Chesapeake Shores Nursing Center

Based on observation, interview, and documentation review it was determined that the facility staff failed to 1) ensure the dish washing machine was operating at the appropriate water temperature and sanitation levels, and 2) failed to ensure food has reached proper final internal cooking temperatures and/or all hot foods are held at 135 degrees Fahrenheit or higher on the steam table. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. This was evident during random kitchen inspection/observations of food service conducted during the recertification survey. The findings included. 1) On 5/2/24 at 2:05 PM, observation of the staff and dish washing machine were initiated at 2:05 PM. The facility's dish machine was an Ecolab model ES-2000 single rack low temperature machine with chemical sanitation. The manufacture's plaque on the machine revealed that the minimal wash and rinse temperature was to be 120 degrees Fahrenheit (F). Review of the current Dish machine log indicated that the water temperature and chemical sanitation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensure call devices were accessible to residents. This was evident 1) for 1 resident room (room [ROOM NUMBER]-B) and 2) for all residents' bathrooms and facility shower rooms, during the initial resident screening and nursing unit observation of the recertification survey. The findings include: 1) On 5/1/24 at 10:17 AM the surveyor observed resident #35 sitting in a recliner in their room resting. The call device was plugged to the wall but was not within reach of the resident. The resident was asked if s/he had an alternate call device anywhere beside them and s/he said no. The resident was asked how they call for assistance without the call device. The resident stated that s/he uses the call device but sometimes staff would put it out of reach, which makes it difficult to call sometimes so would yell out for help instead. Staff #7, an activity director walked into the room on 5/1/24 at 10:26 AM while the surveyor was still…

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 staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 3 residents (Resident #74, #43, and #89) of 5 residents reviewed for pain during the recertification survey. The findings include: A pain scale is a numerical scale, usually 0-10, used to rate a person's severity of pain. 1) On 4/30/24 at 1:19PM during the initial interview, Resident #74 was asked if s/he had pain and how that was managed. Resident stated that they were on pain medication and would ask for it before their pain level gets too high 10/10. Review of the physician's order on 5/6/24 at 10:00 AM revealed an order written on 3/23/24 as Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug *Give 1 tablet by mouth every 4 hours as needed for PAIN and Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for PAIN. Further review did not reveal a pain scale to determine at what pain level each medication should be given. Review of Resident #74 January 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 resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 10 (#4, #23, #24, #30, #43, #45, #56, #72, #82, #289) of 19 residents selected in the final sample and a failed test tray was identified on the unit that was served last. The findings included: Upon initiation of the survey on 4/30/24 random food complaints from residents included: Interview of Resident #56 at 10:59 AM was asked about the food and responded, It's not that good and needs seasoning. Resident #56 was unaware of an alternative menu. At 11:09 AM Resident #23 indicated food is bland sometimes. At 12:50 PM Resident #24 indicated the food is nasty, some days it is okay and some days it's not. At 1:36 PM Resident #30 indicated, the food is bad, does not look or taste appetizing, overall food is bad, they don't give you choices, don't get milk any more. The following residents' comments occurred on 5/01/24 when asked about 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 and staff interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by failing to serve all residents at the same table at the same time during dining observations. This was evident for 1 of 40 residents observed during the survey (resident #83). The findings include. On 5/9/24, observations of the lunch time lunch meal service in the Potomac dining room were initiated at approximately 12:10 PM. The lunch cart was already in the dining room and the Social worker (staff #2) and the A-wing unit manager (staff # 15) were delivering meals to the residents in the dining room. At 12:15 PM resident #83 was noted to be sitting at a table without lunch, and the other two residents on each side of resident #83 had their lunch. The unit manager was assisting and feeding one of the two residents seated at the table with resident #83. At approximately 12:25 PM staff #15 requested staff #2 to check on resident #83's lunch. The social worker was able to retrieve a lunch tray from the kitchen and served resident #83's lunch at 12:30…

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 clinical record review and staff interviews, it was determined the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 2 residents (Resident #71, #74) of 5 residents reviewed for advance directives during the recertification survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. 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…

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, it was determined that the facility failed to ensure that residents care areas and furniture were kept in good repair. This was evident for 1 resident's bedroom area (Resident #290) and for 1 shared bathroom (room [ROOM NUMBER]/223 shared bathroom) during the initial observation of residents' rooms during the recertification survey. The findings include: 1) On 5/3/24 at 11:41AM an observation of Resident #290's room revealed a nightstand beside the resident's bed that appeared to be in disrepair. The Plastic veneer on the four edges surrounding the top of the nightstand were completely off on one side exposing the rough wood. The other 2 sides of the nightstand were partially peeled off with the Plastic veneer sticking out. The bottom drawer was hanging out of the nightstand and the edges were half peeled off. The wall at the head of the resident's bed was observed with spackled areas measuring about 1x2 foot long. In an interview with Resident #209 on 5/03/24 at 11:45…

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 orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 resident (Resident #76) of 4 residents reviewed for transfer to the hospital. The findings include. Review of Resident #76's medical record on 5/01/24 at 7:47 AM revealed an einteract SBAR Summary note dated 4/06/24 for 4:55 PM indicating the resident had a fall and a recommendation to transfer the resident to the hospital. The health Status Note that followed indicated the resident was sent out to the hospital for a fall. Review of the einteract note and the health Status note did not document what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why. An interview was conducted with the unit manager (staff #18) on 5/07/24 at 10:35 AM with a discussion related to progress note documentation of resident #76's fall on 4/6/24. The note did not indicate if the fall was observed or where 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 record review and interview, it was determined that the facility failed to code accurately for the discharge status of a resident on the Minimum Data Set (MDS) assessment. This was evident for one (Resident #87) of three residents reviewed for discharge during the annual survey. The findings include: Minimum Data Set: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, forming the foundation of a comprehensive assessment. On 5/02/24 at 12:35 PM, during an annual survey process, the program selected Resident #87 for a closed record review about hospitalization. The surveyor reviewed electronic medical records for Resident #87 on 5/02/24 at 2:05 PM. The progress note written by a registered nurse (RN #33) on 3/01/24 at 10:24 AM said, Patient d/c (discharge) home with 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 interviews it was determined that the facility failed to provide residents with baseline care plans. This was evident for 1 resident (Resident #82) of 5 residents reviewed for urinary catheters/urinary tract infections. The findings include: On 5/09/24 at 9:24 AM a clinical record review for Resident #82 was conducted. The resident's record lacked any documentation that a baseline care was reviewed and provided to the resident. on 5/09/24 at 10:20 AM the surveyor asked the Business Office Manager, Staff #22, who was also responsible for access and management of the facility's electronic medical record, for a copy of Resident #82's baseline care plan. On 5/09/24 at 10:45 AM in an interview with Staff #22 and the facility's Minimum Data Set (MDS) nurse (Staff #8), a printed copy of Resident #82's care plan was provided. When asked for evidence that the baseline care plan was provided to the resident within 48 hours of admission to the facility, they said they would look for that evidence and get back to me. On 5/09/24 at 11:03 AM in an interview with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 1 resident (Resident #71) of 5 residents reviewed for unnecessary medications, and for 1 resident (Resident #191) of 1 residents reviewed for falls 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. An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident for 1 resident (Resident #82) of 1 residents reviewed for respiratory care and 1 resident (Resident #76) of 1 residents reviewed for dementia during the recertification survey. The findings include: 1) On 5/02/24 at 8:37 AM Resident #82 was observed seated on his/her bed. The resident was alert, conversant, and denied having any active infection, distress, or diarrhea. The resident was not connected to any intravenous device, and none was observed in the resident's room. On 5/09/24 at 10:27 AM a record review of Resident #82's care plan revealed current active problems for dehydration or potential fluid deficit r/t Poor intake/diarrhea initiated on 3/14/24 and revised on 3/18/24. The associated interventions/orders included administer 2 liters IV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint, medical record review, and interview it was determined that the facility failed to ensure 1) staff properly assessed a resident on admission, and 2) staff monitored a resident's blood sugars . This was evident for 2 residents (Residents #347 and #24) of 40 residents reviewed during the recertification/complaint survey. The findings include: 1) A rectal probe is a thin, long wire that monitors the internal body at a safe rectal temperature. In a review of a facility self-reported incident, MD00201894, on 5/06/24 at 10:02 AM, facility staff found Resident #347 had a rectal probe wire attached to his/her sacral dressing on 1/24/24. Further review of the facility's investigation revealed that a Geriatric Nursing Aide (GNA #39) had written a statement on 1/30/24, On 1/22/24, I was changing [Resident #347], and I saw a patch on his/her bottom, and I just figure it was something that was supposed to be there. So I was very careful when cleaning him/her cause I figure it was supposed to be there.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to provide appropriate care to residents with pressure ulcers. This was evident for 1 resident (Resident #349) of 4 residents reviewed for pressure ulcers during the recertification survey. The finding include: A pressure ulcer, also known as a pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 5/02/24 at 10:28 AM during 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, medical record reviews and staff interviews it was determined that the facility failed to provide appropriate treatment, care, and services to residents with a urinary catheters. This was evident for 2 residents (Resident #19 and Resident #93) of 5 residents reviewed for urinary catheter or UTI during the recertification survey. The findings include: 1) On 4/30/24 at 11:31AM, during the initial assessment, the surveyor observed that Resident #19 had a Urinary Catheter, a device that drains urine from the bladder. The resident said they've had it for about 1-2 years and that the nurses and the Geriatric Nursing Assistants (GNA) are responsible for providing care associated with this device. Review of the physician's order on 05/03/24 at 08:20 AM revealed an order written on 3/17/24 as Foley Catheter: Obtain output every shift. and on 3/29/24 Enhanced Barrier Precautions. every shift. Further review did not yield any further orders associated with catheter care/ management. A review of the January 2024 Treatment Administration Record (TAR) on 5/03/24 at 8:30 AM…

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

Based on complaint, reviews of a closed electronic record, and staff interview, it was determined that 1) the nursing staff failed to obtain a physician's order for a specific diet, 2) notify a resident's physician when the nursing staff performed a daily concurrent review and a resident was not eating or consuming liquids, and 3) initiate a nutritional care plan to address a resident's history of choking. This was evident for 1 (Resident #339) of 40 residents reviewed during the survey process. The findings include: Review of complaint MD00175602 on 05/14/24 revealed an allegation Resident #339 left in his/her room, alone, and was unable to feed himself/herself. The complainant alleged Resident #339 was blind, severely sick, and needed 24-hour nursing care. In an interview with the complainant for complaint MD00175602 on 05/14/24 at 8:40 PM, the complainant stated that Resident #339 was his/her in-law and that Resident #339 had passed away at home 2 years ago. The complainant stated that Resident #339 was had been on hospice but after being admitted to the facility s/he would cry…

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 review of Geriatric Nursing Assistant (GNA) employee records and staff interviews, it was determined the facility failed to conduct and/or record yearly performance reviews at least every 12 months. This was evident for 3 (GNA #38, #39, and #40) out of 3 GNAs' employee files reviewed during this survey. The findings include: On 5/07/24 at 10 AM, the surveyor requested randomly selected three GNAs' employee file facility GNAs. A review of these records revealed that GNA #38 and #39 were hired in July 2020. There was only one performance evaluation in 2023; no other documentation was recorded. GNA #40 had been working in this facility for more than thirty years. Only one performance evaluation was conducted in 2023, and no additional evaluation was documented. On 5/08/24 at 10:08 AM, in an interview with the Nursing Home Administrator (NHA), she stated since GNAs had been working with the previous company, their evaluation (including performance review) should be filed in their system. The surveyor requested three GNAs' (#38, #39, and #40) yearly evaluation records from…

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 review of the medical record and interview with staff, it was determined that the facility staff failed to ensure narcotics removed from the resident's supply were administered to the resident, as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the drug was administered to the resident. This was evident for 2 residents (#74, and #89) of 5 residents reviewed for pain management during the annual survey. The findings include: Acetaminophen/codeine (acetaminophen-cod #3) is a member of the narcotic analgesic combinations drug class and is commonly used for Cough, Osteoarthritis, and Pain. Opioid (also known as narcotics) pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and be able to reconcile administered doses of opioids with evidence of that medication's dispensation. A controlled medication utilization record (known as a count…

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

Based on record review and staff interviews, it was determined that the facility failed to properly store a patient's medication. This was evident for 1 (Resident #345) of 4 residents reviewed for personal property during an annual survey. The findings include: On 5/06/24 at 5:12 PM, the surveyor investigated the facility's self-report, MD00196024, about Resident #345's medications (Alprazolam: psychotropic medication for anxiety and panic, also known as Xanax), which were brought from home upon admission were taken by a former employee (Registered Nurse #46). Further review of the facility's investigation revealed that the facility obtained two written statements from Staff #47 and #48 about the incidents. Staff #47 wrote a statement on 8/24/23: Staff #48 didn't feel comfortable having Alprazolam in her cart without a count sheet, and she was told to give them to RN #46 to return to the family upon discharge. We were unable to find the medications, so we called RN #46 to ask about the location of the meds. RN #46 found the medications in her belongings that were taken out of her…

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 resident and staff interview it was determined that the facility failed to document a resident's likes and dislikes and failed to provide supplemental dietary sandwiches. The was evident for 1 resident (Resident #56) of 19 residents selected in the finalized sample during the recertification survey. The findings include. 1) Resident #56 was interviewed on 4/30/24 at 11:00 AM. Resident #56 was asked about the food provided by the facility and he/she responded that the food is not good and it needs seasoning. Resident #56 indicated that he/she did not have a menu and was unaware of alternative diets. When asked if resident #56 had any dislikes the resident responded, green peas are the worst. A follow-up interview was conducted with Resident #56 at 1:05 PM on 4/30/24. There were peas on the lunch plate. Review of Resident #56's paper meal ticket indicated that Peas were substituted for squash Medley. The ticket did not reveal any likes or dislikes. Resident #56'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 medical record review, interviews, and observations, it was determined that the facility failed to 1) make electronic medical records available to the survey team and 2) maintain complete and accurate medical records. This was evident for 4 residents (Residents #4, #74, #90, and #339) of 40 residents reviewed during the recertification/complaint survey. The findings include: 1) During a review of Complaint MD00175602 on 05/14/24, the nurse surveyor was given access to the Matrix Care electronic medical record to perform a chart review. A username and password were obtained from the survey team leader. There were no issues accessing Resident #339's closed medical records on 05/14/24. A request for any paper chart records for Resident #339 was also requested on 05/14/24. In an interview with the facility BOM (business office manager) on 05/14/24 at 2:00 PM, the BOM stated that s/he was unable to locate any thinned/closed paper records for Resident #339 since the facility had been purchased by another…

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

Based on observation, medical record review, and staff interviews, it was determined that the facility failed to utilize appropriate infection control processes when handling 1) a resident's personal pillows (Resident #19), and 2) residents' linen in the laundry room. This was evident during the investigation of the facilities infection control process during an annual survey. The findings include: 1). On 5/1/24 at 10:48 AM The surveyor walked into Residents #35's room and observed the resident sitting in a recliner next to their bed. The resident's bed was not made and two personal pillows in a flower-patterned pillowcase were observed on the bare floor by the walls, to the right, one on top of the other. While the surveyor was still conducting an interview with the residents, Staff #34 a Geriatric Nursing Assistant (GNA) came into the resident's room and proceeded to make the residents bed. After she was done, she was asked if the pillows on the floor belonged to the resident and why they were left there. She said she did not know if it belonged to the resident. She, however,…

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 interviews, it was determined that the facility staff failed to show proof that some residents in the facility and/or their Responsible Party (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines or that the vaccines were consented to and administered in the current year. This was evident for 2 (Resident #19, #30) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United…

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 ensure resident bed rails were safely maintained. This was evident for 1 resident (Resident #36) of 19 residents reviewed during the recertification survey. The findings include: On 5/07/24 at 3:44 PM an observation of Resident #36's bed was conducted. There was no one present in the semi-private room. Resident #36's bed had quarter side rails. The surveyor was able to grab the siderails which pulled easily away from the bed and the surveyor's arm was able to be placed in between the rails and the mattress and bed frame. On 5/07/24 at 3:57 PM a review of Resident #36's clinical record revealed an order dated 12/08/22 for 1/4 top bilateral side rails as enablers. On 5/07/24 at 3:57 PM an interview with the facility Maintenance Director, Staff #49 was conducted. He explained that resident beds were inspected routinely, and that he does visual inspections every day. When asked how often the bed rails are checked, he stated every day. Staff #49 and the surveyor sent to Resident #36's room and Staff #49…

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 review of facility records, interviews with facility staff, and interviews with residents, it was determined that the facility staff 1) failed to ensure that all allegations of abuse, medication storage issues, and unusual incidents were thoroughly investigated and 2) failed to provide interventions to avoid repeated allegations. This was evident for 4 residents (Residents #36, #343, #345, #347) of 18 reported resident incidents reviewed during the survey. The findings include: 1) On 4/30/24 at 10:00 am during the entrance conference of the recertification survey, a request for the facility's investigation files for self-reported incidents was made to the Nursing Home Administrator (NHA). On 5/08/24 at 9:04 AM a review of the facility reported incident # MD00188190 dated 1/24/23 was conducted. The report described the discovery on 1/23/24 of a bruise on Resident #36's arm and an allegation by Resident #36 that a black male GNA had hit the resident a few days before. On 5/08/24 at 9:15 AM a review of the facility's investigation file for #MD00188190 revealed witness…

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 provide behavioral health monitoring for residents. This was evident for 1 facility reported incident (#MD00193233) of 18 facility reported incidents reviewed during the recertification survey. The findings include: On 5/08/24 at 3:11 PM a review of the facility reported incident #MD00193233 dated 6/07/23 was conducted. The report described staff witness of inappropriate physical contact with his/her genitals by Resident #61 to Resident #341's person. Further review of the facility's investigation report revealed that Resident #61 had a history of sexually inappropriate behavior prior to the incident and that staff were aware. On 5/08/24 at 3:22 PM a review of Resident #61's medical record revealed a lack of behavior monitoring documentation for any part of June 2023, although there were clinical notes that described the resident's behavior. On 5/09/24 at 1:37 PM an interview with Unit Manager (Staff #15) was conducted. He said that resident behavior issues were discussed in the facility's weekly…

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

Based on observation, medical record review and staff interview it was determined the facility failed to obtain a physician's order for the use of an upper body wheelchair harness for Resident #61. This was evident for 1 of 31 resident's reviewed during the survey. The findings include: On 5/14/19 at 10:31 AM, Resident #61 was observed sitting in a custom wheelchair and wearing an upper body harness and seat belt. On 5/16/19 beginning at 11:43 AM, the medical record for this resident was reviewed. An Informed Consent for Use of Restraints signed on 3/23/18 by the Responsible Party and Facility Representative documented the reason for the 4-point upper body harness was for proper positioning in the wheelchair and is to be released and the resident checked and repositioned every 2 hours when out of bed and in the wheelchair. At 3:44 PM when Unit Manager (UM) #2 was interviewed, she confirmed that the resident was able to self-release from the seat belt but could not release the harness without assistance and that nursing staff were checking and repositioning the resident every 2 hours…

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

Based on observation and staff interview it was determined the facility failed to ensure that items used for personal hygiene were appropriately labeled and stored in a bathroom shared by Residents #64; #38; #15 and #158. This was evident for 4 of 31 residents reviewed during the survey. The findings include: On 5/14/19 at 10:34 AM the bathroom shared by Residents #64; #38; #15 and #158 was inspected. On a shelf in the bathroom shared by these 4 residents, a washbasin that was labeled for Resident #64 was found stacked inside a washbasin labeled for Resident #38, and an unlabeled bedpan was inside the top washbasin. Another unlabeled bedpan inside a plastic bag was also on the shelf and had been placed inside another unlabeled washbasin. It is a minimum standard of nursing practice that when residents share a room, items used for personal hygiene must be labeled and/or stored separately to prevent potential cross-contamination of infections. The findings were confirmed by Unit Manager #2 and the Director of Nursing.

Based on medical record review and interview with the Director of Nursing DON) the facility failed to provide a care plan for Resident # 52 going out to the hospital. This was evident for 1 out of 31 residents reviewed. The findings include: On 2/16/19 Resident # 52 had a fall not witnessed. He was found on the floor mat face down with head stuck between bed and chair. The resident was transferred to the hospital at 11:30 PM on 2/16/19 and was admitted to the hospital for Aspiration Pneumonia. Resident # 52 returned to the facility on 2/21/19. Family and Dr. were made aware. All transfer paperwork was sent to the hospital with the resident except for a copy of the care plan.

Based on observations and staff interviews it was determined the required staff posting information was not in a prominent place readily accessible to residents and visitors. This was evident during the survey process. The findings include: On 5/14/19, 5/15/19 and 5/16/19 the required nursing staffing information per this regulation was observed posted in the nursing administration area of the facility facing the interior wall not visible or readily accessible to residents and visitors. On 5/16/19 at 3:00 P.M. an interview with the Administrator and Director of Nursing verified that the required staff posting was not available to residents or visitors during the survey process.