Complete Care At Laplata LLC

Based on the review of a facility reported incident 2598625, medical record review, interview with facility staff and review of facility policies, it was determined that the facility failed to ensure that residents medications were free from misappropriation. This was evident for 1 of 1 allegation of misappropriation.The findings include:The facility reported incident 2598635 was reviewed starting on 1/7/26 at 2:50 PM. The facility had initially only provided the initial report and an initial report that was sent to the Board of Nursing regarding staff RN #3, the previous Unit A manager. According to what was provided, on 8/11/25 the previous unit manager took 2 sheets of narcotics (Oxycodone) from a medication cart and destroyed them without following proper procedures including having a witness. Staff RN#3 also left early that day and failed to notify the nurse of that medication cart. Therefore, when the nurse that was working on that cart went to appropriately waste the medication from her cart, she found that it was already gone. She contacted staff RN #4, asking if she did it.…

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 an allegation of abuse was reported to the state agency (SA) within the required 2-hour timeframe. This was evident for 2 (Resident #1 and 2598625, 2593945 ) of 7 residents/investigations reviewed for abuse allegations.The findings include: 1. A medical record review for Resident #1 on 1/9/26 at 10:36 AM revealed a care plan meeting note initiated on 8/12/25 at 3:19 PM by unit manager (UM) #4 was incomplete. Another care plan meeting note was entered by Social Services Director (SSD) on 8/13/25 as a late entry for 8/12/25 at 10:33 AM, indicating the care plan meeting occurred at that time. On 1/8/26 at 4:19 PM a review of the facility's investigation file for the facility reported incident #2593945 revealed the initial report form that documented Resident #1 made an accusation that 2 male therapists kicked him/her in the chest and stomach. Staff documented they became aware of the allegation of abuse on 8/12/25 at 4:00 PM and failed to include to whom it was reported. Review of the final…

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 conduct a thorough investigation and ensure a written record of the investigation was maintained. This was evident for 2 (#1 and #5) of 7 residents reviewed for abuse allegations and an incident (2598625) regarding misappropriation. The findings include: Minimum Data Set (MDS) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1. A medical record on 1/9/26 at 11:29 AM for Resident #5 revealed an admission Minimum Data Set (MDS) with the assessment reference date of 10/10/25. Review of the MDS revealed the resident had no cognitive impairment. Staff documented in section F that it was very important for the resident to choose if s/he wanted a shower or a bed bath. Staff documented in section I that the resident had a diagnosis of chronic pain syndrome (which is chronic pain associated with significant psychosocial…

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

Based on medical record review, interview and review of facility policy, it was determined that the facility staff failed to ensure the verification of the narcotic count at the end of each shift was signed and completed. This was evident for 1 of 2 medication carts on the A wing. The findings include:The narcotic logbooks for the A wing were reviewed on 1/7/26 secondary to a facility report from August 2025 that there were discrepancies when the previous Unit Manger allegedly wasted narcotics without a witness.Review of the narcotic logbook on 1/7/26 at 3:10 PM revealed multiple days between August 2025 and December 2025 where staff failed to ensure that there were 2 nurses verifying the narcotic count at shift change.The unit manager for Unit A, staff # 2, was interviewed on 1/7/26 at 3:15 PM about the process for signing out narcotics and what is to occur at shift change. She stated that 2 nurses are to sign each shift and if someone works a double shift, they are to do the narcotic count with the shift supervisor. She was notified at that time of the multiple holes that were…

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 random observations, interviews it was determined that the facility staff failed to keep resident medications secure from vulnerable residents. This was evident during a random tour of the facility.The findings include: During tour of the facility on 1/8/26 at 4:20 PM upon approaching the C/D unit, a medication cart was observed pushed up against the nursing station. On this medication cart were; 2 insulin syringes, 2 hypodermic needles, and Budesonide (steroid inhaler). There was a ward clerk sitting at the desk and the C/D unit manager staff #13 was observed in her office, however, neither were assigned to or in charge of the medication cart. The facility Nurse Practice Educator (NPE), staff #14 arrived down the same hall minutes after this surveyor walked down and immediately made the same observations and was seen looking for the nurse that belonged to the medication cart that was observed against the nursing station. He was notified by this surveyor of the same observations, time frame of waiting and that this surveyor too was waiting for the nurse. He then spoke to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure required information was sent to the hospital when the resident was transferred. This was found to be evident for 1 (Resident # 1) out of 2 resident complaints. The findings include: On 4/10/25, a review of Resident #1's closed medical record revealed that Resident #1 was admitted to the facility on [DATE] and was transferred to the hospital on 3/24/25. Review of the medical record failed to reveal documentation to indicate the resident's care plan goals were sent to the hospital when the resident was transferred on 3/24/25. No documentation was found to indicate the education provided included review of the specific information required to be sent to the receiving facility at the time of transfer. In an interview with the Director of Nurses (DON) on 4/10/25 at approximately 11:25 AM, the DON stated that Resident #1 was sent back to the hospital to be evaluated for wandering into other resident rooms, being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to provide a notice of discharge to Resident #1 before or during before being sent back to the hospital on [DATE]. This was found to be evident for 1 (Resident # 1) out of 2 resident complaints. The findings include: On 4/10/25, a review of Resident #1's closed medical record revealed that Resident #1 was admitted to the facility on [DATE] and was transferred to the hospital on 3/24/25. Review of the medical record failed to reveal documentation to indicate the resident's care plan goals were sent to the hospital when the resident was transferred on 3/24/25. No documentation was found to indicate the education provided included review of the specific information required to be sent to the receiving facility at the time of transfer. In an interview with the Director of Nurses (DON) on 4/10/25 at approximately 11:25 AM, the DON stated that Resident #1 was sent back to the hospital to be evaluated for wandering into 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 medical record review and interview it was determined that the facility failed to provide documentation to Resident #1 or the responsible party before being transferred to the hospital on [DATE]. This was found to be evident for 1 (Resident # 1) out of 2 resident complaints. The findings include: On 4/10/25, a review of Resident #1's closed medical record revealed that Resident #1 was admitted to the facility on [DATE] and was transferred to the hospital on 3/24/25. Review of the medical record failed to reveal documentation to indicate the resident's care plan goals were sent to the hospital when the resident was transferred on 3/24/25. No documentation was found to indicate the education provided included review of the specific information required to be sent to the receiving facility at the time of transfer. In an interview with the Director of Nurses (DON) on 4/10/25 at approximately 11:25 AM, the DON stated that Resident #1 was sent back to the hospital to be evaluated for wandering into 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 medical record review and interview it was determined that the facility failed to provide a bed hold notice to Resident #1 or the responsible party before being transferred to the hospital on [DATE]. This was found to be evident for 1 (Resident # 1) out of 2 resident reviewed during a complaint survey. The findings include: On 4/10/25, a review of Resident #1's closed medical record revealed that Resident #1 was admitted to the facility on [DATE] and was transferred to the hospital on 3/24/25. Review of the medical record failed to reveal documentation to indicate the resident's care plan goals were sent to the hospital when the resident was transferred on 3/24/25. No documentation was found to indicate the education provided included review of the specific information required to be sent to the receiving facility at the time of transfer. In an interview with the Director of Nurses (DON) on 4/10/25 at approximately 11:25 AM, the DON stated that Resident #1 was sent back to the hospital to be evaluated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to issue an involuntary discharge to Resident #1 before being transferred to the hospital on [DATE]. This failure did not allow Resident #1 to become aware of all his/her legal rights as a resident in a Long Term Care Facility. This was found to be evident for 1 (Resident # 1) out of 2 resident reviewed during a complaint survey. The findings include: On 4/10/25, a review of Resident #1's closed medical record revealed that Resident #1 was admitted to the facility on [DATE] and was transferred to the hospital on 3/24/25. Review of the medical record failed to reveal documentation to indicate the resident's care plan goals were sent to the hospital when the resident was transferred on 3/24/25. No documentation was found to indicate the education provided included review of the specific information required to be sent to the receiving facility at the time of transfer. In an interview with the Director of Nurses (DON) on 4/10/25…

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

Based on observations and interviews it was determined that the facility failed to ensure that food was prepared in a form designed to meet the needs of individuals with alterations in their ability to chew and swallow. This was evident during 1 of 1 observation of meal preparations in the kitchen. This deficient practice has the potential to affect all residents on a therapeutic diet. The findings include: Some individuals may require food consistency to be altered due to their inability to chew and/or swallow. If the consistency required for a resident is not followed, it could result in the resident having food blocking their airway or entering their lungs resulting in serious breathing complications. A pureed Diet has a pudding-like texture that is smooth, blended, or pureed. A mechanical soft diet consists of foods that are easily chewed and swallowed, often involving modifications like chopping, grinding, or pureeing to create a softer texture, and is suitable for individuals with difficulty chewing or swallowing During a kitchen observation on 3/19/25 at 13:27 PM Pureed food…

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 of the Kitchen it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary and safe food service operations. This was evident during multiple observations of the kitchen food service operations. This deficient practice has the potential to affect all Residents. The findings include: During observations in the kitchen on 3/17/25 at 8:40 AM the freezer was found to have a buildup of ice and an ice sickle hanging from a pipe connected to the cooling unit. Further investigation showed ice [NAME] had formed on the wire food rack below the pipe. Additional tracking of the ice led to the discovery of a clump of ice on top of a box of Vanilla Magic Cup Dessert below the ice [NAME]. The wire rack below the Magic Cups had a box of Precooked Lunch Patty with a layer of ice buildup on top of it. During an interview with the Kitchen Manager on 3/17/25 at 8:40 AM he said he had just noticed the ice buildup a couple of days ago. During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined the facility failed 1) to use appropriate infection control practices such as Enhanced Barrier Precautions (EBP) during a high contact care for residents with indwelling urinary catheters, tracheostomy tube, feeding tube and wounds. This was evident for 3 (Resident #45, #384 and #386) of 51 residents reviewed for infection control practices during the recertification survey and 2) to properly store and handle personal clothing. This was evident during the observation of laundry services and has the potential to affect all residents. The findings include: Per Centers for Disease Control (CDC), EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g.,…

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

Based on observation and interview, it was determined that the facility failed to provide residents with access to their call bell. This was found to be evident for 4 (Resident #102, #29, #42, #25) of 4 residents reviewed for call bells. The findings include: On 03/17/25 between 09:00 AM and 09:45 AM, it was observed that Residents #42, #29, #102 and #25 did not have access to their call bells. When asked if they could demonstrate reaching their call bells, it was observed that each of these residents could not reach them. On 03/20/25 at approximately 2:00 PM, this surveyor was walking in the halls when Resident #102 called out from his/her room for the surveyor. Resident #102 reported that he/she was miserable and needed to sit up. When asked if the Resident had tried to call for help, he/she reported, No, I can ' t. The call bell was observed wrapped around the bed rail. The Resident was unable to reach the call bell. It was also observed that Resident #29 was not able to reach his/her call bell - it was lying on top of the nightstand where the Resident could not reach it. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff and resident interviews, it was determined that the facility failed to 1) ensure the dignity of the residents as evidenced by the nursing staff (#7) not knocking on resident room doors before entering resident rooms and nursing staff (#8,9,10 and 11) not wearing a name tag and 2) provide an environment that promotes resident respect and dignity. This was evident for 3 (Resident #46, #112 and #76) of 3 residents reviewed for dignity. The findings include: 1) On 03/17/2025 at 08:20 AM the surveyor conducted an initial tour of the A/B Wing nursing unit. The surveyor observed 4 Geriatric Nursing Assistants (GNA) not wearing name badges. GNA #8, 9,10 and 11 on the A/B Wing nursing unit did not have name badges visible for Resident identification. At 10:15 AM on 03/17/2025 Geriatric Nursing Assistant (GNA) #10 was later observed with a piece of tape on her uniform with her name on the tape. At 10:55 AM on 3/17/2025 Geriatric Nursing Assistant (GNA) #11 entered room [ROOM NUMBER]. GNA #11…

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, surveyor record review and facility staff interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1) a resident that was dependent on dialysis and 2) the resident's discharge status. This was found to be evident for 2 (Resident #112 and #132) of 2 residents reviewed for accuracy of MDS assessments. The findings include: Hemodialysis is a treatment that filters waste products and excess fluid from the blood when the kidneys are no longer able to do so. It is a life-sustaining treatment for people with end-stage kidney disease. A person who receives hemodialysis requires an arteriovenous (AV) fistula shunt because it is the preferred method of vascular access for hemodialysis, providing a direct connection between an artery and vein, creating a larger, stronger blood vessel that allows for efficient blood flow and easier needle insertion during dialysis treatments. 1) On tour of A/B Wing nursing unit on 03/18/2025 at 09:00 AM 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, record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for the use of oxygen. This was evident for 2 (Resident #45 and #46) of 51 residents reviewed for care planning during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The care plan consists of focus, goal and interventions. 1) On 3/17/25 at 9:37 AM, Resident #45 was observed lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the left side of the resident's bed. The resident was on humidified oxygen at 2 liters/minute via nasal cannula that was connected to the concentrator. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. On 3/17/25 at 4:57 PM, a review of Resident #45's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to conduct care plan meetings and failed to review and revise the residents' care plans. This was evident for 7 ( Resident #4, #23, #45, #105, #55, #76, #66, and #11) of 51 residents reviewed for care planning during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each Resident. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. On 03/17/2025 at 08:20 AM the surveyor conducted a tour and interviewed Resident #4 and #23 on A/B Wing nursing unit. Resident #4 was interviewed at 11:39 AM regarding care plan meeting and Resident #4 stated what is that when asked if he/she was invited to care plan meeting and if he/she attended care plan meeting. Resident #23 was interviewed at 12:29 PM about care plan meeting and stated that he/she has not attended care plan meeting, but maybe my daughter attended the meeting. The surveyor reviewed Resident #4'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 observation, record review and interview, it was determined the facility failed to provide appropriate care and services to residents with parenteral and intravenous (IV) access device. This was evident for 2 (Resident #23 and #385) of 2 residents reviewed for parenteral and IV care and services during the recertification survey. The findings include: Intravenous means within a vein. Most often it refers to giving medicines or fluids through a needle/catheter or tube inserted into a vein. This allows the medicine or fluid to enter your bloodstream right away. 1) On tour of the A/B Wing nursing unit on 03/17/2025 at 08:20 AM the surveyor observed Resident #23 with intravenous (IV) tubing attached to the IV needle/catheter in the right upper arm. Further observation revealed Resident #23 with an intravenous antibiotic infusing through the tubing into the IV needle/catheter in Resident's right upper arm. The intravenous tubing was not labeled and dated. A care plan is a guide that addresses the unique needs of each Resident. It is used to plan, assess, and evaluate the…

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

Based on observation, record review and interview, it was determined that the facility failed to provide necessary respiratory care services for residents by failing to 1) label oxygen administration equipment 2) put an oxygen order in place and 3) put up a sign Oxygen in use, no smoking. This was evident for (Residents #45 and #46) of 5 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen therapy is a treatment that provides a person with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. 1) On 3/17/25 at 9:37 AM, Resident #45 was observed lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the left side of the resident's bed. The resident was on humidified oxygen at 2 liters/minute via nasal cannula that was connected to the concentrator. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. However, the…

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

Based on observation, interviews, and record review, it was determined that the facility did not provide drinks that adequately meet the needs of residents. This was observed in 1 (Resident #92) out of 1 resident observed for drink-related needs. The findings include: Nectar-thick liquids refer to liquids with a consistency similar to that of fruit nectars, milkshakes, eggnog, or tomato juice. The purpose of a nectar-thick liquid diet is to make swallowing easier and reduce the risk of liquids entering the airway. Thin liquids like water and juice can be thickened using special thickening packets, allowing them to reach the desired consistency, such as nectar-thick or honey thick. A dys-adv diet, also known as a dysphagia advanced diet, consists of foods that are close to normal textures but easy to swallow. These foods are typically moist, bite-sized pieces that resemble near-normal textures. This diet excludes hard, sticky, or crunchy foods, such as dried fruits or nuts, which could be difficult to swallow. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES) test utilizes a…

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

Based on observation and interview, it was determined the facility staff failed to implement measures to provide warm palatable food to the facility residents. This was evident for 2 of 2 test trays sampled and has the potential to affect all residents who receive meals from the facility kitchen. The findings include: A complaint was reviewed on 12/2/24 at 8:00 AM which included an allegation that the resident's meals were cold. During an interview on 12/2/24 at 10:46 AM, Resident #9 was asked about meal/food temperatures. S/he indicated that the food was not warm sometimes. On 12/2/24 at 12:01 PM, the surveyor requested a test tray during lunch service. At 1:03 PM, the food cart with the test tray was delivered to the C-wing accompanied by Staff #16 the Food Service Manager (FSM). The last tray was delivered from the tray cart to the residents at 1:28 PM and the test tray was sampled immediately afterward. The test tray contained a slice of roast pork, mixed vegetables and rice on a plate covered by a dome lid. There was no base or pellet under the plate. Pellets are metal disks…

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

Based on medical record review, observation and interview, it was determined that the facility failed to complete accurate assessments of a resident related to the use of 1. side rails and 2. functional use of extremities on the quarterly and annual minimum data set (MDS). This was determined during the review of side rails for 3 of 3 residents reviewed (#29, #5, #30). The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need The findings include: 1. Review of the medical record for Resident #29 on 11/21/24 at 2:10 PM and observations on multiple occasions including on 11/21, 11/25 and 11/26/24 revealed the presence of 1/2 size side rails on the bed. A review on 11/25/24 at 2:29 PM of Resident #29's MDS, section 'P' restraints revealed for the first section 'A,' 'not used' was coded for bed rails used for the following assessments:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that facility staff failed to removed their personal protective equipment based on the Centers for Disease Control's guidelines during a COVID 19 outbreak. This was evident for 1 of 1 COVID 19 unit. The findings include: Personal Protective Equipment (PPE) - gloves, gowns, eye protection (safety glasses or shield), and mask. Center for Disease Control (CDC) 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in a Healthcare Settings that was last updated 9/2024 states that for a resident on contact isolation, staff should remove their gloves and gown before exiting the resident's room. www.cdc.gov An observation of the designated COVID 19 unit on 11/21/24 at 8:42 AM, the hallway was cluttered on both sides with several items to include isolation bins sitting outside the resident's rooms and open trashcans. The isolation bins had drawers that were left open across from room [ROOM NUMBER]. The isolation bin outside of room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to maintain a safe environment for their residents. This was evident for 3 (Unit A, B, D) of 4 nursing units. The findings include: 1. On 11/21/24 at 8:42 AM, the surveyor toured the A wing unit. The hallway that contained rooms 101 -120 was cluttered on both sides of the hallway leaving less than 3 feet to maneuver down the hallway. At the end of the hallway was an empty wheelchair (w/c) sitting in front of the exit door beside room [ROOM NUMBER]. Also lined up on the left side of the hallway were 2 w/c, dining room chair, isolation cart, trashcan, and a bed pan with a toilet plunger was on the left side of the hallway. On the right side was an isolation cart. Two beds and a dresser were in hallway between 115 and 116 and between rooms [ROOM NUMBERS] was two beds. Bedside tables, isolation cart, and a dresser were between rooms [ROOM NUMBERS]. An interview with the Unit Manager for Unit 2 on 11/21/24 at 9:28 AM, while she 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 medical record review and interview with facility staff, it was determined that the facility failed to follow the wishes of a resident as identified in his/her advanced directive and follow the wishes of the resident's representative for decision making purposes. This was identified for 1 (#5) of 3 residents reviewed during a complaint survey. Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. The findings include: A review was completed on 11/21/24 at 9:20 AM secondary to a complaint for Resident #5 submitted by a family…

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 with staff it was determined the facility staff failed to report an allegation of abuse timely to the State Agency. This was evident for 1 (#8) of 43 residents reviewed during the complaint survey. The findings include: Facility reported incident #MD00205961 was reviewed on 11/25/24 at 12:47 PM. The report revealed that on 5/22/24 at approximately 5:30 PM, Resident (R)#8 reported to Staff #21 a Licensed Practical Nurse, that s/he was hit on the right and left cheek at approximately 3:00 AM by a male and female staff member. The facility reported the allegation of abuse to the state agency on 5/22/24 at 10:30 PM, 5 hours after staff were made aware of the allegation, not within 2 hours as required. The Director of Nursing was made aware of these findings on 11/25/24 at 1:55 PM.

Based on record review and interview with staff, it was determined the facility staff failed to thoroughly investigate an allegation of resident abuse. This was evident for 1(#6) of 43 resident's reviewed during the complaint survey. The findings include: Facility report #MD00206238 was reviewed on 11/22/24 at 12:08 PM. The report indicated that, on 6/2/24, a family member reported that Resident (R)#6 was struck on the hand by Staff #19 a receptionist on the night of 5/31/24. The report also included that R#6's family member indicated the resident's roommate confirmed it was true. The facility investigation documentation included an assessment of the resident and statements from staff. The facility was unable to conclude that the alleged abuse occurred. However, during their investigation the facility failed to interview R#6's roommate and other residents. During an interview on 11/25/24 at 11:00 AM, Staff #5 an Assistant Director of Nursing, confirmed she investigated R#6's 6/2/24 allegation of abuse. She indicated that her process for investigating included talking to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to assess residents (resident #22 and #28) after a significant change, a reduction of elopement risk score, causing the residents to be monitored using a elopement deterrent device when it was not necessary. This was evident for 2 out of 43 residents reviewed during a complaint survey. Findings include: 1.Review of resident #22's medical record on 11/22/24 at 11:09 am revealed the resident was admitted to the facility on [DATE] after a stroke left the resident unable to care for him/herself. The stroke caused the resident to require a cane to assist with the resident's balance while walking. The resident was assessed by two physicians on 12/18/15 and 12/30/15 to lack adequate decision-making capacity. Additional review of resident #22's medical record on 11/22/24 at 11:30am revealed that the resident eloped from the facility on 8/3/23. The facility assessed the resident for elopement risk after the 8/3/23 elopement and determined 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 medical record review and interview, the facility failed to update the resident's care plan after a change in status (Resident # 1). This was evident in 1 of 43 residents reviewed during a complaint survey. The findings include: On 11/21/24 at 1:03 pm, the surveyor reviewed facility reported incident MD00197571 and complaint MD00211157 sent to the Maryland's Department of Health Office of Health Care Quality Long Term Care Unit in 9/2023. The complaint and the facility reported incident expressed concern from resident #1's family regarding the resident's g-tube care. Review of Resident #1's medical records on 11/21/24 at 1:30pm revealed the resident had several incidents when his/her g tube became dislodged, and the resident needed to be transferred to the local hospital for a g tube replacement. The resident was sent out for g tube replacement after the resident's g tube became dislodged on the following dates: 8/20/22, 9/3/23, 7/10/24, and 10/7/24. The facility investigation for each incident determined that facility staff did not cause the g tube to be dislodged.…

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 facility staff, it was determined that the facility failed to document that care was provided to a resident that was dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 2 of 3 (#11 and # 16) residents related to quality of care. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need The findings include: 1. Review of the complaint #MD00180328 revealed concerns related to quality of care and activities of daily living (ADL) and care for incontinence episodes provided in 2021. Resident #11 had since been discharged to the hospital and expired. Review on [DATE] at 10:19 AM revealed multiple days where staff failed to document that care related to bowel 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 record review and interviews, it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (25) of 3 residents reviewed for trauma informed care. The findings include: A medical record review for Resident #25 on 11/25/24 at 9:30 AM revealed the resident was admitted to the facility on [DATE]. Further review revealed no evidence that an assessment or care plan had been completed to ensure the resident received trauma informed care. On 11/25/24 at 1:13 PM, an interview with Social Worker #7, stated that trauma informed care assessment was done on admission, and annually. Social Worker #7stated that the facility was not administering the trauma informed care assessment at the time s/he was admitted . Social Worker #7 further stated that the trauma informed care assessment was presently incorporated in facility assessments. Further record review revealed that a trauma…

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

Based on medical record review, observation and interview with facility staff, it was determined that the facility failed to assess a resident for the use of side rails when there was a documented change in condition in the resident's functional status. This was evident for 2 of 2 residents observed and reviewed (#26 and #3) during a complaint survey. Bed rails -Adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Synonymous terms are side rails, bed side rails, and safety rails. The findings include: 1. On 11/21/124 at 2:10 PM, the surveyor toured and observed Resident #26 lying in bed, leaning to the right with his/her face against the right-side rail. S/he was making motions with the left arm but could not grasp the side rail. Resident #26 was reviewed and observed secondary to a facility report (FRI) related to Resident #26 having a fractured nasal bone from falling out of bed over the side rails Record review on 11/21/24 at 2:30 revealed an…

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

Based on Observation, record review, and interview, it was determined that the facility failed to ensure that residents were free of significant medication errors as evidenced by facility staff failing to administer medications in accordance with professional standards. This was evident for 1 (#17) of 1 resident reviewed for medication administration. The findings include: Medication is to be administered according to the five rights of medication administration: right person, right medication, right route, right dosage, and right time. On 12/2/24 at 11AM, a review of Complaint MD00199498 alledged that Resident #17 medications were not given as prescribed by the physician. A record review of Resident #17's medication administration audit for 11/2023 revealed Resident #17 had been receiving his/her medications late on a regular basis. On 11/23/23, the following medications were administered outside the 1-hour time frame: Tylenol tablet 325 mg by mouth 3 times a day via G-Tube. It was scheduled for administration at 8 AM,12 noon and 8 PM, however this medication was administered…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to ensure that the physician was notified of lab results. This was evident for 1 of 5 lab results reviewed. The findings include: Review of the medical record for Resident # 27 on 12/2/24 at 11:55 AM revealed multiple comorbidities including uncomplicated diabetes of which medication coverage was recently stopped and anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body). The facility Nurse Practitioner (NP) saw Resident #27 on 10/12/22. During that visit, she reviewed the previous labs that were completed on 9/19/24 and the resident's active diagnosis including leukocytosis (a condition where the white blood cell (WBC) count in the blood is higher than normal) that was noted on the previous lab report with no 'apparent source of infection.' The NP ordered a repeat CBC (complete blood count, a blood test that measures the number and quality of cells in your blood, including red blood cells, white blood cells, and platelets) for the…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that an ordered lab report was available on the chart for review. This was evident for the review of 1 of 5 labs reviewed during a complaint survey. The findings include: Review of the medical record for Resident # 27 on 12/2/24 at 11:55 AM revealed multiple comorbidities including uncomplicated diabetes of which medication coverage was recently stopped and anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body). The facility Nurse Practitioner (NP) saw Resident #27 on 10/12/22. During that visit, she reviewed the previous labs that were completed on 9/19/24. The NP ordered a repeat CBC (complete blood count a blood test that measures the number and quality of cells in your blood, including red blood cells, white blood cells, and platelets) for the morning of 10/13/22. Surveyor reviewed the paper and electronic medical record. The lab report and results for the 10/13/22 lab was not available on the chart. This surveyor requested the lab report…

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

Based on interviews, and record review, it was determined the facility staff failed to honor resident food preferences. This was evident for 1(#9) of 43 residents reviewed during the complaint survey. The findings include: A complaint alleging that residents food preferences were not honored by the facility staff was reviewed on 12/2/24 at 9:53 AM. The complainant indicated that Resident (R)#9 did not like shrimp, so when shrimp was served, R#9 did not eat. In an interview on 12/2/24 at 12:01 PM, Staff #16 the Food Service Manager (FSM) was asked to describe the process for honoring the residents' food preferences. She explained that the actual dislikes were not listed on the resident meal ticket, that preferences were entered into the system, the alternative food item would print on the resident's meal ticket for each meal that the disliked item is served, and staff would provide the alternative rather than the disliked item. She indicated either she or the Dietician were responsible for identifying the residents' dislikes. She was asked to provide the surveyor with a list of food…

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 administration failed to provide a surveyor with QA and risk management records after an incident when a resident (resident #41) sustained injury from being burned by a hot liquid. This was evident for 1 out of 43 residents reviewed during a complaint survey. Findings include: On 12/2/24 at 10:45 am, the surveyor reviewed complaint MD00176117 sent to the Maryland's Department of Health Office of Health Care Quality Long Term Care Unit in 12/2021. The complaint expressed concern from resident #41's family regarding the facility's failure to monitor the resident, causing the resident to be burned by hot liquids. Review of Resident #41's medical records, on 12/2/24 at 11:30am, revealed the resident was admitted to the facility on [DATE] due to complications involving Multiple Sclerosis (MS). The resident required extensive assistance and modified drinkware/utensils when eating due to numbness in hands and fingers as a result of MS. Change in condition…

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 administration failed to maintain QA and risk management records for five years after a resident was discharged from the facility. This was evident for 1 (resident #41) out of 43 residents reviewed during a complaint survey. Findings include: On 12/2/24 at 10:45 am, the surveyor reviewed complaint MD00176117 sent to the Maryland's Department of Health Office of Health Care Quality Long Term Care Unit in 12/2021. The complaint expressed concern from resident #41's family regarding the facility's failure to monitor the resident causing the resident to be burned by hot liquids. Review of Resident #41's medical records on 12/2/24 at 11:30am revealed the resident was admitted to the facility on [DATE] due to complications involving Multiple Sclerosis (MS). The resident required extensive assistance and modified drinkware/utensils when eating due to numbness in hands and fingers as a result of MS. Change in condition documentation on 12/4/21 revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medication cart observations and staff interviews it was determined that the facility staff failed to ensure that residents medical records were kept in a confidential manner. This was evident in 1 out of 9 medication carts. The Medication Administration Record (MAR) / Treatment Administration Record (TAR) is commonly referred to as a drug chart, its report serves as a legal record of the drugs administered to a patient at a facility by a health care professional. This record is a permanent record in the patient's medical record/chart. The findings include: On 01/26/20 at 10:10 A.M. on A-wing Long Term Care Unit, the surveyor observed on top of a standing unattended medication cart in front of room [ROOM NUMBER], an opened Treatment Administration Record (TAR) book that was not kept in a confidential manner. There were visible nursing notes concerning residents' medications, treatment orders and wound measurements with comments visible for public viewing. This practice involved resident's R#82, R#127,…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that medication carts were not left unlocked and unattended. This was evident for 1 of 4 observations of medication carts. The findings include: During an observation of Nursing Wing D that took place on 1/26/20 at 11:00 AM, it was noted that a medication cart was unlocked and unattended on the unit. Geriatric Nursing Assistant (GNA) #15 was present at the end of the hallway and stated that the cart was used by the nurse. GNA #15 also identified that Licensed Practical Nurse (LPN) #16 was responsible for the cart that morning. LPN #16 was located in one of the resident rooms on the D unit immediately. LPN #16 joined the surveyor at the mediation cart and confirmed it was unlocked, describing it as the G-tube (gastrostomy tube) cart. The nurse demonstrated that the cart contained medication for residents who had a G-tube, as well as, other supplies necessary to care for residents with G-tubes. LPN #16 locked the cart at that time, stating that she did not know that it was…

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

Based on observation and staff interview it was determined that facility staff failed to treat residents with respect and dignity by knocking on resident's room doors before entering rooms. This was evident for 2 out of 39 residents (R#10 and R#68) during the survey process The findings include: On 7/23/18 at 3:00 PM an interview occured with Resident #68 and a family companion to Resident #68 at bedside with the room door closed. The Surveyor observed that both Geriatric Nursing Assistants (GNA), staff #3 and #4, knocked on Resident #68's room door. However, they entered the room without waiting for the resident to grant staff permission to enter his/her room during the interview. On 7/23/18 at 3:05 PM during staff interviews, with (GNA's) staff members #3 and #4, both stated, they both knocked on the resident's door and didn't wait for permission from the resident to grant permission to enter the room. On 7/25/18 at 12:35 PM during an interview with Resident #10 and his/her family member, the door to the room was closed. The Surveyor observed that Geriatric Nursing Assistant (GNA)…

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

Based on observations and resident interviews it was determined that the facility failed to maintain an effective pest control program. This has the potential to impact all residents. The findings include: An interview on 7/20/18 at 11:00 AM with Resident #10 took place in the resident's room at his/her bedside. The surveyor observed flies flying around and landing on Resident's #10 face, hands, arms, chest, and bedding which R#10 replied I have and use my fly swatter to keep the flies off of me but what can I do. On 7/23/18, 7/24/18, 7/25/18, 7/26/18 and 7/15/18 the surveyor observed that flies were still in Resident #10's room and flying and landing on and around the resident. On 7/25/18 at 1:00 PM during a staff interview with the B-Wing Unit Nurse Manager who accompanied the surveyor to Resident #10's room, it was verified and observed that flies were still flying and resting on and round Resident #10. On 7/25/18 at 10:30 AM a staff interview ws conducted with the facilities Director of Maintenance who replied that he/she had the pest control contractor in the facility 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 interviews the facility staff failed to document interdisciplinary Care Plan Meetings that informed Resident #31 of the resident's admission status and discharge planning. This was evident for 1 out of 39 residents investigated during the survey process. The findings include: On July 20, 2018 at 10:30 AM while interviewing Resident #31, the resident was asked if the resident was aware of what was going on with therResident. Resident #31 expressed to the writer that no one talks to the resident, and that the resident did not know what was going on. Review of the residents' record revealed documentation about the resident, 8 times from 11/10/17 - 5/3/18. At no time did the Social Worker document any meetings with the resident or the resident's daughter at a care plan meeting or discuss anything about the resident's status or any plans for the resident's future. During a meeting with the Social Worker on 7/24/18 at 11:17 AM, the Social Worker confirmed that the meetings never took place.

Based on observation and staff interviews the facility staff failed to ensure that Resident #76's finger nails and hands were clean when assessed. This was evident for 1 out of 39 residents investigated during the survey process. The findings include: On 07/23/18 during resident interviews, the surveyor noted that both of Resident #76's hands were contracted. Further assessment of the resident's hands revealed dirty fingernails with a broken nail hanging from the 5th digit of the left hand. Both hands were noted to have a foul odor to them. The surveyor notified the Unit 2 Manager. It is the staffs responsibility to maintain appropriate hygiene for residents needing extensive assistance, for infection control, and to maintain resident dignity.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review it was determined the facility failed to document activities conducted with Resident #232. This was evident for 1 of 39 residents reviewed during the survey. The findings include: Residents #232 was admitted to the facility on [DATE] and has multiple diagnoses which include a stroke. The resident requires extensive assistance from staff for personal care and is dependent upon staff for transferring from the bed into a Geri chair. A Geri chair is an upholstered recliner on wheels that can be pushed around like a wheelchair. The resident also breathes through a tracheotomy and requires oxygen and suctioning at times. On 7/23/18 and 7/24/18, Resident #232 was seen up in a Geri chair in his/her room and was not observed attending activities or receiving activities in his/her room. According to his resident's Activity Care plan initiated on 7/11/18, the resident likes to go out of the room to attend religious services or sit outside and likes to stay in his/her room to read,…

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 interviews the facility staff failed to ensure that Resident #31 had a sufficient amount of oxygen in the portable oxygen tank prior to transferring the resident to Therapy. This was evident for 1 out of 39 residents investigated during the survey process. The findings include: On 07/20/18 at 10:40 AM while interviewing Resident #31, the resident complained that the facility ran out of oxygen for the resident and had to go and find some for the resident. On 07/25/18 around 3:10 PM the writer observed the resident being pushed down the hall from the room for therapy by Staff #6. The writer observed the resident with a portable oxygen tank on the wheel chair and the cannula in the resident's nose. This writer stopped staff #6 and asked to see the O2 (oxygen) tank. The O2 tank gauge was in the red section that said replace. When the staff saw that the tank's gauge was in the red zone the staff yanked the tank out of the holder stating this needs to be replaced and proceeded to exchange the portable oxygen tank. The Surveyor asked staff #7 in Physical…

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 and staff interview, it was determined that the facility failed to properly dispose of expired medications. This was evident in 2 out of 8 medication storage areas observed during the survey process. The findings include: 1) On 7/20/2018 at 10:00 A.M. the surveyor observed expired medications in one of the medication carts on D wing. The expired medication was Hydrocortisone Acetate 25 mg Suppositories that were individually packaged. 4 of the suppositories had an expiration date of 6/2017 and 3 of the suppositories had an expiration date of 5/2017. The Unit Manager of D wing confirmed that the medications were expired. 2) On 7/20/2018 at 10:30 A.M. the surveyor observed expired medication in one of the medication carts on A wing. The expired medication was a multi-use bottle of low dose 81 mg aspirin. The expiration date was 4/2018. The Unit Manager of A wing was made aware and confirmed that the medication was expired.

Based on observation, interviews and review of medical records, the facility failed to follow the Doctors orders for 1 resident (#107) out of 39 during the investigation phase of the survey process. The findings include: On 7/20/2018 the surveyor observed on two occasions that Resident #107 heals were lying flat on the bed. This occurred at 11:27 A.M. and 1:02 P.M. on 7/20/2018. The Doctors order were written on 6/7/2018 that Resident #107 heals were to be, float both heels at all times while in bed. Interview with the Director of Nursing confirmed that the Doctors orders are for float both heals at all times while in bed. But that the resident keeps kicking the pillows out from under his/her legs. Failure not to follow the doctor's order has the potential to cause harm to the resident. The facility is responsible to find a way to keep the heals elevated at all times while in bed.

Based on staff interviews and review of medical records, it was determined that the facility staff failed to properly document in the Treatment Administration Record (TAR). This occurred for one resident (#107) surveyed during the investigation stage of the annual facility survey. The findings include: On 7/26/2018 at 11:00 AM a review of the Treatment Administration Record (TAR) and the facility's Progress Notes for July 6, 7, and 18 of 2018 revealed that an order for Float Both Heels At All Times was not filled out for Resident #107. The Progress Notes did not support that the staff elevated the resident's heels on those dates. Interview with the Director of Nursing on 7/26/2018 at 12:00 PM verified that the documentation was not done and that the documentation was required for that resident to be assessed daily. Failure to keep resident heels off the bed has the potential to cause unnecessary skin brake down for Resident #107.