Green Acres Nursing And Rehab

Based on observation and interview, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of practice, resulting in an overall medication administration error rate of 11.54%. This deficient practice was evident for 3 of 26 medication administrations observed. The findings include:On 01/16/26 at 9:35 AM, during observation of medication administration, Staff #21 was observed crushing divalproex sodium 125 mg delayed-release (DR) and preparing it for administration to Resident #122. Delayed-release medications are not to be crushed due to alteration of the medication's intended release properties.At 9:47 AM, Staff #21 administered Humalog insulin to Resident #122 via injection into the deltoid region, rather than the recommended subcutaneous injection site on the back of the arm, inconsistent with accepted medication administration practices.At 9:52 AM, Staff #21 prepared and attempted to administer medication to Resident #152 immediately after administering medication to Resident #122 without performing hand…

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

Based on record reviews and interviews, it was determined that the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented the resident current medical diagnosis. This was evident for 1 (resident #4) out of 7 residents' Care Plans reviewed during the annual survey.The Findings include:On 01/14/2026 at 9:07 AM during the initial observation, resident #4 was observed in bed and eating breakfast, being fed by GNA #24 while seated. Resident #4 was relaxed, smiling at and able to respond to this Surveyor interaction. Resident #4 denied any discomfort and concerns, yet was unable to answer detailed questions and pleasantly confused.On 01/20/2026 at 11:18 AM during record review it revealed resident #4 has the following diagnosis of: PAROXYSMAL ATRIAL FIBRILLATION (I48.0), CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE (I50.32), ESSENTIAL (PRIMARY) HYPERTENSION (I10), VITAMIN D DEFICIENCY, UNSPECIFIED (E55.9), DEPRESSION, UNSPECIFIED (F32.A), NEURALGIA AND NEURITIS, UNSPECIFIED (M79.2), OTHER…

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 interviews, it was determined that the facility failed to: 1) maintain infection prevention and control by not ensuring a sanitary and comfortable environment within the resident care areas. This was evident for 6 (rooms 101. 102, 108, 119, 121, and 123) out of 24 resident rooms observed; and 2) ensure staff performed appropriate hand hygiene during medication administration, placing residents at risk for cross-contamination. This deficient practice was evident for 1 of 5 medication administration observations.The findings include: 1) On 01/14/2026 at 8:20 AM the Surveyor observed resident room [ROOM NUMBER], the hand sanitizer dispenser on the wall near the door designated for staff use, was empty. On 01/14/2026 at 8:22 AM the Surveyor observed resident room [ROOM NUMBER], within the bathroom, a pair of discarded plastic clear gloves were observed on the floor near the rear base of the toilet. On 01/14/2026 at 8:41 AM the Surveyor observed resident room [ROOM NUMBER], within 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had an Advance Directive or was offered the opportunity to create one. This was evident for 5 residents (#21, #98, # 286, # 287, and # 296) out of 52 in the survey sample. The findings include: 1. A review of Resident #21's clinical record on 8/6/24 revealed the resident did not have a copy of an Advance Directive in either the current electronic health record or the previous record used by the former nursing home company. A progress note dated 7/21/23 listed, Patient states POA [Power of Attorney] is in progress of being completed. No evidence of follow up to this request. The DON and Administrator were interviewed on 8/16/24 at 1:20 PM. They were informed that an Advanced Directive could not be located, and that the resident started the process but there was no follow up. They said they understood the findings and would review the electronic records and speak with the Social Worker. 2. A review of Resident #98's electronic clinical record on 8/8/24 at 10:00 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 facility investigations, record reviews, interviews and observations, the facility failed to protect residents from abuse and neglect. This was found to be evident for 5 (# 7, # 27, # 50, # 62, # 82) out of 38 residents investigated during the annual survey for abuse and neglect. The findings include: 1. A review of a facility investigation on 08/14/24 at 3:37 PM for an allegation made by the Responsible Party (RP) for Resident #7 revealed the following. On 9/29/23, the RP arrived at the facility at 11:00 AM. The RP dressed the resident and then placed the resident in bed but on top of the sheets. The RP arrived the next day at 12 noon. The resident was still on top of the bedsheets and still dressed in the clothes from the day before. Bed sheets were folded under the resident and the resident's catheter bag was full. The RP asked the nurse about being dressed in the same clothes, but she did not know for sure since she had not worked the day before. RP asked the Geriatric Nursing Assistant (GNA) who had worked the day before. She said the resident was dressed like this…

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 the facility failed to respect the resident's dignity as evidenced by the resident meal tray taken away before the meal was finished. This was evident for 1 out of 1 resident (resident #50) reviewed for dignity. The findings include: During an observation conducted on 08/06/2024 at 07:51 AM, this surveyor observed Resident #50 in bed with an empty cold cereal cup on the tray table and a breakfast casserole that sat directly on top of the tray table. This surveyor asked the resident if he/she had a plate that the food was on, the resident stated yes, they took his/her plate and left the resident with casserole. On 08/06/2024 at 07:53 AM an interview was conducted with Licensed Practical Nurse (LPN) #5. During the interview the LPN asked Resident #50 if he/she was done with the breakfast casserole. The Resident stated yes, and the LPN removed the breakfast casserole off the tray table with a napkin. The LPN further stated that she would find out who the Geriatric Nurse Assistant (GNA) was that removed the resident's meal tray and…

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

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to honor resident choices with showering. This was evident for 2 (#21 and #73) out of 52 residents in the survey sample. The findings include: 1. Resident #21 was interviewed on 8/6/24 at 11:26 AM. The resident stated that they do not always get 2 showers each week. The resident stated that their scheduled days are Tuesday and Friday, but they will not get a shower unless there are 4 or more geriatric nursing aides (GNA's) on duty. A review of the electronic health record revealed the last documented shower was on 9/19/23. The Administrator and Director of Nursing (DON) were interviewed on 8/16/24 at 1:25 PM. The resident allegation of no showers was presented to them. They said they understood the findings and would review both electronic medical records as well as review the shower sheets. 2. Resident #73 was interviewed on 8/08/24 at 09:00 AM. The resident stated that they do not receive showers and only get bed baths. The resident had a very distinct odor…

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 interviews and record review it was determined that the facility failed to ensure the Power of Attorney (POA) was notified of a pressure ulcer. This was found to be evident for 1 (Resident #29) out of 1 resident reviewed for notification. The finding include: Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as bedsores or pressure sores. Pressure ulcers are categorized into four stages based on the extent of skin damage: Stage 1: The skin is intact but may appear red, even when no pressure is applied. It may also feel warmer or colder, softer or harder, or more sensitive to pain than the surrounding tissue. Stage 2: The upper layers of the skin are damaged, and there may be a blister, scrape, or bruise. The skin may appear as a shallow open ulcer with a red or pink wound bed. Stage 3: The skin is completely damaged, and the ulcer may extend to the subcutaneous fat. The lesion may be…

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

Based on family interview, staff interview, and clinical record reviews, it was determined that the facility failed to ensure that allegations of missing money was reported to the State Survey Agency (Maryland Department of Health - Office of Healthcare Quality) and neglect were reported within the required time frame. This was evident for 2 (#7, #136) out of the 52 residents reviewed for reporting of alleged violations. The findings include: 1. A review of a facility investigation on 08/14/24 at 3:37 PM for an allegation made by the Responsible Party (RP) revealed the following. On 9/29/23, the RP arrived at the facility at 11:00 AM. The RP dressed the resident and then placed the resident in bed but on top of the sheets. The RP arrived the next day at 12 noon. The resident was still on top of the bedsheets and still dressed in the clothes from the day before. Bed sheets were folded under the resident and the resident's catheter bag was full. The RP asked the nurse about being dressed in the same clothes, but she did not know for sure since she had not worked the day before. RP…

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 facility record review and interviews it was determined that the facility failed to ensure that thorough investigations were conducted for alleged violations. This was found to be evident for 2 (Resident #72 and #136) out of 2 Residents reviewed for investigation of alleged violations. The findings include: The surveyor reviewed the facility investigation file for the facility reported incident (FRI) for Resident #72 on 8/13/2024 at 7:45 AM for an allegation of sexual assault. The initial report was submitted by the facility Nursing Home Administrator (NHA) at 11:45 AM on 6/28/2024 to the Maryland Department of Health - Office of Health Care Quality (OHCQ). The final report was submitted by the Nursing Home Administrator (NHA) on 7/2/2024 at 5:25 PM to the Office of Health Care Quality (OHCQ). The Ombudsman, local police department, Responsible Party and Medical Director were notified of the allegation of sexual assault. Resident #72 was transferred to the hospital for further assessment and evaluation. Further review of the facility investigation file for Resident #72 on…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure the local Ombudsman was notified of a facility initiated resident discharge or transfer. This was evident for 2 (#19 and #108) of 7 residents reviewed for hospitalizations during the annual survey. The findings include: 1. On 08/13/24 at 12:55 PM, a review of Resident # 19's clinical record revealed that Resident #19 was transferred to the hospital for treatment and further evaluation of his/her medical needs on 1/15/2024. Further review of Resident #19's clinical record revealed no documentation that the local ombudsman was notified of the hospital transfer. On 08/15/24 at 01:25 PM, an interview conducted with Social Work Director #6 revealed that the Ombudsman is sent a monthly transfer log by email. The Social Work Director #6 stated that prior to February 2024, she was not responsible for sending the transfer notices to the Ombudsman and that it was being done by the previous DON. The Social Work Director #6 further stated that some transfer notices to the Ombudsman…

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 staff interview and clinical record review it was determined that the facility staff failed to ensure a bed hold policy was provided to the resident upon hospitalization. This was evident for 1 (#88) out of 52 residents that were part of the survey sample. The findings include: A review of Resident #88's clinical record on 8/12/24 revealed that the resident was sent to the hospital on 7/30/24. A transfer form was found but no evidence that a bed hold policy was provided to the resident and/or their Responsible Party, if appropriate, was found. The Director of Nursing (DON) and the Administrator were interviewed on 8/16/24 at 1:30 PM. This surveyor presented the finding to them, and they said they understood the need for the bed hold policy to be sent. They said they would review the electronic health records for any evidence it had been provided.

Based on clinical record review, a review of intake MD00166696, and staff interview it was determined that the facility staff failed to ensure a resident's assessment was accurate. This was evident for 1 (#142) out 52 records as part of the survey sample. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of Resident #142's clinical record on 8/22/24 revealed that a nursing note on 3/24/21 at 2:24 PM said Resident's sister phoned requesting resident's glasses. This author stated that she had never seen the resident wearing eyeglasses or eyeglasses in the resident's room. Nursing was aware at this time that the resident used eyeglasses. Further review revealed that the resident had an MDS completed on 5/21/21. Section B Vision noted the resident had impaired vision but no eyeglasses. An MDS 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 resident interview, clinical record review and staff interview it was determined that the facility staff failed to ensure that the resident had care plan meetings. This was evident for 2 (#4 and #21) out of 52 residents that were part of the survey sample. The findings include: 1. Resident #4 was interviewed on 8/6/24 at 9:16 AM. The Resident stated not having a care plan meeting since admission. A review of the resident's clinical record suggested a care plan meeting may have been held on 2/14/24. A sign-in sheet and/or other evidence of a meeting where the resident was invited could not be found. A second care plan meeting should have been held 90 days later in May but evidence of that was also not present. The Administrator and Director of Nursing were interviewed on 8/16/24 at 1:28 PM. The finding was presented. They acknowledged the importance of care plan meetings as well as the need to invite a resident. They said they would review the clinical records. Evidence of care plan meetings was not presented to the team prior to the survey exit. 2. Resident #21 was…

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

Based on clinical record review and an investigation of Intake MD00166696 it was determined that the facility staff failed to ensure that a resident wore their eyeglasses. This was evident for 1 (#142) out of 52 residents reviewed as part of the survey sample. The evidence includes: A review of complaint Intake #MD00166696 revealed family was concerned that the resident was not wearing his/her eyeglasses. A review of the clinical record revealed that on 3/24/21 at 2:24 PM nursing wrote: Resident's sister phoned requesting resident's glasses. This author stated that she had never seen resident wearing glasses or glasses in resident's room. The Minimum Data Set (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 need to be accurate to ensure that each resident receives the care they need. Review of the resident's clinical record revealed that the resident had an MDS completed on 5/21/21. Section B Vision noted the 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.

Based on record review and interview it was determined that the facility failed to ensure that a Resident received care in a timely manner. This was found to be evident for 1 (Resident #57) out of 1 Resident reviewed for Quality of Care during the recertification survey. The findings include: On 08/16/2024 at 8:43 AM a review of the Facility's Reported Incident (FRI) investigation was conducted. The investigation revealed that Resident #57 had notified Licensed Practical Nurse (LPN) #31 that he/she had pain in his/her right arm. According to the investigation the physician was notified, a new order for an X-ray of the right arm was obtained, and Tylenol was administered. However, the facility staff failed to place the order for Resident #57 to receive an X-ray for 3 days. The resident received the Xray of the right arm on 08/23/2023 although the order for an Xray was obtained on 08/20/2023. The Xray showed the resident had a fracture of the right proximal humerus. The resident was sent to the emergency per physician orders after the result of the Xray. During an interview conducted…

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, observation, and clinical record review it was determined that the facility staff failed to ensure a resident wore an ordered brace. This was evident for 1 (#73) out of 3 residents reviewed for range of motion in the survey sample. The findings include: Resident #73 was interviewed on 8/8/24 at 9:31 AM. Resident #73 was asked about the brace on the bedside table. The resident replied that not all staff put the brace on the arm. There was a sign on the wall above the bed observed to say that the brace should be put on after morning care. Interviewed the resident on 8/16/24 at 11:40 AM. Resident was in the dining room sitting at a table with a glass of water. The resident did not have the brace on. I asked him/her if he/she had it on earlier and he/she replied no. I asked if it was his/her choice not to have it on. The resident replied no, some put it on and some don't. I'm tired of complaining so I accept it. The Administrator and Director of Nursing were interviewed on 8/16/24 at 1:40 PM. This surveyor informed them of the interviews and…

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

Based on clinical record review, observation and staff interview, it was determined that the facility staff failed to ensure that additional water ordered for flushes via gastrostomy tube (G-tube) was administered according to the prescriber's orders and notify the physician of a change in the color of the tubing. This was evident for 2 (Resident #6, #73) of 4 residents reviewed for tube feeding during the annual survey. The findings include: 1. A feeding tube is a device to administer nutrition to a person who cannot safely take food by mouth. A review of Resident #73's clinical record revealed that on 6/29/24 a nursing note read Patient's gtube [gastrostomy tube] is black in color. I am a bit concern[ed] of infection. I recommend tube change. The Unit Manager (Staff #15) was interviewed on 8/16/24 at 8:47 AM. She confirmed the resident had a g-tube and that it was not being used so it was not changed. Once shown the specific note she replied: Okay, I see it. I don't have an answer, but I'll look into it and get you one. Staff #15 was interviewed on 8/16/24 at 11:16 AM. She stated…

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

Based on observations, review of facility documentation, clinical record review, and staff interview it was determined that the facility failed to maintain oxygen therapy equipment according to facility policy and physician orders. This was found to be evident for 2 (# 62, #286) out of 4 residents reviewed for respiratory care during the annual survey. The findings include: 1. During an observation on 08/06/24 at 08:48 AM, the surveyor observed oxygen in use by Resident #286. There was no label or date on the oxygen tubing or humidifier bottle. On 08/07/2023 at 08:05 AM, the surveyor observed the oxygen lying on the floor by Resident #286. There was no label or date on the oxygen tubing or humidifier bottle. During an interview conducted on 08/07/24 12:35 PM, the 300 Unit Manager was asked if she could find a label and date on the oxygen tubing. The Unit Manager confirmed that there was no label or date on the oxygen tubing or humidifier bottle. When asked about the facility policy, she stated that oxygen tubing is changed, labeled, and dated every Sunday. I will get new tubing and…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to physician's orders. This was evident for 1 (#53) of the 5 residents reviewed for unnecessary medications. A review of Resident #53's clinical record on 8/13/24 revealed the resident's primary physician ordered Novolog pen 100 unit/ml 16 units before meals and to be held if blood sugar is less than 150. A review of the resident's Medication Administration Record (MAR) revealed that the resident's blood sugar was below 150 on those days but the insulin was still administered. The blood sugars were 8/1 = 143, 8/3 = 145, 8/5 = 117 and 140, 8/6 = 143, and on 8/9 = 142. This represents 6 times out of 43 opportunities that the resident received insulin when it should have been held. The surveyor interviewed the Administrator and Director of Nursing on 8/16/24 at 1:20 PM. The concerns were presented and the facility said they understood the findings and would review the MAR's.

Based on interview and record review it was determined that the facility staff failed to promptly provide or obtain visit/appointments for routine dental care or treatment. This was found to be evident for 1 (Resident # 49) out of 1 resident reviewed for dental services during an annual survey. The findings include: A record review of Intake # MD00194162 on 08/19/24 at 10:45 AM, Resident # 49's daughter stated that the facility does not provide dental care. During a record review on 08/19/2024 at 1:24 PM, a dental consult was found on Resident # 49's chart completed on 7/20/23 with recommendations for x-rays and possible extractions. No follow up appointments or exams were found on the record. On 8/20/24 at 9:13 AM the 300 Unit Manager was interviewed regarding dental care for Resident # 49. She stated that Resident # 49 was part of the dental consult program, and she would investigate and let the surveyor know if he had received dental care. The surveyor was provided with a copy of the dental consult. During an interview with the Director of Nursing (DON) and the Administrator 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 observation, interview, and medical record review, it was determined that the facility failed to provide dental services and assessments. This was found to be evident for 1 out of 1 resident (Resident #97) reviewed for dental care. The findings include: During a phone interview conducted on 08/07/2024 at 9:39 AM, Resident # 97's family stated that the resident had missing teeth and needed a dental consult. When asked if the concern was brought to the attention of the facility, she stated she was unsure. On 08/07/2024 at 11:07 AM an observation of Resident #97 was conducted. This surveyor observed missing teeth and what appeared to be plaque buildup on the bottom front teeth. During a record review of Resident #97's medical records conducted on 08/13/24 at 07:35 AM did not reveal a dental consult. On 08/13/2024 at 09:07 AM the Director of Nursing (DON) stated during an interview that the facility had not obtained a provider for dental services since the facility changed ownership on 04/01/2024 but would work to obtain dental services. The DON returned and provided this…

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 observation it was determined that the facility staff failed to ensure a resident's meals matched their preferences. This was evident for 1 out of 52 residents in the survey sample. The findings include: This surveyor observed Resident #73 in the dining room on 8/21/24 at 12:40 PM. The resident waved me over and showed the plate of food. The resident had bread on the plate despite it being listed on the meal slip as a dislike. The resident was interviewed at 12:40 PM. The resident stated that he/she also requested coffee with every meal, but it was not on the tray. Staff #32 was interviewed on 8/21/24 at 12:45 PM. Staff #32 confirmed that the resident does not want bread and wants coffee with every meal. He stated that when it happens it upsets the resident. He said he would take care of it and would ensure resident received a correct plate of food and a cup of coffee.

Based on observation and staff interview it was determined that the facility staff failed to ensure food items in the kitchen were maintained in a safe and appropriate manner. The findings include: During the tour of the kitchen on 8/6/24 at 8:29 AM several slices of salami deli meat were partially wrapped in plastic wrap with the label indicating the bologna was opened on 7//26/24 with a use by date of 8/2/24. There was an opened bag of shredded mozzarella cheese (not in a sealed container), and 2 bags of bologna without dates on the labels. The Food Service Manager was interviewed on 8/6/24 at 8:36 AM. She said the lunchmeat is good for 7 days and that they wrote the wrong date. I asked for clarification -- was she suggesting that the meat was sliced and wrapped on 7/26/24 and should have had a use by date that was 7 days later. She replied that 7 days is correct. The Administrator was interviewed and informed of the findings on 8/16/24 at 12:25 PM. She acknowledged and took note.

Based on medical record review, observations, and staff interview it was determined the facility failed to keep complete and accurate medical records related to: 1) documenting oxygen administration without valid orders for 2 (#158, #75) of 2 residents reviewed for respiratory care, 2) failing to document the administration of a prescribe medication, for 1 (#158) of 2 residents reviewed for respiratory care, and 3) failed to transcribe medication for administration with progress note documentation that is receiving medication as ordered for 1(#44) of 9 residents reviewed for nutrition. The findings include: 1) Review of a nursing progress note revealed that Resident #158 had was administered medication for anxiety on 2/25/20. Interview of the Director of Nursing (DON) revealed that there was an order in the electronic medical record for Resident #158 to be administered Lorazepam 0.5 mg on 2/25/20. Review of Resident #158's February 2020 Medication Administration Record (MAR) on 2/27/20 did not have the prescribed medication lorazepam documented on the MAR to show that it was ordered…

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 during environmental tours. It was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable building interior. The findings include: All environmental concerns were measured and confirmed by the facilities Director of Building Services. On 02/25/20 at 2:20 P.M. during an environmental observation within Resident #158's room, the surveyor observed an accumulation of saw dust on the corner of the heating element closest to the bed caused by the removal of the heating unit's cover. The dust and dirt covered the area of the heating and air conditioning unit that was open and exposed to the residents and public due to the removal of the cover. On 02/24/20 at 7:07 P.M., as observed in room [ROOM NUMBER], the cove molding in the bathroom had separations and cave-ins (indented into the wall). On 3/3/20 at 11:45 A.M. this surveyor's observation was verified by the Director of Building Services who took…

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 ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#158) of 2 residents reviewed for respiratory care. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Observation was made on 2/25/20 at 2:15 PM of Resident #158 receiving oxygen through a nasal cannula. Review of the Treatment Administration Record (TAR) for February 2020 revealed an ordered treatment for continuous oxygen (started on 1/26/19) with nursing staff signing off on all three shifts. Review of the quarterly MDS assessment with an assessment reference date (ARD) of 2/17/20,…

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

Based on observation, medical record review and resident and staff interview it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was exemplified for 2 (#75, #158) of 2 residents reviewed for nutrition. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #75 was initially observed on 2/25/20 in bed receiving oxygen therapy via a nasal canula. Review of the Care plans written for Resident #75 revealed a plan of care that was not resident centered to this resident. The facility has written a plan of care for at risk for aspiration r/t dysphagia. The goal for this care area was written as Will have no episodes of aspiration and no s/s dehydration due to dysphagia and tube feedings in the next 90 day. The resident was not observed to be on tube feeding. ON 3/2/20 at 3:31 PM the Director of Nursing (DON) and an Minimum Data Set (MDS) Assessment Coordinator (staff # 10) both confirmed that 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 review of the medical record it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time. This was exemplified for 2 (#158, #75) of 2 for 2 residents reviewed for respiratory care. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #75's medical record was reviewed on 3/2/20 at 9:30 AM. On 3/2/20 at 9:30 AM, review of Resident #75's medical record revealed the resident had severe cognitive impairment, impaired mobility and dependent for all ADLS (activities of daily living). An annual Minimum Data Set (MDS) assessment was dated for 1/15/20 and a care pan meeting was held on 1/16/20. The MDS assessment indicates that the resident is rarely/never understood. A palliative care order was prescribed on 11/12/19. There were multiple care plan pages with identified care areas. The former Director of Activities wrote a care plan 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 observation, medical record review, resident and staff interview it was determined the facility staff failed to provide respiratory care that was consistent with professional standards as evidenced by 1) failing to have a valid order for administering oxygen, and documenting resident was receiving oxygen without a valid order, failing to implement the written plan of care, and failing to label and date oxygen/nebulizer tubing for a resident; This was identified for 2 (#158, #75) of 2 residents reviewed for Respiratory Care. The findings include: 1) Observation was made on 2/25/20 at 2:15 PM of Resident #158 was in bed and receiving oxygen through a nasal cannula (a lightweight tube that is hooked onto an oxygen concentrator that delivers oxygen to a resident who needs respiratory help). The nasal cannula was hooked onto the oxygen concentrator and was delivering at 3.5 liters (L) of oxygen. The nasal cannula was not dated with the date that the tubing was attached to the oxygen concentrator. The resident indicated that the facility does not change the oxygen tubing. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to ensure that the physician fully evaluated and addressed a resident with significant weight loss. This was evident for 1 (#44) of 9 residents reviewed for nutrition. The findings include: Resident #44 was admitted to the facility on [DATE]. Review of the medical record on 3/3/20 revealed that the resident had a 10.23 % significant weight loss from a 12/26/19 weight of 176 pounds to 158 pounds on 1/7/20. Resident's weight continued to decrease as evident of the recorded weight of 153 pounds on 1/13/20 (-13.07 %). Review of a nursing note dated 1/14/20 7:30 AM, indicated poor po (by mouth) intake noted. Review of the next nursing note was written at 2:45 PM on 1/14/20, indicating that the resident was seen by a Nurse Practitioner and Remeron 7.5 mg PO qhs (at bedtime/hour of sleep) for appetite stimulant and Ensure 240 mls (milliliters) PO daily for nutritional supplement. The nursing note further explained 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.

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 assure that residents are seen by a physician at least once every 30 days for the first 90 days following admission to the facility. This was evident for 1 (#44) of 9 residents reviewed for nutrition. The findings include. 1) Resident #44 was admitted to the facility on [DATE]. Review of the medical record on 3/3/20 revealed that the resident's attending physician examined the resident on 12/16/19. The next physician visited was documented on 2/10/20. There was a lapse of 56 days between the two visits during the resident's first 90 days of her/his admission to the facility. The Director of Nursing (DON) was informed at 9:02 AM on 3/3/20 of Resident #44's attending doctor not seeing the resident every thirty days upon admission. The DON returned at 9:16 AM indicating that the doctor had seen the resident in December, and she acknowledged that the attending physician missed seeing the resident in January, but 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.