evident for 7 (Resident #5, #9, #10, #17, #4, #1, #2) of 51 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. Review of Resident #5's medical record on 9/26/24 revealed…

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 complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health This was evident for 5 (Resident #7, #8, #10, #24, #3) of 51 residents reviewed for quality of care during a complaint survey. The findings include: 1. The facility staff failed to administer Methadone as ordered for Resident #7. Review of Resident #7's medical record on 9/25/24 revealed the Resident was admitted to the facility on [DATE] with a diagnosis of opioid dependence. Opioid dependence is a chronic disease that occurs when someone regularly uses opioids, leading to a strong internal drive to use them. Further review of Resident #7's medical record revealed the Resident was ordered on 4/30/24 by the physician to receive Methadone 10 mg 3 tablets in the morning for pain. Methadone is a medication used to treat Opioid Use Disorder. Review of Resident #7's Medication Administration Records for July 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 provide treatment/services to prevent/heal pressures ulcers (Resident #40). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint 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). Review of Resident #40's medical record on 10/1/24 revealed the Resident 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 observation and staff interview, it was determined that facility staff failed to treat each resident in a dignified manner by pulling a resident down the hallway backwards. This was evident for 2 (#48, #4) residents observed during random observations on 2 of 3 nursing units during a complaint survey. The findings include: On 9/25/24 at 2:27 PM observation was made in the hallway of licensed practical nurse (LPN) #7 pulling Resident #4 down 2 hallways backwards. LPN #7 pulled Resident #4 from the dining room to the end of the hallway, turned the corner and pulled Resident #4 down towards the end of the Potomac hallway where his/her room was located. On 9/26/24 at 11:33 AM observation was made in the hallway by the Chesapeake unit of geriatric nursing assistant (GNA) #30 pulling Resident #48 down the hallway backwards and placing Resident #48 in the activity room. The surveyor walked up to GNA #30 to ask what the resident's name was and she looked at the resident and said, I don't know his/her name. Resident #48 blurted out the name. On 10/2/24 at 9:10 AM an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to notify a resident's physician for a change in status (Resident #10). This was evident for 1 of 51 residents reviewed during a complaint survey. The findings include: Review of Resident #10's medical record on 9/26/24 revealed the Resident was admitted to the facility on [DATE] and transferred to the hospital on 6/23/24. The Resident did not return to the facility. Further review of Resident #10's medical record revealed the facility staff documented the Resident's blood pressure as 73/49 mmHg on 6/4/24 at 10:39 AM. Review of the nurse's notes and assessments on 6/4/24 revealed the facility staff failed to notify the physician of the low blood pressure. Low blood pressure occurs when blood pressure is much lower than normal. This means the heart, brain, and other parts of the body may not get enough blood. Normal blood pressure is mostly between 90/60 mmHg and 120/80 mmHg. Interview with the Director of Nursing on 9/30/24 at 10:50 AM…

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 interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #40). This was evident for 1 of 3 residents reviewed for baseline care plans during a complaint survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. Review of Resident #40's medical record on 10/1/24 to investigate a complaint regarding lack of communication to the Resident's representative on admission to the facility revealed the Resident was admitted to the facility on [DATE] from the…

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

Based on medical record review and interview it was determined the facility staff failed to ensure a resident's plans of care included individual resident care needs and interventions to assist each resident in reaching their highest practicable level of wellbeing. This was evident for 1 (#24) of 51 residents reviewed during a complaint survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: Review of Resident #24's medical record on 9/23/24 revealed on 5/21/23 the Resident left the facility without notifying staff to go to a family member's house. Further review of Resident #24's medical record revealed a nurse's note on 5/25/23 at 4:00 PM that stated, While doing my round, resident was observed sitting alone by the Gateway dining room exit door. He/she requested writer open the door for him/her to exit but was reminded that as per MD order, he/she cannot go out unaccompanied. Review of Resident #24's care plans revealed no care plan that the Resident is…

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 complaint, medical record review and staff interview it was determined the facility failed to develop an individualized discharge plan and update a discharge care plan for a resident admitted to the facility for rehabilitation. This was evident for 1 (#1) of 27 residents reviewed for complaints. The findings include: On 9/24/24 a review of complaint MD00209271 revealed Resident #1's responsible party (RP) had been trying to have Resident #1 return to his/her home state since January 2024. The RP alleged that the facility had not done their due diligence in coordinating a discharge plan. On 9/24/24 at 12:28 PM an interview was conducted with Resident #1's RP who stated that Resident #1 was in an accident and in the hospital for 3 months and had been at the nursing facility since 2023. She stated, we were having a hard time getting the discharge process moved along. Resident #1's RP stated that she had been talking to the previous SW #11, but after he left the current SW assistant had been thrust into the position and nothing was getting done. On 9/24/24 at 2:29 PM a review…

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 colostomy care was provided to a resident with a colostomy. This was evident for 1 (16) of 1 resident reviewed with a colostomy. The findings include: The Minimum Data set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. A medical record review was done on 9/23/24 at 11:12 for Resident # 16. Records revealed Resident # 16 had a colostomy. The resident had a diagnosis of malignant neoplasm. A subsequent record review completed on 9/23/24 at 10:51 AM revealed an order summary report of January 1/8/24 which revealed an attending providers orders for 1) colostomy care every shift, initiated on 1/8/24 and discontinued on 2/9/24 at 4 AM, 2) Monitor ostomy site for discoloration, change ostomy every shift and as needed, initiated on 1/8/24 and discontinued on 12/9/24. A continued review showed a MDS assessment, dated 1/11/24, which…

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 administrative and medical record reviews and staff interview, it was determined that the facility failed to 1) maintain access to all closed medical records, and 2) maintain accurate electronic medical records. This was evident for 3 ( #35, #8, #26 ) of 51 resident records reviewed for accuracy during a complaint survey. The findings include: 1) Resident #35 was admitted from the hospital to the facility on [DATE]. A review of facility reported incident (FRI) MD00177812 on 09/24/2024 revealed details that Resident #35 eloped from the facility on 05/28/2022. Resident #35 did not return to the facility after 05/28/2022. A request for Resident #35's closed medical record was made to the director of medical records on 09/24/2024 at 1:50 PM. An interview with the medical records director proceeded after the medical record request. The medical records director stated that S/he had been in this position for 6 years and that the facility uses an outside vendor to house the paperwork from closed medical…

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

Based on surveyor review of the clinical records, interviews with residents, resident's representatives and facility staff, it was determined that the facility failed to ensure timely interdisciplinary care conferences for residents. This finding was evident for 2 of 34 residents selected during the survey (Resident #26 and Resident #45). The findings include: 1. On 10-28-2020 surveyor review of Resident #26's clinical record revealed the resident had an admission comprehensive assessment completed by staff on 06-02-2020. However, there was no evidence of a care plan conference with the interdisciplinary team, resident, and/or resident's representative to review the plan of care. Further review of Resident #26's clinical record revealed the resident had a significant change assessment completed by staff on 08-01-2020. However, there was no evidence of a care plan conference with the interdisciplinary team, resident, and/or resident's representative to review the plan of care. On 10-29-2020 at 12:10 PM, surveyor interview with Resident #26's representative stated that they have never…

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

Based on review of the clinical record, interview with Resident #26's representative and facility staff, it was determined that the facility failed to ensure standards of professional practice. This was evident for 1 of 34 residents selected for review during the survey (Resident #26). The findings include: On 10-28-2020 review of Resident #26's clinical record revealed the Resident was re-admitted to the facility on 07-25-2020, after a hospitalization, with a percutaneous endoscopic gastrostomy tube (PEG) to receive artificial nutrition. A PEG tube is used to provide a route for artificial nutrition, hydration, and medication administration in residents who are likely to have prolonged inadequate or absent oral intake. Further review of Resident #26's clinical record revealed page 2 of the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) was completed on 07-28-2020 by Resident #26's attending physician. Page 2, section 7C was selected by the physician, which states, may give fluids for artificial hydration as a therapeutic trial, but do not give artificially…

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.