Doctors Community Rehabilitation And Patient Care

Based on record review, observations, and staff interviews, it was determined that the facility failed to follow appropriate infection control practices. This was evident for 2 (Resident #4 and #6) out of 33 residents reviewed during the recertification survey.The findings include:Enhanced Barrier Precautions (EBP), are infection control guidelines for nursing homes, recommended by the Centers for Disease Control and Prevention, to stop the spread of dangerous antibiotic-resistant germs by requiring gowns and gloves only for high-contact care (bathing, dressing, wound care, device care) for residents with wounds, devices, or known multi-drug-resistant organisms. 1) On 12/09/2025 at 11:21 AM A review of Resident #6's medical records was conducted. The review revealed that the resident had a pressure ulcer on the sacrum that required daily dressing change. There was an order that indicated EBP should be followed during wound care. On 12/09/2025 at 11:33 AM An observation of Resident #6's wound care was conducted. Assisting with the wound care procedure was Staff #7 (Wound Team Lead)…

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 maintain an effective pest control program so that the facility is free of pests. This was evident in the kitchen during the initial kitchen tour. The findings include: On 12/03/2025 at 8:43 AM, an observation was made during the initial kitchen tour. A small brown insect was observed crawling on kitchen wall by hand wash sink near the walk-in Refrigerators. On 12/03/2025 at 9:11 AM, a surveyor conducted an interview with Resident #6's representative. They reported that they had observed roaches in the resident's room. On 12/04/2025 at 12:05 PM, an interview was conducted with the Maintenance director (Staff #1). When asked if the facility had any issues with pest control, Staff #1 stated that any issues will be reported directly to the pest control company and the facility keeps copies of their reports. This surveyor made Staff #1 aware of the surveyor's insect sighting in the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations, the facility failed to maintain an environment free from staff-to-resident verbal and non-verbal abuse for 2 (Resident #28, #3) of 19 residents. Specifically, 1) Housekeeper 1 (HK1) used curse words toward and made a threatening gesture toward Resident (R) 28 by raising his/her middle finger one time within R28's bedroom and when 2) General Nursing Assistant (GNA) verbally abused R3 and used derogatory comments while providing care. The facility census was 126. The facility implemented effective and thorough corrective measures following these incidents and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 1) 8/1/24 and 2) 5/10/25.The findings include: 1) A review of the facility's Center Operations Policies and Procedures Manual including a policy titled, “OPS300 Abuse Prohibition,” dated 7/1/13 with a revision dated…

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

Based on surveyor observation, medical record review and staff interview, it was determined that the facility failed to maintain confidentiality of resident medical records as evidenced by accessibility of a laboratory log. This was found to be evident for 7 (Residents #3, 16, 42, 51, 55, 71 and 77) out 7 Residents reviewed for confidentiality of medical records. The findings include: On the initial tour of the nursing unit 400 conducted on 4/15/24 at 8:38 AM the surveyors observed a black binder that sat on the countertop at the nursing station. The review of the black binder revealed a laboratory log that included Residents #3, #16, #42, #51, #55, #71, and #77 names and laboratory information. The laboratory log included the following documents for April 1, 2024 through April 15, 2024: resident lab test log divided by dates, list of residents who were scheduled for a specific lab by dates, Clinical Laboratory Outpatient Requisition forms that were attached for each resident that had a lab scheduled, and the lab and diagnostic record from Point Click Care (PCC) (a computer software…

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 residents that transferred or discharged . This was found evident of 3 (Resident #17, #90 & 73) of 5 residents reviewed for hospitalization during the survey. The finding include: 1a) On 4/15/24 at 11:56 AM, the surveyor interviewed Resident #17. During this interview Resident #17 stated he/she had recently been hospitalized . On 4/19/24 at 7:47 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident # 17 was transferred to the hospital on 3/15/24. On 4/19/24 at 11:33 AM, the surveyor requested documentation that the Ombudsman was notified of Resident #17's March hospitalization. The Director of Nursing (DON) stated she would look for the documentation. On 4/19/24 at 2:13 PM, the DON stated she was not able to find any documentation that the Ombudsman was notified, and she believed the communication was not done after speaking with the Social Worker and business office. 1b)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review it was determined that the facility failed to: 1) revise residents care plans and 2) to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for in 3 (Resident # 42, #75 and #80) and 1 (Resident #322) of 10 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. A wound vac is a negative pressure wound therapy device that decreases air pressure on the wound and helps wounds heal more quickly. The Minimum Data Set is part of the federally mandated process for clinical…

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, review of resident's medical records, and interviews, it was determined that the facility staff failed to provide activities of daily living care in accordance with the Resident's care plan for dependent Residents. This was found to be evident for 5 (Resident #322, #97, #321, #41 and #80) out of 7 reviewed during the survey for activities of daily living. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. A care plan is a federally mandated tool that is based on a resident's assessment and describes the services that the facility will provide to the resident to attain or maintain the resident's physical, mental, and psychosocial health. The care plan must be developed and revised after each assessment. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility failed to maintain proper sanitation for storage of food in the kitchen and on the nursing units. This was evident in the kitchen, on 2 out of 4 nursing units, and on 1 random observation of a beverage cart found during an annual survey. The findings include: 1a) During the initial tour of the kitchen on 4/15/24 at 8:15 AM the surveyors observed the following: dish machine log missing evening temperature on 4/10/24, walk-in freezer stocked too full of food items and disorganized with food items on floor, gnats flying around the freezer and around bread cart, freezer fan on ceiling with ice and sediment, ice on food in freezer, open loaf of bread dated 3/14, kitchen floor with crumbs and dried stains, aluminum pan on the floor underneath the food preparation table, pair of shoes on kitchen floor, trash piled up at the entrance to kitchen door, and wet-nesting on serving pans on the drying rack in the dishwashing area.…

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 ensure that staff respond to call bells in a timely manner. This was found to be evident for 1 (resident #80) out of 3 residents observed for call bell response time. The findings include: During an interview conducted on 4/18/24 at 8:50 AM, Resident #80 stated that his/her call bell had not worked, and that maintenance had worked on it. This surveyor pressed the red button on the call bell, went to the hallway, and observed the resident's call bell light illuminated. The surveyors continued to observe Resident #80's call bell illuminated on 4/18/24 at 9:00 AM. The surveyors observed Geriatric Nursing Assistant (GNA) #13 & #14 walk down the hallway and go into Resident #51's room who did not have a call bell light illuminated. During an interview conducted on 4/18/24 at 9:12 AM, the surveyors witnessed an audible beep sound that came from the nursing station. The Unit Secretary #12 explained that the sound was the call bell alarm for Resident #80. The Unit Secretary further stated that she had spoken…

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 interview, and record review it was determined that the facility failed to have a resident's and/or Resident Representative's acknowledgement of change in coverage including any charges for services not covered under Medicare/Medicaid. This was found evident in 2 (Resident #92 ) of 3 residents for beneficiary notice review. The finding include: Center for Medicare and Medicaid Services (CMS) form 10055 is known as the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage form (SNF-ABN). Center for Medicare and Medicaid Services (CMS) form 10123 is known as the Notice of Medicare Non-Coverage form (NOMNC). It is a written notice that informs a beneficiary when their Medicare-covered service will end. Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF-ABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: 1. Not medically reasonable and necessary; or 2. Considered custodial. The SNF-ABN form provides information…

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 1b) On 4/15/24 at 11:56 AM, the surveyor interviewed Resident #17. During this interview Resident #17 stated he/she had recently been hospitalized . On 4/19/24 at 7:47 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident # 17 was transferred to the hospital on 3/15/24. On 4/19/24 at 11:33 AM, the surveyor requested documentation that written notice was given to Resident #17 of the bed hold policy when he/she was transferred to the hospital. The Director of Nursing (DON) stated she would look for the documentation. On 4/19/24 at 2:13 PM, the DON stated the nursing staff should be providing the bed hold policy at the time of transfer and that the business office is supposed to follow up with the resident or family member the next day. She further stated, they should be sending the policy in the mail or via email. However, she was not able to find any documentation a bed hold policy was provided to Resident #17. 1b) On 4/15/24 at 3:26 PM, the surveyor conducted a phone…

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 staff interview and medical record review, it was determined that the facility failed to accurately document a resident assessment on the MDS (Minimum Data Set) as evidenced by an inaccurate coding for a resident. This was found to be evident for 1 (Resident #42) out of 1 resident reviewed for accuracy of MDS assessments. The findings include: The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident ' s functional capabilities and helps nursing home staff identify health problems. A pressure ulcer is a bedsore or decubitus ulcer and is classified into a series of stages based on the depth of the wound. The stages include: stage 1 - intact skin with non-blanchable redness of a localized area usually over a bony prominence;…

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

Based on medical record review, and staff interviews, it was determined the facility staff failed to provide the resident and their representative with a summary of the baseline care plan. This was found evident for 1 (Residents #90) of 10 residents reviewed for care planning during the annual survey. The finding include: On 4/15/24 at 3:44 PM, the surveyor conducted a phone interview with Resident #90's son and daughter. During the interview the family expressed having minimal communication regarding changes to their parent's (Resident #90) plan of care. Resident #90's son stated he was the Power of Attorney for Resident #90, however his sisters were also involved. On 4/17/24 at 7:46 AM, the surveyor reviewed Resident #90's medical record. The review revealed Resident #90 had been admitted to the facility in early January of 2024 and had been recently readmitted to the facility after a hospitalization. Further review revealed two certifications related to medical condition decision making by two different providers. Both providers certified that Resident #90 lacked adequate…

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 develop and implement a comprehensive care plan to meet the needs of a resident. This was found evident of 2 (Resident #17 & #103) of 10 residents reviewed for care planning during an annual and complaint survey. The finding include: On 4/15/24 at 11:56 AM, the surveyor interviewed Resident #17. During the interview Resident #17 stated he/she had recently been hospitalized due to an infection after having his/her suprapubic tube (a catheter that is surgically placed in the bladder, leaves the abdomen and allows urine to drain from the bladder) was changed. On 4/19/24 at 7:47 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident #17 was readmitted to the facility March 20th after a urinary tract infection associated with his/her suprapubic catheter. On 4/19/24 at 11:33 AM, the surveyor reviewed Resident #17's Minimum Data Set (MDS) assessment completed on 3/23/24. The assessment documented the resident had an indwelling catheter (suprapubic catheter) and urinary…

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 review of facility policy, it was determined that the facility failed to utilize professional standards during medication administration. This was found evident in 1 of 26 medications observed being administered on the survey. The findings include: Nursing and other health care professionals utilize the five rights of medication administered to ensure accurate safe medication administration. The right patient, the right drug, the right route, the right time, and the right dose. All five are used as a standard for safe and medication administration practices. On 4/30/24 at 8:14 AM, the surveyor observed Certified Medication Assistant CMA Staff #37 gather medications to administer to Resident #53. The medications were located in a medication cart just outside Resident #37's room. The surveyor observed Staff #37 pull out 6 punch cards from the medication cart. Each of the cards had a label identifying the resident by the name, the name of the drug, how to be given (route) the time the medication was due to be given, and the amount. Staff #37 also…

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

Based on observation, interview, and record review, it was determined the facility failed to follow professional standards of practice during the administration of intermittent intravenous (IV) antibiotic infusions. This was found to be evident in 2 (#43, and #376) out of 2 residents observed during the recertification survey. The findings include: Intravenous (IV) antibiotics are medications active against bacterial infections delivered into a vein by injection or through a catheter. On 04/22/24 at 07:56 AM, the surveyor observed that Resident #43's IV tubing was not labeled with the date and the end of the tubing was inserted to an upper tubing port. The Director of Nursing (DON) was at the nurses' station, so the surveyor showed her the IV tubing that was not labeled and had the end inserted to the upper port. When asked what the facility procedure was, she stated that the IV tubing end should be capped when not in use and the IV tubing should be labeled and dated. The DON stated she would talk to the nurse responsible right now and left the room. During an interview on 04/22/24…

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 administer medication according to procedures that assure accurate dispensing of medications. This was found evident of 1 of 26 medications observed being administered on the survey. Then finding include: On 4/30/24 at 8:14 AM, the surveyor observed Certified Medication Assistant CMA Staff #37 gather medications to administer to Resident #53 from a medication cart just outside Resident #37's room. The surveyor observed Staff #37 pull out 6 punch cards from the medication cart. Each of the cards had a label identifying the resident and the prescription label with administration instructions. Staff #37 also pulled out a bottle of a stock medication from the top drawer and a medication cup with a white pill in it. Staff #37 placed 1 pill from each punch card into a second mediation cup and added one pill from the stock medication bottle. 7 pills were noted in the 2nd medication cup and the one white unlabeled pill in the first medication cup. The surveyor asked Staff #37 what the white pill in the…

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

Based on record review, interviews, and review of facility policy, it was determined that the facility failed to have a process in place that ensured a Resident 's medication irregularity reports were reviewed by the primary care physician and that the recommendations were addressed timely. This was found evident of 3 (#103, #90 & #42) of 5 Residents reviewed for medication regimen review. Then findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Interdisciplinary Team (IDT), including the resident, their family, and/or resident representative. 1a) On 4/18/24 at 7:42 AM, the surveyor reviewed the Medication Regimen Review (MRR) for 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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that psychotropic medication had an adequate indication for use. This was evident for 1 (#103) of 5 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are medications that affect the brain and nervous system's chemical makeup. They are prescribed to treat a variety of conditions including mental illnesses. The Center for Medicare and Medicaid requires that any psychotropic medication prescribed to residents in long term care facilities must be prescribed, as necessary, to treat a documented, specific condition. On 4/16/24 at 12:51 PM, the surveyor reviewed Resident #103's medical record. The reviewed revealed that Resident #103 had a past medical history that included, but not limited to, cerebral infarction (stroke), abnormal gait, unspecified dementia , unspecified severity, without behavioral disturbance, psychotic disturbance, mood…

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 1c) On 4/30/24 at 7:12 PM, the surveyor observed a medication cart that was unattended and unlocked located on 200 Unit. The medication cart was approximately 15 feet down the hallway from another mediation cart located just across from the nurses station. Two staff were observed counting medications on the cart across from the nurses station. No staff was by the unlocked medication cart. The surveyor observed both staff walk away after they were finished counting at the medication cart across from the nurses station. On 4/30/24 at 7:19 AM, the surveyor was able to open the top draw of the unlocked mediation cart located just down the 200 Unit hallway. The top drawer had multiple bottles of medications. The second drawer had punch cards with multiple doses of residents medications. The surveyor asked a nurse coming out of the nurses' station who was responsible for the unlocked medication cart. Registered Nurse Staff #38 stated she was. At that time, the Unit Manager Staff #42, came over to the medication cart.…

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 have laboratory results in the resident's medical record. This was found evident of 1 of 6 (Resident #324) residents reviewed for vancomycin dosing. The findings include: On 4/23/24 at 9:42 AM, the surveyor reviewed the medical record for Resident #324. The review revealed that Resident #324 had an order placed on 3/29/24 by Medical Director Staff #3. The order was for a laboratory (lab) blood draw to obtain; a complete blood count, comprehensive metabolic panel, hemoglobin A1c, varicella titer, c-reactive protein, vancomycin trough on Monday, one time only for a baseline until 4/1/24. An additional lab order was written on 4/3/24 for a complete blood count, basic metabolic panel, erythrocyte sedimentation rate, c-reactive protein, vancomycin level every Wednesday. On 4/23/24 at 9:53 AM, the surveyor reviewed the policy titled, Diagnostic Tests. In step 2 it calls for the diagnostic service to be notified. Step 3 states, obtain report of diagnostic test. The last step states, maintain signed 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 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 2 (Resident # 74 and #88) out of 2 residents reviewed for dental services during an annual survey. The findings include: 1) During an initial screening, on 04/16/24 at 12:24 PM, Resident #74 stated, I did not remember if I ever had a dentist visit here. Record review, on 4/17/24 at 01:47 PM, of Resident #74's record revealed that he/she was admitted on [DATE] to this facility with the diagnoses of cardiac arrhythmia, dementia, and anemia. Resident #74 was on Medicaid since 2/11/2023 and he/she was able to answer questions appropriately and made his/her needs known. During interview, on 4/24/24 at 09:38 AM, Unit Manager, Staff #9, stated that this resident did not have any dental visit since he/she was admitted to this facility on 6/09/22. She stated that she had just completed a dental referral and 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 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 3 of 54 (Resident #322, #4 and #103) residents reviewed during the survey. The findings include: MOLST is a 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. 1a) On 4/16/24 at 12:18 PM, the surveyor reviewed Resident # 322's paper medical chart. The review revealed a D.C. Medical Order for Scope of Treatment (MOLST). The order indicated the resident wished to have [NAME]-Pulmonary Resuscitation if he/she were to have no pulse or was not breathing. The resident's verbal signature was noted on 3/26/24. On 4/19/24 at 12:27 PM, the surveyor reviewed Resident #322's electronic medical record. The review revealed 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 failed to document the rational for non-administration of the pneumococcal vaccination. This was found evident for 1 (Resident #86) out of 5 residents reviewed for vaccinations during an annual survey. The findings include: Pneumococcal vaccines are vaccines against the bacterium Streptococcus pneumoniae. Pneumococcal vaccine can prevent some cases of pneumonia, meningitis, and sepsis against the bacterium Streptococcus pneumoniae. Prevnar 30 is a pneumococcal vaccine. Point Click Care (PCC) is a cloud-based healthcare software provider helping Long-Term Care. ImmuNet is Maryland's immunization information system (IIS). An IIS is a confidential and secure computer database designed to collect and maintain vaccination records of children and adults. When the surveyor requested copies of the vaccination pneumococcal consent/declination for Resident #86 on 4/24/24 at 08:34 AM, the Director of Nursing (DON) stated that they were not up to date with documentation of the vaccines getting placed in PCC especially 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 and staff interview it was determined the facility failed to keep the kitchen walk-in freezer in safe operating condition. This was evident during the initial tour of the kitchen and during subsequent visits. The findings include: 1. On 7/18/24 at 8:39 AM, an initial tour of the facility's kitchen was performed with the Dietary Manager. When the door was opened to the walk-in freezer it was like walking into a cloud and the visibility of items in the freezer was very difficult to see. 2. There were small mounds of ice covering the entire ceiling of the freezer. There was a built-up ice clump and ice cycles of the 2 circular fans of the main unit. Ice was observed to be on boxes of food, shelving and on the food packages. 3. The Strip curtains were missing from the freezer and refrigerator. At 11:45 AM a revisit of the freezer revealed the following: 1. The fans were not running. 2. The ice on the fans was melting and water was noted on the floor. 3. The ice built up on the ceiling has now melted. 4. The boxes were wet along with the food on the shelves. 5. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of rodents and insects. This was found to be evident during observations for pest control in the kitchen and nursing unit. The findings include: On the initial tour of the facility's kitchen on 4/15/24 at 8:15 AM with the Assistant Food Service Director (#6), the surveyors observed gnats flying around by the bread cart. At 9:45 AM on 4/15/24 the surveyors and the Nursing Home Administrator (NHA) observed gnats in the entrance of the kitchen. On 4/17/24 at 8:19 AM during a random tour of the Nursing Unit 300, the surveyors observed gnats and 2 mouse traps in room [ROOM NUMBER]. At 8:47 AM on 4/24/24 the surveyors conducted a follow-up tour of the kitchen with the Food Service Director (FSD) #5. On this tour of the kitchen the surveyors observed a large amount of mouse droppings on the floor in the dry storage room behind and in between 2 storage…

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

Based on record review and interviews it was determined that the facility failed to ensure that a podiatry consult was provided in a timely manner. This was found to be evident for 1 (Resident #122) out of 1 resident reviewed for foot care. The findings include: Erythema means reddening of the skin due to inflammation which is usually a result of accumulation of cells of the immune system and chemicals these cells release. There can be many reasons for the occurrence of erythema: exposure to heat, insect bites, infections, allergy, non-ionizing radiation (sunlight, UV) and ionizing radiation (X-ray, nuclear radiation). According to the Centers of Disease Control and Prevention (CDC) cellulitis is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems. On 04/29/2024 at 6:43 PM review of the provider's note (encounter note) dated 07/28/2022 for Resident #122 explained that the provider was alerted by nurses to erythema noted in the right first toe. The provider noted 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 interview, the facility staff failed to report the elopement of a resident (resident #43) from the facility. This was evident for 1 out of 44 residents reviewed during a complaint survey. Findings include: Review of resident #43's medical record on 12/5/23 at 9:22 am revealed the resident was admitted to the facility on [DATE] for rehabilitation from a fall that occurred in his/her home. The resident ambulates using a wheelchair. Additional review of the resident's medical record on 12/5/23 at 9:24 am revealed the resident has no evidence of medical incapacitation and his/her BIMS assessments revealed the resident was cognitively intact. Review of resident #43's medical record on 12/5/23 at 9:30 am revealed the resident had an elopement attempt on 10/28/23 at approximately 3:00 PM. Facility nursing staff discovered the resident was outside of the building at 3:00 PM. Assessments completed on 10/28/23 at approximately 4:00 PM revealed the resident sustained no injuries 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.

Based on record review and staff interview it was determined the facility failed to conduct a thorough investigations into allegations of neglect and abuse. This was evident for 4 of 4 (#5 and #9, # 12, and # 27) residents reviewed during this complaint investigation. The findings include: 1. Review on 12/1/23 at 9:56 AM of the FRI occurring on 8/17/22 regarding an allegation of employee to resident abuse occurring in 8/2022, failed to include interviews with any other residents or staff regarding their experience or observations with the staff in question. 2. Review on 12/1/23 11:30 AM of the facility reported incident (FRI) regarding an allegation of employee to resident abuse occurring in 12/2021 failed to include interviews with any other residents or staff regarding their experience or observations with the staff in question. The surveyors review of that FRI found concerns related to the assigned GNA #27's transfer protocol. The DON was interviewed on 12/4/23 at 12:12 PM and made aware of the concerns at that time and throughout the survey. She was not employed here at the 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 medical record review and interview, the facility staff failed to assess a resident (resident #43) after a significant change, an elopement attempt, from the facility. This was evident for 1 out of 44 residents reviewed during a complaint survey. Findings include: Review of resident #43's medical record on 12/5/23 at 9:22 am revealed the resident was admitted to the facility on [DATE] for rehabilitation from a fall that occurred in his/her home. The resident ambulates using a wheelchair. Additional review of the resident's medical record revealed the resident has no evidence of medical incapacitation and his/her BIMS assessments revealed the resident was cognitively intact. Review of resident #43's medical record on 12/5/23 at 9:30 am revealed the resident had an elopement attempt on 10/28/23. Facility nursing staff discovered the resident was outside of the building at 3:00 PM. Assessments completed on 10/28/23 at approximately 4:00 PM revealed the resident sustained no injuries but 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 the review of a complaint, observations, interview, and medical record review, it was determined that the facility failed to provide the ordered feeding assistance to a resident. This was evident for 1 of 2 residents observed on the 400 unit. The findings include: Review of the medical record for Resident #9 revealed diagnosis including dysphagia (trouble swallowing) following a stroke and hemiplegia (weakness) affecting the right dominant side. Review of the physician orders for Resident #9 on 12/1/23 at 9:56 AM revealed an order from 9/2022; Patient to be fed- patient may say [resident] is full this is due to [resident] stroke. please attempt at least 3 (three different times- she will take a little each time) Resident #9 was interviewed and observed on 12/4/23 from 8:39 AM to 9:13 AM. At 8:55 AM his/her breakfast tray was delivered and set up, then the GNA left the room. The surveyor walked the hallway outside the room for the next 18 minutes to see if any staff entered the room to assist Resident #9. Resident #9 was observable from the hallway. S/he could be seen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and review of a facility reported incident, it was determined that the facility failed to follow the plan of care for transferring a resident. This was evident for the review of 3 of 3 (#5 and # 27 and # 43 ) residents reviewed during the complaint survey. The findings include: 1. Review of the medical record for Resident #5 on 12/4/23 at 11:30 AM revealed diagnosis including Parkinsons disease, a progressive disease affecting the nervous system. A further review of Resident #5's medical record revealed care plan notes documenting that assistance was needed and that s/he was dependent on activities of daily living and for transfers. Additionally, a minimum data set (a standardized assessment tool that measures health status in nursing home residents) assessment was completed on 12/15/21 under functional status assessing him/her as an 'extensive assist' of 2 persons. On admission the facility staff completed a lift transfer reposition assessment on 12/6/21 assessing…

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 a random tour of the facility, it was evident that the facility failed to secure all medications out of the reach of all vulnerable adults. This was evident during a tour of the facility on 1 of 4 wings. (400). The findings include: On 12/4/23 at 9:06 AM, surveyor entered the 400 unit via the closed double doors. Immediately on the floor the surveyor saw a pinkish colored item in front of rooms [ROOM NUMBERS]. Resident #42, whose diagnosis includes dementia with behavioral disturbances, was observed in the vicinity wheeling slowly around. S/he resides in room [ROOM NUMBER]. Upon closer observation the pinkish item was identified as a pill with an inscription of 894 on it. A search of the national institutes of health (NIH) and the Food and Drug Administration web sites to confirm, the pill was identified as an Eliquis-anticoagulant. The closest staff was immediately notified to please come over. The staff, later identified as CMA #28, initially stated that she was busy, then came over at the surveyor'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 reported incidents, interviews, and review of employee files, it was determined that the facility failed to ensure abuse training was completed prior to Geriatric Nursing Assistants (GNA) working on the floor with residents. This was evident during the review of 1 of 3 employee files. The findings include: During the review of 2 facility reported incidents concerning potential abuse, the employee file of staff GNA #27 was requested on 12/3/23 at 11:05 AM from the facility Director of Nursing. On 12/5/23 at 12:36 PM after interviews with the facility Nurse Practice Educator and the DON as well as concurrent review of GNA #27's employee file, who was hired in 2021, failed to reveal documentation on the needed and necessary training of activities that constitute abuse, neglect, or misappropriation of resident property and dementia management and further the procedures for reporting and prevention.

Based on record review and interview with the Director of Nursing DON) on 4/24/19 at 8:30 AM a care plan was not sent with Resident # 22 that was sent to the hospital on 3/29/129. This was evident for 1 of 42 residents. The findings include: On 3/29/19 Resident #22 was transferred to the hospital with bilateral leg cellulitis, severe sepsis, altered mental status and A-FIB. The resident had redness and swelling in bilateral lower legs. Resident # 22 returned to facility on 4/6/19. The following transfer papers were sent with the resident: Resident transfer form, Any personal belongings identified, Face sheet, Current medication list, Change of condition report, Advanced Directives, Any other orders, flow sheets, lab, x-rays . Bed hold policy was given to resident. A written letter of transfer and bed hold policy was given to Responsible Party (RP). A care plan was not sent with resident to the hospital. The DON (Director of Nursing) on 04/24/19 08:30 AM stated that a copy of the care plan was not sent.

Based on observation of Resident # 15, interview with staff # 2 on 4/25/19 at 11:12 AM and record review, the facility failed to do an accurate assessment for Resident # 15 that smokes. This was evident for 1 out of 2 residents that smoke. The findings include: The latest smoking assessment for Resident # 15 was completed on 3/20/19. Resident # 15 has a BIMs of 15, has no dementia, does not have poor memory, and resident is able to show the location area for smoking. The same smoking assessment also states that resident cannot hold a cigarette safely, cannot light a cigarette, cannot properly dispose of a cigarette and cannot smoke safely without a smoking apron. Assessment indicated the Resident # 15 is not allowed to smoke as this is a nonsmoking facility. Interview with Unit Manager staff #2 on 4/25/19 at 11:12 AM who stated that the resident does smoke as she was grand fathered in, although this is a nonsmoking facility. A care plan is on the chart for smoking. The Unit Manager stated, I did the assessment and it is not correct. Staff member # 2 restated the assessment was wrong…

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

Based on observation of Resident # 109 on 4/25/19 at 10:30 AM and record review, the resident was not turned and repositioned every 2 hours as ordered by the physician. This was evident for 1 out of 42 residents. The findings include: On 3/20/19 Resident # 109 received an in house acquired pressure wound on his coccyx that measured 1.8 cm x 1.5 cm. Pressure ulcer is a stage 2. The wound now measures 1.3 x 0.2 as of 4/19/19. Treatment orders include: clean wound with wound cleanser, apply hydrogel and cover. The resident is to be turned and repositioned every 2 hours. A care plan is in place, an observation of Resident #109 was done on 4/25/19 at 10:30 AM. The resident was currently in the bed on back. Resident # 109 stated he/she cannot turn and reposition self and that staff do not turn reposition him/her on a routine basis. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities 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.