Autumn Lake Healthcare At Patuxent River

Based on record review and interview it was determined the facility failed to ensure the care plan for Resident #117 was comprehensive. This was evident for 1 out of 4 residents reviewed for urinary catheters during the facility's recertification survey. The findings include: Review of the medical record by the surveyor on 8/4/25 at 10:51AM revealed Resident #117 had an active medical order for an indwelling urinary catheter which was dated as beginning on 3/31/25, and diagnoses listed which included urinary tract infection as well as an active medical order dated as beginning on 6/15/25 for contact precautions. On 8/4/25 at 11:00AM the surveyor reviewed the medical record of Resident #117 which revealed their care plan had no documentation of the resident's urinary catheter. Additionally, the enhanced barrier precautions focus on the resident's care plan did not include a catheter as one of the indications that were listed for the precautions, and the care plan did not reflect the active medical order in place dated as beginning on 6/15/25 for contact precautions. Review of…

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

Based on record reviews and interviews, it was determined that the facility failed to clarify residents pain medication orders and ensure residents' medications were administered and physician's orders were followed in accordance with professional standards. This was evident for 2 (#14 and #24) residents out of 66 residents investigated during the survey.The findings include: 1. On 07/31/25 at 12:00 PM during Resident #24's medical record review revealed a doctor's order dated 11/06/2024 for oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 6 hours as needed for Pain (5-10). Take 10 mg by mouth every 4 hours as needed for Pain (5-10). The orders had two administration frequencies for the same pain level within the order. On 07/31/25 at 12:06 PM during medical record review, it revealed the Medication Administration Record(MAR) dated 7/1/2025 - 7/31/2025, that the medication oxycodne HCl was given to Resident #24 for 17 days of 31 days, on July 1, 2, 3, 4, 5, 6, 10, 11, 12, 14, 15, 16, 17, 18, 20, 23, and 26. On 08/01/25 at 11:00 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.

Based on observation, interview, and record review, it was determined that the facility failed to provide and document individualized activities to support the physical, mental, and psychosocial well-being of 1 (Resident #6) of 1 resident reviewed for activities.The findings include:On 07/30/2025 at 9:08 AM, Resident #6 was observed lying in bed with no activities occurring in the room or any evidence of engagement in individualized activity.On 08/01/2025 at 9:04 AM, the resident was again observed lying in bed with no materials or indications of participation in any activity.At 9:10 AM, the surveyor requested documentation of activities provided for Resident #6 for the last 30 days from Staff #4. Staff #4 checked the electronic medical record and stated there were no recorded activities for the last 30 days. At 9:22 AM, Staff #4 reported that he was unable to locate any documentation for Resident #6 in the activity department's logbook. Staff #4 stated that musical encounters, involving a musician (typically a guitarist) visiting residents' rooms, occur approximately twice a month.…

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 the facility failed to ensure a resident's care was reviewed by the physician. This was evident for 1 out of 10 residents reviewed for advanced directives during the facility's recertification survey. The findings include:On 8/4/25 at 11:51AM SW #6 provided the survey team with a second certification of incapacity form dated 6/19/25 for Resident #117. This form was observed to have a different person's first name and the same last name as the resident written on it at the top as the person that information was being certified about instead of the resident. The surveyor reviewed documentation provided by the facility and observed an additional copy of the certification of incapacity form which had the resident's name at the top of the form. Part 1 of both of the physician certifications related to medical condition, substitute decision making, and treatment limitations forms was observed to be left blank which was missing the following information: 1.) Patient: I am certifying information about . 2.) Certifying practitioner…

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

Based on record reviews and interviews the facility failed to ensure that a resident must be seen by a physician at least once every 60 days after the first 90 days after admission. This was evident for 1 (#24) resident out of 8 residents investigated during the facility's annual survey.The findings include:On 07/31/25 at 12:00 PM during medical record review of Resident #24, it revealed an MD General Note for date of service of 01/10/2025 at 21:15 PM created by Physician #08; and no other MD General Notes for any subsequent dates of services during this review.On 08/01/25 at 11:30 AM the surveyor conducted an interview with the facility's Nursing Home Administrator (NHA), staff #01 and Director of Nursing (DON), staff #02 and shared the concern for lack of physician visit at least once every 60 days after the first 90 days after admission.On 08/06/25 at 14:10 PM during follow-up interview after surveyor discussion and intervention, NHA #1 and DON #02 provided the surveyor with a Late Entry MD General Note for date of service 05/14/25 at 18:32 PM created by Physician #08 on 08/04/25…

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 observation, interview and record review it was determined the facility failed to ensure the accuracy and completeness of Resident #117's medical record. This was evident for 1 out of 10 residents reviewed for advanced directives; and failed to ensure accuracy of room numbers on resident medical records This was evident for 5 out of 32 residents located on the lighthouse nursing unit during the facility's recertification survey.The findings include:1.) On 7/31/25 at 8:53AM the surveyor observed and reviewed the medical record of Resident #117 which revealed one physician's certification of incapacity present within their medical record completed by Physician #5 dated 6/17/25. The surveyor noted that on the certification of incapacity form signed as completed by Physician #5 titled Part 1: Identifying information; Patient: I am certifying information about: this section failed to include the resident's name. On 8/4/25 at 10:18AM the surveyor conducted an interview with the facility's Administrator who confirmed with the surveyor that Resident #117 was incapable of medical…

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

Based on observations, record reviews, and interviews, it was determined that the facility failed to: 1.) maintain infection prevention designed to prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #1) of 2 residents reviewed for Trach Care; 2.) maintain proper infection control practices to prevent cross-contamination with Foley catheters. This was evident for 1 (Resident #7) of 3 residents reviewed for Foley Care; and 3.) ensure infection control precautions were followed. This was evident for 2 residents (Resident #117, and Resident #125) of 2 residents reviewed for infection control precautions during the survey.The findings include: 1. On 07/30/25 at 7:57 AM the surveyor observed Resident #1 supine in bed with Trach Collar intact to neck and Trach Collar Oxygen mask, dated 07/23/25 laying lateral to the left side of the resident bed on the floor. On 07/30/25 at 8:16 AM during follow-up observation rounds of Resident #1 with LPN Unit Manager staff #03, the resident remained supine in bed with Trach Collar intact…

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 complaints, tray tickets, observation, and interview, it was determined the facility failed to serve residents food that was palatable and appealing and failed to follow the selections residents had chosen. This was evident for 13 (#10, #65, #63, #61, #68, #67, #66, #58, #70, #64, #62, #17, #71) of 73 residents reviewed during a complaint survey. The findings include: Review of complaints MD00202967, MD00206399, and MD00201718 alleged, inferior quality of food that was tasteless, cold, and often old. Badly cooked food without any nutrition or nourishment. Food was cooked raw with blood in it. I have been forced to order food regularly for my mother. They give patients a food menu and it's not what they have on their tray. 1) On 4/15/25 at 8:30 AM Resident #10 was observed sitting in the dining room. Resident #10 was asked how the food was, and the reply was, it is ok, but I don't like biscuits and that is what they sent me instead of toast. Observation of Resident #10's breakfast plate revealed a hard-boiled egg yolk sitting on the plate along with a biscuit.…

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 a complaint, observation of resident wheelchairs, and interviews, it was determined the facility failed to provide maintenance services necessary to keep all wheelchairs in a sanitary, comfortable, and well maintained condition. This was evident on 2 of 3 nursing units observed. The findings include: On 4/15/25 at 8:30 AM a review of complaint MD00203718 alleged wheelchairs in the facility were in disrepair. On 4/15/25 at 8:50 AM observation was made of Resident #60 sitting in the dining area eating breakfast. The vinyl was missing on the right front wheelchair armrest approximately 1 inch. The vinyl on the left wheelchair armrest was missing vinyl and the remaining vinyl was cracked. On 4/15/25 at 1:15 PM Resident #59 was observed sitting in the hallway in a wheelchair. The vinyl on the left wheelchair armrest was cracked along the edge and missing 1 inch of vinyl in the front. On 4/18/25 at 10:49 AM Resident #56 was observed sitting in a wheelchair. The left armrest was missing vinyl. Resident #56 was interviewed and stated that the armrest had been like that…

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

Based on medical record review, documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) (Resident #7, #8). This was evident for 2 of 24 residents reviewed for allegations of abuse, neglect or an injury of unknown origin during a complaint survey. The findings include: 1. Review of Resident #7's medical record review on 4/16/25 revealed the Resident was admitted to the facility in January 2023. Further review of the Resident's medical record revealed a nurse's note on 3/31/23 at 2:38 PM that stated, Patient noted with swelling on right thumb. On assessment there is dark discoloration noted, which is tender and warm to the touch. Patient voiced pain on assessment on the scale of 3 out of 10. Review of the facility reported incident the facility staff submitted to OHCQ on 3/31/23 revealed Resident #7 had an injury of unknown origin. Further review of the facility's investigation documentation…

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, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 3 (#10, #9, #8) of 24 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) On 4/15/25 at 9:38 AM a review of facility reported incident MD00194205 alleged that on 7/7/23 in the evening, 3 staff members held Resident #10 down while the resident fought them off. Review of the facility's investigation revealed that 7 residents were interviewed, however there were no staff interviews conducted. On 4/17/25 at 11:44 AM the Nursing Home Administrator (NHA) was interviewed and stated that it was prior to her time at the facility. The NHA was informed of the findings of an incomplete investigation. The NHA stated that the investigations that she does are more thorough. 2) On 4/16/25 at 1:55 PM facility reported incident MD00192876 was reviewed and alleged that Resident #9 was noted on 5/29/23 to have swelling and…

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

Based on complaint, record review, and interview, it was determined the facility failed to have documentation that residents were offered and/or received a shower on the resident's assigned shower day. This was evident for 1 (#20) of 25 residents reviewed for complaints during a complaint survey. The findings include: On 4/17/25 at 1:47 PM a review of complaint MD00203718 alleged unacceptable means of personal cleanliness for Resident #20. Review of Resident #20's medical record revealed the resident was admitted to the facility at the end of November 2023 from an acute care hospital for rehabilitation following a wedge compression fracture of the lumbar vertebra. Review of a 11/28/23 nurse's note documented that the resident had intermittent confusion and required extensive assistance with activities of daily living (ADL) needs. Review of geriatric nursing assistant (GNA) ADL documentation for bathing documented the resident did not receive any bathing on 11/30/23 and 12/1/23. From 12/2/23 to 12/16/23 Resident #20 received a bed bath. There was no documentation that Resident #20…

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

Based on interview, record review, and facility document and policy review, the facility failed to ensure neurological evaluations were comprehensively conducted per facility policy/procedure after falls for 1 (Resident #30) of 2 sampled residents reviewed for falls. Findings included: A facility policy titled, Neurological Evaluation, dated 10/2024, indicated, Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: a. Vital signs and c. Neurological evaluation for changes in: i. Physical functioning ii. Behavior ii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions. The policy also indicated, Perform neuro [neurological] checks as indicated or as specified by the physician. Neuro checks: -q [every] 15 minutes x [for] 1 hour -q 30 minutes x 1 hour -q 1 hour x 4 hours -q 4 hours x 24 hours -q shift until 72 hours. An admission Record revealed the facility originally admitted Resident #30 on 08/10/2022 and readmitted the resident on 08/31/2024.…

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 staff failed to ensure a resident received podiatry services as ordered (Resident #12). This was evident for 1 of 3 residents reviewed for podiatry care during a complaint survey. The findings include: Review of Resident #12's medical record on 4/15/25 revealed the Resident was admitted to the facility in 2010. Further review of the Resident's medical record for podiatry care revealed the last time the Resident was seen by the Podiatrist was 1/10/24. A podiatrist is a medical doctor devoted to the treatment of disorders of the foot, ankle, and related structures of the leg. During interview with the Unit Manager (Staff #19) on 4/15/25 at 11:33 AM, the Surveyor advised Staff #19 the Surveyor can not find any documentation the Resident was seen by the Podiatrist since 1/10/24. At that time the Surveyor accompanied Staff #19 to medical records. At that time Staff #30 pulled up a list of all residents that were seen the last time podiatry was in the facility on 4/8/25. Staff #30, Staff #19 and the Surveyor reviewed the list…

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 facility documentation review, it was determined that facility staff failed to keep a medication cart locked when unattended. This was evident on 1 of 4 nursing units observed during a complaint survey. The findings include: On 4/17/25 at 2:31 PM observation was made of an unlocked and unattended medication cart sitting in the hallway outside of room [ROOM NUMBER]. The surveyor was able to open all of the drawers and visualize all the medications in the medication cart. Unit Manager #24 walked up to the surveyor on 4/17/25 at 2:36 PM and asked if she could help the surveyor. At that time the surveyor informed her of the unlocked and unattended medication cart. At 2:37 PM Agency LPN #25 walked up and asked if someone had pulled on the drawers to unlock the cart. The surveyor informed LPN #25 that the silver lock button was extended out away from the cart prior to opening the drawers. LPN #25 then proceeded to unlock the treatment cart which was sitting next to the medication…

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

Based on medical record review and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #6). This was evident for 1 of 73 residents reviewed during a complaint survey. The findings include: Review of Resident #6's medical record on 4/15/25 the Resident was admitted to the facility in October 2022 with a diagnosis to include tracheostomy. Tracheostomy is a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. Further review of the Resident's medical record revealed on 1/26/23 the Resident went to the ENT (ear, nose and throat doctor). Review of the ENT's Report of Consultation revealed the Resident's trach was changed and ordered to see the Resident was scheduled to see a specialist in head and neck surgery on 2/14/23. Further review of the Resident's medical record revealed the Resident did not go to the appointment on 2/14/23. Interview with the Administrator on 4/16/25 at 11:01 AM confirmed the facility staff failed to ensure Resident #6 went to a scheduled…

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

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #12). This was evident for 1 of 73 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #12's medical record on 4/15/25 revealed the Resident was admitted to the facility in 2010. Further review of the Resident's medical record for podiatry care revealed the last time the Resident was seen by the Podiatrist was 1/10/24. During interview with the Unit Manager (Staff #19) on 4/15/25 at 11:33 AM, the Surveyor advised Staff #19 the Surveyor can not find any documentation the Resident was seen by the Podiatrist since 1/10/24. On 4/16/25 at 8:14 AM the Administrator provided…

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: 1) failed to ensure that medication carts were locked, code carts were locked, and medications were secure inside the medication cart. This was found to be evident for 3 out of 5 carts observed during the recertification survey and, 2) failed to ensure that medications were stored properly as evidenced by unopened insulin pens stored in medication carts. This was found to be evident for 2 out of 2 medication carts observed during medication storage observation. The findings include: 1) During a tour of the facility on 4/20/2022 the Surveyor observed an unlocked cart on the Light House unit unattended from12:06 PM- 12:12 PM located at the nurse's station, however no staff was around. At 12:12 PM the Unit Manager (UM), staff #28 was observed walking past the open medication cart and pushed in the button to lock the cart. Surveyor spoke to her about the time it was unlocked and further asked whose cart it was assigned to. She stated that it was assigned to RN staff #23. We went back to look at the cart and 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 a resident concern, interviews and the sampling of 2 test trays, it was determined that the facility failed to prepare a palatable meal for residents. This was evident in 1of 2 test trays. The findings include: On 4/28/2022 the survey team requested a lunch test tray based on random complaints from residents about the taste and flavoring of the food provided by the facility. A lunch test tray was presented to the survey team around 12:00 PM on 4/28/2022 that according to the menu consisted of Homestyle Meatloaf with a Ketchup glaze, Au Gratin Potatoes, seasoned green peas, a dinner roll and sliced peaches. Surveyor cut open the meatloaf and found the meat to be a pale brown/gray color. Two surveyors on the team tasted the meatloaf and determined that there was no taste or flavoring to the meatloaf in addition to the off-putting color. The peas were overcooked identified by their mushy appearance. A breakfast tray was requested on 4/29/2022 at 8:00 AM to follow up on identified concerns with the lunch tray. The breakfast according to the menu was supposed to be an egg and…

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

Based on observation and interview with facility staff, it was determined that the facility failed to: 1) ensure that food was prepared and stored in accordance with professional standards for food service safety, 2) properly label and date food items and remove expired food items, and 3) to maintain food service equipment in a manner that ensures sanitary food service operations. This was evident through multiple observations and has the potential to affect all residents in the facility. The findings include: The surveyor conducted an initial tour of the kitchen on 4/20/2022 at 8:30 A.M. During the tour, the surveyor observed: - an uncovered tray of uncooked chicken breasts submerged in a clear solution thawing in the sink, - a green bucket of soapy water next to the tray of uncovered uncooked chicken breasts, - Staff #49 took a cloth rag out of a green bucket then rung it out in the sink that was next to the uncovered chicken breasts with potential to splash on uncovered chicken, - kitchen utensil used to serve/dispense apple sauce into dessert cups was rinsed in the sink adjacent…

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 staff failed to ensure the dignity of a resident (#68) as evidenced by the resident's urine catheter bag attached to the arm rest of a wheelchair. The was found to be evident for 1 out of 2 residents observed for catheter care. The findings include: A suprapubic catheter (tube) drains urine from your bladder into a urine catheter bag. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. During a tour conducted on 04/26/22 at 1:15 PM, the Surveyor observed from the nursing unit hallway Resident #68's urine catheter bag attached to the arm rest of a wheelchair. During an interview conducted on 04/26/22 at 1:16 PM, Resident #68 stated that Geriatric Nursing Aide (GNA) #10 placed his/her catheter urine bag on the arm rest of his/her wheelchair. During an interview conducted on 04/26/22 1:23 PM,…

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, review of pertinent facility documentation and interview with facility staff, it was determined that the facility staff failed to: 1) report a fall to the resident's physician and representative (RP). This was evident for 1 of 3 residents reviewed for falls/accidents (#19) and 2) report glucose levels outside acceptable parameters. This was evident for 1 of 5 residents reviewed related to complaints and facility reported incidents about general care (# 122). The findings include: 1) Review of the medical record for Resident #19 on 4/25/2022 at 10:26 AM revealed a note completed on 1/27/2022 at 11:19 PM documenting that the resident had a fracture involving the trochanteric femur with displacement, MD notified via eMedical (electronic notification). Further review of Resident #19's electronic medical record (EMR) revealed an 'SBAR' (situation, back round, assessment, recommendation) created by staff RN #28 on 2/4/2022, effective 1/26/2022 as a late entry for 1/19/2022. The SBAR completed by staff RN #28 stated: What I think is going on with 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 Beneficiary Protection Notification Review and interview with the facility staff, it was determined that the facility failed to document notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare. This was evident in 1 of 3 (resident#101), residents reviewed regarding liability notices. The findings include: Advance Beneficiary Notice (ABN) is a written notice from Medicare, given to you before receiving certain items or services notifying you: Medicare may deny payment for that specific procedure or treatment. An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. A Notice of Medicare Non-Coverage (NOMNC) informs beneficiaries of their discharge when their Medicare covered services are ending. The NOMNC must be delivered at least two calendar days before Medicare covered services end. On 5/4/2022 Resident #101's Beneficiary Protection and Notice review task was conducted.…

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

Based on observation and interview it was determined the facility failed to ensure that resident rooms were maintained in a homelike environment as evidenced by brown stained ceiling tiles. This was found to be evident facility wide during the recertification survey. The findings include: During a tour of the Seaside and Oceanview nursing units conducted on 04/20/22 at 8:30 AM, the Surveyor observed resident # 12, #64, #81 and #318 rooms with brown stains on the ceiling tiles. An interview conducted on 04/21/2022 at 9:50 AM, the Maintenance Director #8 advised the Surveyors the facility had a roof leak that had been repaired and was aware of the brown water-stained ceiling tiles. During a tour of the facility with the Maintenance Director #8 conducted on 04/21/2022 at 10:12 AM, the Surveyors and Maintenance Director #8 observed brown ceiling tiles in several of the resident rooms throughout the facility. The Maintenance Director stated he/she would replace all of the brown stained ceiling tiles in each of the resident rooms.

Based on medical record review, facility policy and training review and interview with facility staff, it was determined that the facility failed to implement their policy on abuse as evidenced by failing to complete in-services on all employees after alleged incidents of abuse occurred in the facility. This was evident during the review of 1) 2 of 2 facility reported incidents on abuse (FRI), 2) 2 of 2 in-services that were given to the survey team as evidence of completed in-services trainings and 3) 1 of 5 annual employee trainings on abuse (#11). The findings include: 1.A. On 4/26/2022 at 11:00 AM the Surveyor reviewed an FRI #MD00163236 that was reported on 1/18/21 regarding an allegation of abuse. After the facility completed their investigation, the allegation was substantiated, the residents account of verbal abuse was determined accurate, and the employee was terminated based on code of conduct. In-services for abuse related to this incident for staff were not initiated according to what was provided to the survey team. 1.B. Review of the FRI #MD00167589 occurring 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, medical record review and interview with facility staff, it was determined that the facility failed to develop a baseline care plan related to a resident's pain. This was evident in 1of 3 Residents (#19) reviewed for pain during the investigative portion of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. Review of the medical record for Resident #19 on 4/25/2022 at 9:31 AM revealed admission on [DATE] including nondisplaced intertrochanteric fracture of the left femur admitted for routine healing and history of falling. A review of Resident #19's care plans on the electronic health record at this time revealed that no care plan for pain was developed until 12/21/21 after Resident #19 had his/her 6th documented fall that the facility identified as…

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 update a care plan with interventions after a resident had a fall. This was evident during the review of 1 of 3 Resident (#19) falls/accidents during the investigative portion of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress Review of the medical record for Resident #19 on 4/25/2022 at 9:31 AM revealed admission on [DATE] including nondisplaced intertrochanteric fracture of the left femur admitted for routine healing and history of falling. A review of the medical record for Resident #19 regarding falls on 4/25/2022 at 10:26 AM revealed falls on: 1-5/27/21-fall requiring an emergency room visit for treatment 2- 6/1/21- fall with no injury documented.…

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

Based on observations and interviews it was determined that the facility failed to ensure that appropriate care was provided to a resident with a tracheostomy and contractures as evidenced by: 1) oxygen tubing removed during hygiene care and, 2) physician ordered assistive devices was not placed on the resident. This was found to be evident for 1 (Resident #27) out of 1 resident reviewed for Tracheostomy care. The finding include: Tracheostomy (tray-key-OS-tuh-me) is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing. During a tour on 04/28/2022 at 7:52 AM, the surveyor observed GNA #10 in the process of providing hygiene care to Resident # 27, a resident with a tracheostomy. The surveyor observed the resident lying flat on the bed and the resident's oxygen tracheostomy tubing detached from the resident and lying on a cart next to the resident's bed. 1) During an interview conducted on 4/28/2022 at 7:53 AM, the Geriatric Nursing Assistant (GNA) #10 confirmed that he/she…

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 staff failed to ensure appropriate urinary catheter care as evidenced by a urine catheter bag placed above the urinary bladder. This was found to be evident for 1 (Resident #68) out of 2 residents observed for catheter care. The findings include: A suprapubic catheter (sometimes called an SPC) is a device that's inserted into your bladder to drain urine if you can't urinate on your own. During a tour conducted on 04/26/22 at 1:15 PM, the Surveyor observed resident #68's urine catheter bag attached to the arm rest of a wheelchair above the resident's urinary bladder. During an interview conducted on 04/26/22 at 1:16 PM, Resident #68 stated that Geriatric Nursing Aide (GNA) #10 placed his/her catheter urine bag on the arm rest of his/her wheelchair. During an interview conducted on 04/26/22 at 1:23 PM, Registered Nurse #10 (RN) confirmed that Resident #68's catheter urine bag located on the arm rest of the wheelchair was incorrectly placed. The resident advised the RN that GNA#10 placed the…

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

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure that a resident medication was administered as ordered as evidence by delayed administration of insulin. This was found to be evident for 1 (Resident #321) out of 4 residents reviewed for insulin administration. The findings include: According to the Centers for Disease Control Prevention (CDC) Diabetes is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. When you have diabetes your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. During observation of the medication administration on 04/29/2022 at 8:49 AM, the Licensed Practical Nurse (LPN) #23 stated that Resident #321's blood glucose level at 7:30 AM was 204 but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of an airborne disease as evidenced by: 1) staff did not practice hand hygiene, and 2) staff did not wear a face mask appropriately. This was found to be evident for 3 out of 3 staff observed during a facility tour. The findings include: According to the Centers for Disease Control Prevention (CDC) COVID-19 is a respiratory disease caused by SARS-CoV-2, a coronavirus discovered in 2019. The virus spreads mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks. COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets and particles can be breathed in by other people or land on their eyes, noses, or mouth. In some circumstances, they may contaminate surfaces they touch. Wearing a well-fitting mask that covers your nose and…

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

Based on observation of all rooms on all units, the facility failed to keep a safe sanitary and comfortable environment for residents, staff and visitors by not cleaning the air-condition and heating vents (PTAC UNITS) in all rooms. This was evident for all rooms on all units. The findings include: On 4/21/22 at approximately 10 AM all rooms on all units the air-condition and heating vents (PTAC Units) were checked for cleanliness. Upon observation by all 4 surveyors in the building at the time of the annual survey, all of the vents were dirty with a buildup of black and gray substance on each vent surface that looked like thick mold and dust. This deficient practice was noted in rooms with residents requiring mechanical ventilation and were respiratorily compromised. Therefore, having the potential to jeopardize the already compromised respiratory status of the vulnerable resident by the residents breathing in soiled and contaminated air. On 4/21/22 at approximately 11 AM, the Maintenance Director, # 8, was called to the conference room to discuss this with the surveyors. Staff # 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility staff failed to: 1) follow the Health Care Decisions Act when determining a surrogate decision maker, 2) Notify a resident's guardian when a new MOLST form was created, 3) Properly void an old MOLST form when a new one was created, and 4) Complete incapacity forms in a timely manner. This was evident for 6 (Residents #46, #53, #68, #75, #100, #422) of 6 residents reviewed for advance directives during an annual recertification survey. The findings include: 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. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician…

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, it was determined that the facility failed to provide a safe environment for staff, residents and the public by not maintaining a safe desk top and counter top on the 200 and 300 Halls nurses station. The findings include: During the initial tour of the 200 and 300 Halls on 09/12/18, the surveyor observed that the nurses station upper countertop and the nurses station desk top areas were in disrepair. Broken laminate on both the upper table top and the desk top were observed in disrepair with sharp edges. The facility staff must take steps to maintain a safe environment for residents, staff, and the public.

Based on observation, it was determined that the facility staff failed to provide a dignified environment for a resident. This was evident for 1 (Resident #53) of 2 residents reviewed for dignity during an annual recertification survey. The findings include: During an initial tour and observation of the 200-Hall nursing unit on 09/12/18 at 8:45 AM, the surveyor observed Resident #53 lying in bed with a strong odor of urine in the room. This was again observed on 09/12/18 at 12:45 PM. The facility staff must take steps to provide each resident with a dignified existence.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during the annual survey the facility failed to provide housekeeping services in order to maintain a sanitary, safe, orderly, and comfortable environment. The findings included: During initial environmental rounds on 9-17-18 at 10:00 AM and confirmed by the facility Administrator in training the following was found: room [ROOM NUMBER] has no cove base in the right corner by the bathroom and had a buildup of debris. The pressure relieving mattress' tubing covers were visibly stain with large spills and the motor had one missing hook to hold it on the footboard of the bed. The resident oxygen concentrator had spills and dust and the left bedrail had noticeable dried brown spills and old tape. The second environmental rounds on 9-19-18 at 11:00 AM found the following: 1. room [ROOM NUMBER]A wheelchair with debris and left arm rest torn and jagged. 2. room [ROOM NUMBER] A and B had scraped paint and gouges out of the wall behind the beds. 3. room [ROOM NUMBER]B wheelchair had…

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

Based on medical record review it was determined the facility staff failed to notify the resident and/or the resident's representative(s) in writing the reason for a transfer to the hospital. This was evident for 1 of 43 sampled residents selected for review. Resident #100 was affected by the deficient practice. The findings include: Resident #100 has resided in the facility since December of 2012. The resident's medical record was reviewed on 9/13/18. Medical record review revealed that on 7/3/18 the nurse documented in the progress notes that Resident #100 was assessed with altered mental status and hypotension. The Nurse Practitioner was notified and gave an order to transfer the resident to the hospital emergency department. The nurse documented that the resident's representative was notified of the transfer, and the bed hold policy was sent with the resident at the time of the transfer. Medical record review revealed that there was a copy of a Reservation Agreement dated 7/4/18 that described the facility's bed hold policy and reservation agreement that was sent with 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 staff interview, it was determined that the facility failed to screen a resident (#85) to determine if the resident had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 1 of (Resident #85) of 4 residents reviewed for pre-admission screening and resident review (PASARR) requirements during an annual recertification survey. A review of Resident #85's medical record on 09/17/18 revealed a psychiatric assessment, dated 03/20/18, that indicated that Resident #85 was suffering from a Bipolar I disorder. This was, also, reflected in the 05/18/18 Minimum Data Set (MDS) assessment under section, active diagnoses, section I 5950 the box was checked ,yes, for an identified psychiatric disorder. In an interview with the facility Social Worker on 09/19/18, the facility Social Worker stated that Resident #85 should have had a PASARR screen after the facility psychiatrist diagnosed Resident #85 with Bipolar I disorder back in March 2018. The facility staff failed to take steps to screen 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, it was determined the facility failed to develop a baseline care plan for a resident within 48 hours of readmission to the facility. This was evident for 1 (Resident #105) of 43 residents reviewed during an annual 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. Review of Resident #105's medical record on 09/20/18 revealed that Resident #105 was readmitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a baseline care plan was developed within 48 hours of admission. Further review of Resident #105's medical record revealed a baseline care plan and assessment was initiated on 08/20/18. The facility staff must take steps to initiate a baseline care play within 48 hours of a resident's admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and medical record review it was determined the facility staff failed to ensure that residents received the necessary services to maintain good grooming. This was evident for 3 of 43 sampled residents selected for review. Resident #7, Resident #41 and Resident #100 were affected by the deficient practice. The findings include: Observation of Resident #7 on 9/13/18 at 1:00 P.M. and 9/18/18 at 10:30 A.M. revealed that the resident's fingernails were soiled, jagged and in need of trimming. Review of the resident's Minimum Data Set (MDS), dated [DATE], revealed that the resident needs extensive assistance with activities of daily living, including hygiene. Observation of Resident #41 on 9/13/18 at 1:31 P.M. and 9/18/18 at 2:00 P.M. revealed that the resident's fingernails were soiled, had chipped nail polish on them and were in need of trimming. Review of the resident's Minimum Data Set (MDS), dated [DATE], revealed that the resident needs extensive assistance with activities of daily living,…

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 the facility staff failed to provide adequate activities as indicated on the MDS assessment for a resident (#27). This was evident for 1 of 43 residents selected for review during the survey process. The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. MDS assessments are completed upon admission, quarterly and for any significant change in condition. Categories of MDS are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use 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, observation and interview, it was determined the facility staff failed to provide care which promoted the highest practicable well-being for Residents (#71 and #103). This was evident for 2 of 43 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to hold blood pressure medication for Resident #103 for Systolic Blood Pressure (SBP) readings under 160, as ordered by the Physician. The Systolic Blood Pressure is the top number which refers to the amount of pressure in the arteries during the contraction of the heart muscle. Review of the medical record on 9/18/18 at 2:35 PM for Resident #103 revealed a Physicians order written on 5/17/17 for Hydralazine HCL 25 milligrams (mg) (A medication used to control elevated blood pressure) 1 PO (by mouth) every 8 hours. Hold for SBP less than 110 or HR (Heart rate) Less than 60. Review of the Medication Administration Record (MAR) revealed Hydralazine HCL 25mg was administered on 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 resident and staff interview and reviews of a medical record, it was determined the facility nursing staff failed to document a skin assessment for Resident #105 upon readmission to the facility. This failure to complete a skin assessment for Resident #105 upon readmission on [DATE], lead to the development of a stage III sacrum wound and bilateral heal wounds that were not being treated for 3 days after readmission. This was evident for 1 (Resident #105) of 6 residents reviewed for pressure wounds during an annual recertification survey. The findings include: In an interview with Resident #105 on 09/12/18 at 1:46 PM, Resident #105 stated that s/he had a pressure wound on his/her buttock area and that it has been there for at least 2 weeks. Resident #105 stated that s/he did not know the condition of the wound but that his/her family member was aware. Pressure wound means an inflammation, sore, or breakdown of tissues overlying a bony prominence that has been subjected to pressure, friction or shear.…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to: 1) take steps to maintain emergency equipment by a resident's bedside, and 2) administer oxygen as ordered by the physician. This was evident for 2 (Resident #73, #92 ) of 6 residents reviewed for proper respiratory care during an annual recertification survey. The findings include: 1) During an observation of Resident #73 on 09/12/18 at 12:05 PM, the nurse survey asked Respiratory Therapist (RT) #1 to show were the staff keep a spare tracheostomy tube for Resident #73. RT #1 stated that Resident #73 currently uses a #6 tracheostomy tube. RT #1 checked and was only able to show that Resident #73 had a #4 size replacement tracheostomy tube at the bedside. A review of the facility policy for Tracheostomy Management revealed that the facility staff are to keep a replacement tracheostomy tube and a one size smaller tracheostomy tube at a resident's bedside. The facility staff failed to maintain the required items needed at Resident #73's bedside for emergency tracheostomy care. 2.…

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

Based on medical record review it was determined the facility staff failed to appropriately address the Consultant Pharmacist's recommendations in a timely manner. This was evident for 1 of 43 sampled residents selected for review. Resident #71 was affected by the deficient practice. The findings include: Medical record review on 9/13/18 revealed that Resident #71 had a physician's order for a lidocaine patch 5% to be applied to the resident's right knee. The patch is used for the treatment of pain to an affected area. A lidocaine patch is applied to the skin and should only be left on up to 12 hours within a 24 hour period. Medical record review revealed that on 7/3/18 the Consultant Pharmacist reviewed the resident's medication regimen. The Consultant Pharmacist noted that there was only a place to sign for the time of application and recommended documenting on the medication administration record when the patch is removed. Medical record review revealed that 6/25/18 through 7/13/18 staff documented on the medication administration record (MAR) that the lidocaine patch was applied…

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 upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine dental care. This was evident for 1 of 43 residents (#107) selected for review during the survey process. The findings include: 1. During interview with Resident #107 on 9/13/18 at 12:27 PM, his/her teeth did not appear to be clean. Resident #107 was unable to communicate if s/he had received oral care that morning. Observation of the Resident at that time revealed that the resident has what appears to be decayed teeth brown in color. Review of Resident #107's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including but not limited to: Intermittent confusion; Dysphagia (difficulty swallowing); Cardiovascular Accident x 6 (CVA or stroke), Vascular dementia. A nursing Admission/note assessment was completed on 8/18/18 and the facility staff stated that Resident #107 has his/her own teeth. The facility staff…

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

Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents (#50, #67 and #116). This was evident for 3 of 43 residents reviewed in the annual survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #50's medical record on 9-18-18 at 8:30 AM revealed no current September orders were printed and placed on the record. The orders were for August. 2. Review of Resident #67's medical record on 9-17-18 at 11:30 A.M revealed no current September orders were printed and placed on the medical record. The orders were for August. On 9-18-18 at 9:30 AM the facility Administrator confirmed that Resident's #50 and #67 were without current orders on the medical record. 3. Review of Resident #116's medical record…

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 of facility staff and medical record review it was determined the facility staff failed to ensure that a procedure was in place for adequate surveillance of infections and infectious organisms and failed to ensure that residents' toothbrushes were stored in a manner to prevent contamination. This was evident for 2 Residents (#71 & #107) of 43 residents reviewed in the annual survey. 1. Review of the facility's surveillance activities revealed that the facility did not have a procedure that would enable the facility to adequately identify and track infections and infectious organisms. The findings include: On 9/19/18 review of the pharmacy order listing report for antibiotics revealed that during the month of September a resident was being treated with an antibiotic for osteomyelitis and a resident was being treated with an antibiotic for a possible clostridium difficile infection. Review of the facility's September line listing of residents being treated for infection revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during the annual survey the facility failed to have firmly secured handrails on the corridor walls. The findings included: 1. On 9-17-18 at 9:30 AM the hand railing by the staff bathroom on Unit One and the hand railing by the men's shower room on Unit One were loose and not securely affixed to the wall. This finding was confirmed with the Administrator in training on 9-17-18 at 9:59 AM. 2) The following hand rails were observed to be loose or in disrepair during the annual recertifiction survey: outside the Seaside staff rest room and outside room [ROOM NUMBER].