Egle Nursing Home

Based on record reviews and interviews, it was determined that the facility failed to complete the residents' Matrix accurately. This was evident during the recertification survey. The findings include:The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. The facility completes the resident name, resident room number, and corresponding care categories. All information entered on the form should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of the survey.After the initial entry to the facility for this survey on 10/1/25, the director of nursing (DON) presented a complete matrix for all the residents to the survey team.A review of the Matrix showed that there was no resident receiving end-of-life care/Comfort Care, /Palliative Care. However, a review of Resident #4's medical record included an attending provider's note dated 9/30/25, stating that Pt [patient] seen. Pt is…

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 ensure that resident records were accurate. This was evident for 1 resident (Resident #12) who had duplicate and contradictory active Medical Orders for Life-Sustaining Treatment forms of 2 residents reviewed for advance directives.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 (CPR) and other life-sustaining treatment options for a specific patient.The Maryland MOLST form includes a third page with instructions and states, in part, the MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form. Voiding the…

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

Based on record review and interview, it was determined that the facility failed to ensure that the required attendees participated in the facility's Quality Assessment and Assurance (QAA) committee meetings at least quarterly. This was evident in 8 out of 12 sign-in sheets reviewed during the survey.The findings include:A review of the sign-in sheets for the facility's Quality Assurance (QAA) Committee meetings from August 2024 to August 2025 was completed. The review revealed that meetings were held monthly. However, the review failed to show that the Nursing Home Administrator attended the meetings in November 2024, January 2025, April 2025, May 2025, and September 2025. The review also failed to show that the Director of Nursing attended the meetings in March 2025 and April 2025. An interview on 10/9/2025, at 10:51 AM, with staff #20, the current QA Nurse, and staff #6, the former QA nurse, failed to provide documentation confirming that all attendees were present in all meetings. By the time the survey ended, no additional evidence was provided.

Based on observation, interview, and record review it was determined that the facility failed to properly store clean linens. This was evident for 2 of 2 soiled laundry areas observed during the recertification survey.The findings include:On 10/02/25 at 9:44 AM an observation of the facility's laundry facilities was conducted with the Director of Housekeeping (Staff #7) and the laundry aide (Staff #8). The first area observed was the laundry room which on one side contained two washing machines (dirty area), and on the other side contained two dryers (clean area). There was no separation between the clean and dirty sides of the room. On the dirty side of the room, directly across from the washing machines was a cart with a pile of folded bed pads. When asked, Staff #7 said that they were clean and were ready to be taken to the nursing units for resident use. Staff #7 confirmed that the washing machine area was the dirty linen area in the room. Staff #8 confirmed that clean linens should not have been stored in the dirty linen area.Staff #7 and Staff #8 then showed the surveyor to…

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

Based on record review and interview it was determined that the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status. This was evident for 1 (Staff #16) of 2 staff reviewed for COVID-19 immunizations during the infection control task portion of the recertification survey.The findings include: On 10/02/25 during the entrance conference, a list of all employees was requested. Four staff were randomly selected from this list for health record review. Of the selected staff, two (Staff #10 and Staff #16) would have been eligible for the 2024-2025 version of the COVID-19 vaccine. On 10/06/25 at 2:29 PM ,a review of the health records provided by the facility for Registered Nurse (Staff #16) failed to reveal any evidence that she was screened, educated, or offered the 2024-2025 COVID-19 vaccine. On 10/07/25 at 10:38 AM, an interview with the infection preventionist nurse (Staff #5) was conducted. She stated that it was her understanding that the facility did not offer COVID vaccines to employees due to insurance reimbursement.…

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 provide full visual privacy to a resident residing in a non-private room. This was evident for 1 (Resident #4) of 1 resident reviewed for privacy.The findings include:During the initial pool process on 10/1/25 at 10:56 AM, Resident #4's room was inspected. It was observed during the inspection that the room had two occupied beds, and both were equipped with a railing system for overhead privacy curtains. However, the curtain that was used for Resident #4's bed (window side of the room), when fully extended, only covered one side and left the foot side of the bed completely open.On 10/6/25 at 10:16 AM the charge nurse for the unit where Resident #4 resided, a Licensed Practical Nurse (LPN #1) was interviewed outside the resident's room. LPN #1 was asked how staff maintain privacy when incontinence care is provided to Resident #4. She indicated that she would use the overhead privacy curtain. LPN #1 was asked to demonstrate use of the privacy curtain in Resident #4's room. As LPN #1 pulled the curtain…

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

Based on record review and interviews, it was determined that the facility failed to ensure that staff were educated on abuse. This was evident for 5 (Director of Nursing [DON] and Staff #10, #11, #12, and #13) out of 5 employee training records reviewed during the Sufficient and Competent Staffing task.The findings include: On 10/02/25 at 10:58 AM, the Surveyor reviewed the facility assessment (dated January 2025), Section 3.3 Staff Training/Education, which states:Employees at our facility require various levels of education, training, and certifications to be employed. Upon hire, the following non-exhaustive protocols are followed, which in part include that staff are, at a minimum, educated on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; the procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property; and care and management of persons with dementia and resident abuse prevention. On 10/02/25 at 2:06 PM, the Surveyor interviewed the DON and requested employee training records.…

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 reviews and interviews, it was determined that the facility failed to ensure that nurse aides received in-service education that included dementia management and abuse prevention. This was evident for 2 (Staff #12 and #13) out of 5 staff reviewed under the Sufficient and Competent Staffing task.The findings include:Regulatory guidelines require that nurse aides receive a minimum of 12 hours of in-service education annually. These in-services must include training in dementia management and abuse prevention.On 10/02/25 at 10:58 AM, the Surveyor reviewed the facility assessment (dated January 2025), Section 3.3 Staff Training/Education, which states: Employees at our facility require various levels of education, training, and certifications to be employed. Upon hire, the following non-exhaustive protocols are followed, which in part include: Abuse, neglect, and exploitation training that at minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it was determined that the facility staff 1) failed to properly store food items in the kitchen's walk-in refrigerator, and 2) failed to have a process in place to determine the expiration date of food procured from vendors. This was evident during the initial tour of the kitchen and had the potential to affect all residents. The findings include: On 4/30/24 at 10:35 AM, accompanied by Staff #7, Certified Dietary Manager (CDM), an initial tour of the kitchen by two surveyors identified the following concerns: 1) An observation of the kitchen's walk-in refrigerator revealed there was an uncovered, large rectangle, shallow pan that appeared to be filled with cooked food product. The uncovered pan was dated 4/30/24 and labeled 'potatoes', and there was an uncovered, large rectangle, shallow pan which appeared to be was filled with food product. The uncovered pan was dated 4/30/24 and labeled 'rice pudding'. At that time of observation, Staff #7 stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, it was determined the facility failed to review and revise resident care plans after each assessment. This was evident for 1 (#39) of 7 residents reviewed for accidents, and 1 (#45) of 5 residents reviewed for unnecessary medications. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) Bed rails are adjustable bars attached to the bed. As enablers, bedrails assist to facilitate mobility, and/or repositioning in bed. On 4/30/24 at 12:24 PM, an observation of Resident #39 lying in bed revealed bilateral bed rails attached to the resident's bed. At 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 record review, observation, and interviews, it was determined that the facility staff failed to ensure that the head of bed (HOB) was properly elevated for a resident during medication administration and infusion of a percutaneous endoscopic gastrostomy (peg) feeding. This was evident for 1 (#43) of 3 residents reviewed for tube feeding. The findings include: A percutaneous endoscopic gastrostomy (PEG) feeding tube is placed into the stomach through an opening in the stomach wall. If one cannot eat or drink all the nutrients they need, liquids such as formula, fluids, and medicines are put through the PEG tube. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A review of Resident #43's admission MDS assessment, dated 12/21/20, found that Resident #43 had a PEG feeding tube. A subsequent record review on 4/30/24 at 10:50 AM showed that a care plan, initiated on 12/31/20,had documentation that Resident #43…

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 residents, it was determined that the facility failed to treat residents with respect and dignity as evidenced by failing to knock and request permission before entering a resident's room. This was evident for 1 (#33) of 28 residents included in the resident sample. The findings include: On 5/1/24, at 9:55 AM, an interview was conducted with Resident #33. During the interview, the door to the resident's room was closed. At approximately 10:00 AM, Staff #10, Geriatric Nursing Assistant (GNA) entered Resident #33's room without knocking. On 5/2/24 at 4:11 PM, the Director of Nurses (DON) was made aware that the GNA had failed to knock on the resident's door and request permission from the resident prior to entering the resident's room. The DON responded that the Staff #10 had told her about it, and indicated the GNA was thrown off because the door to the resident's room was closed, and the door was usually kept open.

Based on record review and staff interview it was determined that the facility failed to assess a resident's cognition and mood on a comprehensive MDS assessment. This was evident for 1 (#33) of 1 residents reviewed for care planning. The findings include: The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. The Annual MDS assessment is a comprehensive assessment for a resident that must be completed annually (at least every 366 days) unless a significant change in assessment has been completed since the most recent comprehensive assessment was completed. Completion of the comprehensive annual MDS assessment, must be completed no later than 14 days after the Assessment Reference Date (ARD). 1)…

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 complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This was evident for 1 (#8) of 28 residents reviewed during the recertification survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The nursing home should complete a significant change in status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. A medical record review, completed on 5/7/24 at 1:22 PM, for Resident #8 showed that they were admitted to the facility in June 2019. Further review found a nurse's note, dated 2/13/24, that recorded that Resident was complaining of Left knee hurting. not wanting it touched.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#64 and #35) of 5 residents reviewed for unnecessary medications. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Active diagnoses documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that directly relate to the Resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 1. Medical record review on 5/6/24 at 12:05 PM found that Resident #64 was admitted to the facility in April 2024 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 1 (#43) of 3 residents reviewed for position and mobility. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. Palm Protectors offer relief from hand contractures and cramping. They are put over the thumb and around the hand, providing a cushioning pad for the fingers to curl onto. This prevents the nails from digging into the palms and keeps the fingers warm and supported. An observation was made of Resident #43 on 4/30/24 at 10:55 AM, lying in bed, unable to move his/her left hand, and having no device in place. A medical record review…

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

Based on observation, medical record review, and staff interview, it was determined that prior to the installation of bed rails, the facility 1) failed to identify and use appropriate alternatives prior to installing or using bed rails, and 2) failed to assess a resident's risk of injury or entrapment prior to installing or using bed rails. This was found to be evident for 1 (#39) of 1 residents reviewed for side rails. The findings include: Bed rails are adjustable bars that attach to the bed and are available in a variety of types, shapes, and sizes. As enablers, bedrails facilitate movement and may promote independence. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. On 4/30/24 at 12:24 PM, an observation was made of Resident #39 lying in bed 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 medical record review and staff interview, it was determined that the facility staff failed to ensure that physician progress notes were written, signed, and dated at each visit. This was evident for 2 (#45, #29) of 5 residents reviewed for unnecessary medications. The findings include: 1) On 5/7/24 at 9:59 AM, a review of Resident #45's medical record was conducted. Review of Resident #45's electronic medical record (EMR) and paper medical record revealed that physician's visit notes were not written, signed, and dated at the time of each visit. In Resident #45's EMR, there was a physician's visit progress note, dated 2/3/24 at 7:22 PM, that indicated the day of the physician visit date was 1/22/24, a physician's visit progress note dated 4/7/24 at 2:27 PM, that indicated the date of the physician's visit was 3/25/24, and a physician's visit progress note dated 5/2/24 at 8:58 AM, that indicated the date of the physician's visit was 4/22/24. On 5/7/24 at 4:35 PM, the Director of Nurses (DON) was made aware of the concerns. At that time, the DON acknowledged the concerns 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 medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records as evidenced by 1) failing to transcribe an accurate indication for use of antipsychotic medication, 2) failing to document a resident's wound evaluation in the medical record, and 3) failing to ensure that the a care plan meeting was documented. This was evident for 2 (#45, #35) of 5 residents reviewed for unnecessary medications, 1 (#45) of 2 residents reviewed for pressure ulcers. The findings include: 1) On 5/7/24 at 9:59 AM, a review of Resident #45's medical record was conducted. Review of Resident #45's May 2024 Medication Administration Record (MAR) revealed a 11/29/23 order for Seroquel (quetiapine) (antipsychotic) 25 mg (milligrams) by mouth, special instructions: dementia with psychosis, specific behaviors; paranoia, argumentative with staff, restless, repetitive calling out, once a day at 8:00 AM, and a 11/29/23 order for Seroquel 50 mg (milligrams) by mouth,…

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, observations, and interviews, it was determined that the facility staff failed to wear proper personal protective equipment (PPE) before giving direct care to a resident with a percutaneous endoscopic gastrostomy (peg) feeding tube. This was evident for 1 (#43) of 3 residents reviewed for tube feeding. The findings include: A percutaneous endoscopic gastrostomy (PEG) feeding tube is placed into the stomach through an opening in the stomach wall. It is used to give drugs and liquids, including liquid food. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of infection in nursing homes. It involves gown and glove use during high-contact Resident care activities like dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for…

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 conduct a regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure the equipment was inspected and maintained according to manufacturer's recommendations and requirements and timeframes. This was evident for 1 (#39) of 7 residents reviewed for accidents and had the potential to affect all residents. The findings include: On 4/30/24 at 12:24 PM, an observation was made of Resident #39 lying in bed. At that time bilateral bed rails were observed attached to the resident's bed. On 5/9/24 at 11:14 AM, during an interview, Staff #6, Maintenance Director, stated that all of the resident beds in the facility had bed rails attached to the bed, and when the facility bought new beds, the bed rails were already attached to the beds. When asked if the facility's regular maintenance program ensured the inspection of all bed frames, mattresses, and bed rails, Staff #6 indicated 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 observations and interviews, it was determined that the facility failed to provide full visual privacy for a resident residing in a non-private room. This was evident for 1 (Resident #268) of 25 residents reviewed during the recertification survey. The findings include: Resident #268 was a newly admitted resident of the facility residing in a non-private room with 2 beds. Resident #268 occupied bed B and his/her roommate occupied bed A. On 5/1/24 at 11:58 AM, an inspection of the privacy curtain located between the 2 beds in the room was conducted and revealed that it only extended up to the length of the beds. On 5/3/24 at 8:58 AM, a review of Resident #268's medical records indicated that s/he used a bedside commode in the room for bowel and bladder elimination. A tour of the room was conducted with the Director of Nursing (DON) on 5/3/24 at 9:45 AM. The observation was confirmed and discussed the concern that privacy curtains must extend around the bed to provide total visual privacy in combination with adjacent walls and curtains. The DON reported that the room had a…

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

Based on observation and staff interview, it was determined the facility failed to keep the walk-in freezer in the kitchen in safe operating condition. This was evident during the initial tour of the kitchen. The findings include: On 5/13/19 at 11:55 AM, during an initial tour with the Dietary Manager (DM), observation was made of the walk-in freezer. There were small mounds of ice on the ceiling of the freezer covering 1/2 of the ceiling in front of the 2 condenser fans. Surrounding the inside of the freezer doorframe was a build-up of ice/frost. The DM stated that the company that serviced the freezer would be contacted. The Nursing Home Administrator stated during the exit conference that he/she was aware of the problem and thought that a latch would be needed to correct the problem.

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 7 out of 7 personnel files reviewed. The findings include: A review was conducted of GNA personnel files on 5/15/19: 1) Review of Staff #10's employee file documented a date of hire (DOH) of 6/8/16. The last yearly review found in the personnel file was dated 8/5/17. 2) Review of Staff #17's employee file documented a DOH of 11/13/17. There was no yearly evaluation found in the personnel file. 3) Review of Staff #8's employee file documented a DOH of 2/18/16. The last yearly review found in the personnel file was dated 8/11/17. 4) Review of Staff #18's employee file documented a DOH of 4/22/15. The last yearly review found in the personnel file was dated 9/4/17. 5) Review of Staff #19's employee file documented a DOH of 3/20/18. There was no yearly evaluation found in the personnel file. 6) Review of Staff #20's employee file documented a DOH of 3/11/11. The last yearly review found in the…

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

Based on observation and staff interview, it was determined the facility staff failed to store and distribute food in accordance with professional standards for food service safety as evidenced by failing to discard expired food and by touching food with bare hands. This was evident during the initial tour of the kitchen, during 1 of 2 dining observations observed and during observation of 1 of 2 medication rooms. The findings include: 1) Observation was made on 5/13/19 at 11:55 AM, during an initial tour of the kitchen with the Food Service Manager (FSM) of (3) 6 lb. bags of brownie mix that were received in the building on 6/19/18 with an expiration date of 4/24/19 and (3) 5 lb. boxes of Buttermilk biscuit mix that had expired as of 5/1/19 that were received in the building on 6/19/18. The FSM confirmed the findings at the time of observation. 2) Observation was made on 5/15/19 at 12:16 PM of Staff #15 setting up the lunch tray for Resident #2. Staff #15 pulled a slice of bread out of the plastic bag with his/her bare hands and proceeded to butter the bread while holding the bread…

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 and facility documentation review and staff interview, it was determined the facility failed to timely notify the physician and dietician of a significant weight gain. This was evident for 1 (#29) of 6 residents reviewed for nutrition. The findings include: Review of the medical record for Resident #29 on 5/16/19 revealed that, on 3/31/19, the resident had a documented weight of 122.2 lbs. (pounds). On 5/1/19, the documented weight was 130.4 lbs. which was an 8 lb. (6.71%) gain in 1 month. Further review of the medical record revealed that the resident received a high calorie supplement (90 ml) twice per day for nutritional support at 9:00 AM and 8:00 PM in addition to a house supplement (240 ml) three times per day at 10:00 AM, 2:00 PM and 7:00 PM for nutritional support. On 5/16/19 at 9:42 AM, Staff #14 was asked about the process for taking weights. Staff #14 stated that the GNA (Geriatric Nursing Assistant) would take the weight and that either the GNA, nurse or dietary manager would enter it in the system and then tell the charge nurse. Staff #14 stated…

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

Based on medical record review and staff interview, it was determined that the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 2 (#59, #58) of 4 residents reviewed that were transferred to an acute care facility. The findings include: 1) Review of the medical record for Resident #59 on 5/15/19 revealed documentation that Resident #59 was sent to an acute care facility on 4/4/19. Review of the progress notes that documented Resident #59's transfer out of the facility on 4/4/19 did not reference an explanation of Resident #59's orientation and understanding of the impending transfer. 2) On 5/14/19 at 9:51 AM, review of Resident #58's medical record revealed that, on 3/30/19, in a progress note, the nurse documented that Resident #58 was sent to the hospital emergency room via ambulance for evaluation of his/her right foot. There was no documentation in the medical record that Resident #58 had received an explanation of the purpose of the transfer to the emergency room 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 medical record review and staff interview, it was determined that the physician failed to write a discharge summary that summarized a resident's stay and treatment received in the facility. In addition, the facility staff failed to reconcile pre and post discharge medications. This was evident for 1 (#65) of 2 closed records reviewed. The findings include: Review of Resident #65's medical record on 5/16/19 revealed documentation that the resident was admitted to the facility on [DATE] for rehabilitation following surgery and was discharged from the facility on 3/18/19. There was no physician's discharge summary found in either the paper medical record or the electronic medical record. The discharge summary is a concise summary of the resident's stay and course of treatment in the facility. There was no evidence in the medical record that pre and post discharge medications were reconciled. Medication reconciliation is a process of comparing pre-discharge medications to post-discharge medications for the…

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

Based on observation, medical record review and staff interview, it was determined the facility failed to 1) apply a physician's ordered splint to the right hand, 2) failed to accurately document the use of the brace and 3) failed to follow the care plan for splinting. This was evident for 1 (#29) resident reviewed for positioning. The findings include: Observation was made of Resident #29 on 5/13/19 at 1:28 PM. A blue splint/brace was sitting in a chair while the resident was in bed. Review of Resident #29's May 2019 physician's orders revealed the order, Rt (right) wrist splint to be on at all times; May remove for hygiene/bathing. Continued observations were made on 5/14/19 at 2:00 PM. The resident was lying in bed and there was nothing on the right hand. The blue hand splint was observed under a chair on the floor, however, a review of Resident #29's Treatment Administration Record (TAR) was signed off by the day shift nurse, as of 2:00 PM, that the hand splint was worn during that shift. At 2:20 PM, a second surveyor observed the resident to confirm the findings. On 5/15/19 at…

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 properly store medications as evidenced by failing to ensure that medication properly labeled and dated. This was evident in 1 of 2 medication rooms and 1 of 3 medication carts observed during the survey. The findings include: 1) On [DATE] at 110:30 AM, observation of the refrigerator in the second-floor medication room revealed a Levemir (insulin detemir) Flextouch insulin pen, that was labeled with Resident #40's name and not labeled with the date it was opened. Staff #12 confirmed the finding at that time. 2) On [DATE] at 10:30 AM, observation of a first-floor medication cart revealed a bottle of Lantaprost (Xalatan) 0.005% ophthalmic solution that was labeled with Resident 7's name and an opened date of [DATE], indicating the Lantaprost was expired. Per manufacturer recommendation, once a bottle of Lantaprost is opened, it may be stored for at room temperature for 6 weeks. Staff #7 was made aware of the finding at 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 observation and medical record review, it was determined the facility failed to keep accurate medical records as evidenced by nursing staff signing off that a splint/brace device was worn when it was observed to not be worn. This was evident for 1 resident (#29) reviewed for positioning. The findings include: Observation was made of Resident #29 on 5/13/19 at 1:28 PM. A blue splint/brace was sitting in a chair while the resident was in bed. Review of Resident #29's May 2019 physician's orders revealed the order, Rt (right) wrist splint to be on at all times; May remove for hygiene/bathing. Continued observations were made on 5/14/19 at 2:00 PM. The resident was lying in bed and there was nothing on the right hand. The blue hand splint was observed under a chair on the floor. At 2:20 PM, a second surveyor observed the resident to confirm the findings. On 5/15/19 at 10:33 AM, Resident #29 was observed sitting in a wheelchair in the dining room for activities. The blue splint was not on the right hand and the hand was contracted. A contracture is a condition of shortening 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.