Oakwood SNF LLC

Based on record review and interviews it was determined that the facility failed to identify and provide appropriate interventions and notifications for a resident's condition. This was found evident of 2 (Resident #63 & 4) out of 2 residents reviewed for insulin during the survey. The findings include: 1) On 2/24/26 at 10:18 AM, the surveyor conducted an interview with Resident #63. During the interview Resident #63 stated that he/she thought that he/she did not receive the right amount of insulin because his/her blood sugars were off. On 2/26/26 at 10:48 AM, the surveyor reviewed Resident #63's Medication Administration Record (MAR). The review revealed Resident #63 had an order for Humalog (fast acting insulin) 6 units ordered to be given subcutaneously with meals (to cover the carbohydrate in the meal) for diabetes mellitus. On 2/24/26 the administration was coded with 14. On 2/26/26 at 1:48 PM, the surveyor conducted an interview with the acting Director of Nursing (DON). During the interview the surveyor asked the acting DON what the code 14 meant. The acting DON stated it…

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

Based on interviews and record reviews, it was determined that the facility failed to ensure services were provided to address a resident's hearing needs. This deficient practice was evident for one Resident (#48) reviewed for hearing services during the annual survey.The findings include:On 02/24/2026 at10:39 AM, during an interview, Resident #48 reported that they had requested a hearing screening some time ago; however, the resident stated that the request had not been addressed and they were still waiting to receive a hearing test.A review of Resident #48's medical records on 2/26/2026 at 12:06 PM failed to reveal documentation of a hearing screening appointment or consultation.On 02/27/26 at 12:51 PM, during an interview with the Director of Nursing (DON), the surveyor inquired about outside consultants used by the facility to assess resident's hearing, vision, and dental needs. The DON reported that the facility uses a company consultant service. The surveyor informed the DON of resident #48s concern. The DON stated that she would investigate the matter and follow up 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 observation, medical record review and interviews, it was determined the facility staff failed to clarify appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #74) of 1 resident reviewed for mobility. The findings include: A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing the resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. On 2/24/26 at 9:38 AM, the surveyor observed Resident #74 resting in bed and noted his/her left hand was contracted. On further observation the surveyor noted a hand splint was on the bedside table next to the resident's bed. On 2/26/26 at 11:20 AM, again the surveyor observed Resident #74 in bed and the hand splint on the bedside table. On 2/26/26 at 11:51 AM, the surveyor reviewed Resident #74's orders. The review revealed two orders for his/her left hand splint. On 11/4/25 an order 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 observations, interviews, review of facility's policy and record review, it was determined that the facility failed to provide appropriate treatments to prevent complications for a resident who required enteral nutrition. This was evident for 1 (Resident #12) out of 1 resident reviewed for tube feeding during the survey. The findings include: Enteral nutrition, also known as tube feeding, is a way to deliver dietary needs directly to the stomach or small intestine. A gastrostomy tube or (g-tube) is used when nutrition is delivered to your stomach. A common g-tube placed is called a percutaneous endoscopic gastrostomy (PEG) tube. On 2/26/26 at 11:24 AM, the surveyor observed a bag of water handing along side resident #12's tube feeding bottle. The bag labeled H2O (water) was dated 2/23/26 and timed 2 PM. The tube feeding bottle was dated 2/25/26 and timed 11 PM. On 2/27/26 at 8:50 AM, the surveyor observed Resident #12's tube feeding bag was dated 2/27/26. However, the water bag had what appeared to be the same label as the day before except over the date a 7 was placed over…

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 with staff, it was determined the facility failed to 1) have a designated nurse supervisor/charge nurse and 2) have sufficient staff dispense medications in a timely manner. This was found to be evident during one early hour observation and during an observation of medication administration. Findings include: 1) On 3/2/26 at 6:09 AM, the surveyor asked Licensed Practical Nurse (LPN) #31 who the night shift supervisor was. LPN #31 stated that she was not sure but would ask her coworker LPN #41. The surveyor followed LPN #31 to the Nurses' station between the 500 and 100 hallways where LPN #41 was located. On 3/2/26 at 6:11 AM, the surveyor asked LPN #41 who the night shift supervisor was. LPN #41 stated she did not believe there was a nighttime supervisor last night but the day time supervisor would be in shortly. On 3/2/26 at 7:54 AM, the surveyor interviewed the acting Director of Nursing (DON). The surveyor relayed the concerns that the nighttime staff was unaware of who…

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 post all of the required staffing information on a daily basis. This was evident on 1 out of 6 days on the survey. The findings include: On 3/2/36 at 6:06 AM, the surveyor observed the Plexiglas tray on the front desk empty. On the previous days of the survey this tray had staffing hours posted. On 3/2/26 at 6:09 AM, the surveyor asked Licensed Practical Nurse (LPN) #31 who the night shift supervisor was. LPN #31 stated that she was not sure but would ask her coworker LPN #41. The surveyor followed LPN #31 to the nurses' station between the 500 and 100 hallways where LPN #41 was located. On 3/2/26 at 6:11 AM, the surveyor observed the whiteboard in the nurses' station, where the assignments had been posted during the other days of the survey, and noted it was blank. The surveyor asked LPN #41 if the assignments should be posted on the board. LPN #41 stated that the board was wiped clean so the unit clerk could put up the new assignment. The surveyor asked if the unit manager was on…

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

Based on observations, record reviews, and interviews, it was determined that the facility failed to administer medications according to procedures that ensure accurate dispensing. This was evident for 1(Resident #82) out of 4 residents reviewed for medication administration. The findings included:On 3/2/26 at 8:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #82. During the preparation LPN #5 pulled Resident #82's bupropion hydrochloride extended-release oral tablet 150 MG (antidepressant) and placed one tablet into the medication cup with Resident #82's other medications. Next the surveyor observed LPN #5 administer the medications to Resident #82. Next the surveyor reconciled the medications administered observation to Resident #82's medication orders. The review revealed Resident #82 had an order for 3 tablets of bupropion hydrochloride extended-release oral tablet 150 MG with instructions to give that dose once a day. On 3/2/26 at 1:14 PM, the surveyor conducted an interview with LPN #5. During the interview the surveyor reviewed…

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 the clinical record and staff interview, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed an unnecessary duplicate order for medication. This finding was evident for 1 (Resident #49) of 6 residents reviewed for unnecessary medications during the survey. The findings include: On 3/2/26 at 9:40 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #49. During the preparation LPN #5 pulled Resident #49s Cholecalciferol (Vitamin D) tablet of 1000 units. Next the surveyor observed LPN #5 administer one tablet of Vitamin D to Resident #49. Following the observation the surveyor reconciled the medications administered observation to Resident #49's medication orders. The review revealed Resident #49 had two orders for Cholecalciferol 1000-unit table. The two orders, even though duplicate, gave the impression to give 2, 1000-unit tables, one for each order. There were two areas to document the medication on the Medication Administration Record (MAR) and it appeared both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility's policy and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 1 random observation during the survey. The findings include: On 2/27/26 at 8:57 AM, the surveyor observed Certified Medications Assistant (CMA) #4 walking between two medication carts in the 100's hallway. One of the medication carts was noted to have turned front side against the wall between room [ROOM NUMBER] and 111. On 2/27/2026 at 9:10 AM the surveyor observed a nurse and CMA #4 had walked into the resident's rooms and were no longer in the hallway. Next the surveyor walked to the medication cart pushed against the wall. The surveyor was able to open the side drawer which contained colestipol oral suspension, lactulose and lidocaine patches. The top draw contained multiple bottles of floor stock medication. The second draw contained bubble packs of Resident's medications. The third drawer contained a personal water…

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

Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (Resident #74 and #90) of 2 residents reviewed for dental services during the survey. The findings include: 1) On 2/26/26 at 1:33 PM, the surveyor reviewed Resident #74's medical record. The review revealed that on 1/31/26 an order was placed for Resident #74 to have orajel to be given every 6 hours as needed for tooth pain. Additionally, an order was placed on 2/6/26 that stated Resident #74 had a dental appointment made for early March. It was also noted that on 11/4/25 Resident #74 had an order for several consulting services to be consulted as needed. Dental was listed as one of the consults. Next the surveyor reviewed the progress notes. A progress note written on 11/27/25 stated the reason for the visit was to follow up on tooth pain. It further stated that Resident #74 was treated with Motrin (ibuprofen) for two 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 observation, record review, and interviews, it was determined that the facility failed to ensure that residents were served a meals according to a predetermined menu and their preferences. This was found to be evident for 3 (#3, #5, and #90) out of 8 resident's meals that were observed for correctness during the recertification survey. The findings include: During an interview on 02/24/2026 at 9:15 AM, Resident #99 stated, They don't give me the food that is on the menu. This morning I was supposed to get sausage gravy on biscuits and I got scrambled eggs with dry toast. The surveyor observed that the meal ticket read sausage gravy with biscuits. On 02/24/2026 at 10:04 AM Resident #5 stated, I don't get what I am supposed to on my tray. Although the meal ticket read sausage gravy and biscuits and cottage cheese, the tray contained 2 boiled eggs and toast. Resident #5 further stated, I am supposed to have cottage cheese with all my meals but I never get it. On 02/26/2026 at 8:37 AM, an observation of Resident #2's breakfast tray did not include the alternative breakfast…

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 serve food at residents preferred temperature. This was found to be evident for 2 (#90, #91) out 8 residents interviewed for palatable food during the recertification survey.The findings include:On 02/24/2026 at 1:53 PM Residents #90 and #91stated the facility food is served cold and staff is too busy to heat it up. On 02/26/2026 at 8:37 AM, GNA #18 was asked the procedure for reheating food. GNA #18 stated, We are not allowed to heat up food for residents. On 02/26/2026 at 9:30 AM, the acting Director of Nurses was asked the procedure for heating up residents food when they complain about cold trays. She responded that staff do not heat up resident trays, they are supposed to return the food to the kitchen for reheating. 02/27/2026 9:12 AM GNA #24 was asked what they do when a resident complains about cold food. GNA #25 stated, I go heat it up in the microwave in the break room because we don't have anywhere else to do it. During a meal observation on 02/26/2026 at 12:23 PM, Resident #91 stated, My…

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 record review, it was determined that the facility failed to provide assistive devices for meals to a resident. This was found to be evident for 1 (#14) out of 2 residents reviewed for assistive devices during the recertification survey. The findings include:On 02/26/2026 at 8:35 AM, the surveyor observed Resident #14 eating breakfast with a fork. The resident's hands visibly shook, causing food to fall from the fork as the resident tried to eat.On 02/26/2026 at 1:02 PM the surveyor observed Resident #14 eating breakfast using a fork. Resident #14's hands visibly shook, causing food to fall from the fork. When the surveyor asked the resident if the facility provided assistive utensils, Resident #14 shook their head no.The record review on 02/26/2026 at 1:10 PM revealed an order dated 10/28/2025 that read: Patient to use weighted spoon and fork during meals. The care plan dated 10/29/25 read, divided plate for meals, sippy cup and built up spoon. On 02/27/2026 at 7:34 AM, GNA #18 stated, If a resident needed assistive devices and staff did not find them on…

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

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This was found to be evident in the refrigerators, freezer and storage areas observed during the recertification survey. The findings include:On 02/24/2026 at 7:55 AM, a tour of the kitchen was conducted with the Food Service Director(FSD). In the refrigerator, 3 sandwiches were on a shelf dated 2/20/24. They were discarded by the FSD. Spices in the cooking area lacked labels or dates. The FSD stated that staff should label them with the date opened.The walk in freezer had an unlabeled bag of green beans and a box of hash browns with a large ice formation on top almost covering the box. Icicles hung from the compressor above the box. The FSD stated they would discard the food and request a repair. The walk in refrigerator had ham dated 2/16/26, use by 3/2/26. The FSD stated it should be discarded after 7 days.On 02/27/2026 at 8:00 AM, the Administrator acknowledged the kitchen…

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 a resident's medical record document was accurately completed. This was evident for 1 (Resident #10) of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR).The findings include:Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions.On 02/24/2026 at 11:37 AM, review of Resident #10's medical record revealed a PASARR document dated 2/11/25 which indicated the resident needed a level II screening.At the same time, further review of the Resident's medical record failed to reveal indication of a level II PASARR or that a level II was determined to not be required. On 02/25/2026 at 10:15 AM, an interview with the Director of Social Services…

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 linens were stored to maintain infection prevention. This was evident for 4 of 4 hallways observed during the annual survey.The findings include:1a) On 02/26/2026 at 6:00 AM, an observation of the 500 hallway revealed a linen cart, which on the bottom shelf revealed a seat cushion that was visibly dirty, a wheelchair detachable leg/foot rest, a reusable bed pad, trash bags, and a brief (incontinence underwear). On 02/26/2026 at 8:05 AM, another observation of the 500 hallway revealed the same linen cart with the same items on it. On 02/26/2026 at 8:12 AM, an interview with the Director of Nursing revealed that the expectation for the linen carts on the hallways should only contain linen, to maintain infection prevention. The surveyor noted the linen carts with items on them noted above and requested a dual observation of the 500 hallway linen cart and other (100, 200, and 300) hallways. On 02/26/2026 at 8:14 AM, during the dual observation of the linen carts on each hallway revealed:The 500…

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 equipment in the kitchen in safe, operating condition. This was found to be evident for the walk-in freezer, plate warmer, and the hot water heater during the kitchen tours. The findings include:The surveyor conducted a kitchen tour with the Food Service Director (FSD) on 02/24/2026 at 7:55 AM. Inside the walk-in freezer, the surveyor observed a large ice formation on top of a box of hash browns, almost covering it. Icicles also hung from the compressor above the box. The FSD stated a request for repair would be submitted.On 02/26/2026 at 7:05 AM, the Maintenance Director stated that the compressor in the walk in freezer compressor needed charging and might be serviced that day. On 02/27/2026 8:00 AM the Administrator stated they are working on the compressor today. On 3/2/2026 at 7:30 AM, the surveyor observed the walk-in freezer still showed small drips on the compressor. The FSD stated a plan to have maintenance evaluate the freezer. At 7:34 AM, when the surveyor asked the FSD about food…

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

Based on observations and interviews it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 1 of 3 units observed during the survey. The findings include: On 2/24/26 at 10:35 AM, the surveyor observed the call light in nurses' station #3 continuously beeping however no call lights were going off in the hallway nor room numbers showing up on the screen. The surveyor asked Registered Nurse (RN) #6, who was in the nurses' station, why the call light was beeping every 3 seconds. RN #6 stated it had been like that for a while. She further stated maintenance had looked at it but was not able to fix it. RN #6 confirmed that when a resident called the room number would show up on the screen, but the beeping was continuous. On 2/26/26 at 7:43 AM, the surveyor conducted an interview with the Maintenance Director Staff #17. During the interview Staff #17 stated that he was unaware that the call system was not working properly at nurses' station #3. The surveyor and Staff #17 walked to the nurses' station 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 administrative record review and staff interview, it was determined that the facility failed to ensure staff received training on abuse, neglect, and exploitation. This deficient practice was evident for 2 of 6 employee files reviewed during the annual survey.The findings include:On 02/27/26 at 7:51 AM, during an interview with the Director of Nursing (DON), the DON reported that nursing skills competencies are verified at the time of orientation and reassessed annually. The DON further explained that the facility utilizes a learning platform called Relias to complete required monthly and annual training.On 03/02/2026, the surveyor reviewed the facility assessment which was most recently approved in January 2026. Review of the section related to staff training, education, and competencies identified training requirements for staff including abuse, neglect and exploitation, infection control, dementia management, quality assurance and performance improvement, compliance & ethics.On 03/02/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #36 and Licensed…

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 administrative record review and staff interviews, it was determined that the facility failed to ensure staff received training on Quality Assurance and Performance Improvement (QAPI). This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.The findings include:On 02/27/26 at 7:51 AM, during an interview with the Director of Nursing (DON), the DON reported that nursing skills competencies are verified at the time of orientation and reassessed annually. The DON further explained that the facility utilizes a learning platform called Relias to complete required monthly and annual training.On 03/02/2026, the surveyor reviewed the facility assessment which was most recently approved in January 2026. Review of the section related to staff training, education, and competencies identified training requirements for staff including abuse, neglect and exploitation, infection control, dementia management, quality assurance and performance improvement, compliance & ethics.On 03/02/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA)…

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

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received infection control training. This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.The findings include:On 02/27/26 at 7:51 AM, during an interview with the Director of Nursing (DON), the DON reported that nursing skills competencies are verified at the time of orientation and reassessed annually. The DON further explained that the facility utilizes a learning platform called Relias to complete required monthly and annual training.On 03/02/2026, the surveyor reviewed the facility assessment which was most recently approved in January 2026. Review of the section related to staff training, education, and competencies identified training requirements for staff including abuse, neglect and exploitation, infection control, dementia management, quality assurance and performance improvement, compliance & ethics.On 03/02/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #36, GNA #37 and Licensed Practical Nurse…

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 administrative record review and staff interview, it was determined that the facility failed to ensure staff received compliance & ethics training. This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.The findings include:On 02/27/26 at 7:51 AM, during an interview with the Director of Nursing (DON), the DON reported that nursing skills competencies are verified at the time of orientation and reassessed annually. The DON further explained that the facility utilizes a learning platform called Relias to complete required monthly and annual training.On 03/02/2026, the surveyor reviewed the facility assessment which was most recently approved in January 2026. Review of the section related to staff training, education, and competencies identified training requirements for staff including abuse, neglect and exploitation, infection control, dementia management, quality assurance and performance improvement, compliance & ethics.On 03/02/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #36, GNA #37 and Licensed Practical…

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 the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#3, #6, #7, #8) of 4 residents reviewed for falls during a complaint survey.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 those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 2/3/26 at 10:09 AM a review of Resident #3's medical record was conducted and revealed Resident #3 had a fall on 10/14/25. Resident #3 was noted with a 1 cm. by 0.1 cm. laceration that was bleeding. Resident #3 was sent to the emergency room and had 2 staples placed in the scalp of the head.Further review of Resident #3's medical record revealed Resident #3 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of Resident # 1 room [ROOM NUMBER] B, the facility failed to clean the room, sweep and mop the floor. This was evident for 1 out of 1 resident and room. Findings include:On 2/3/26 at approx. 10:15 AM this surveyor went into room [ROOM NUMBER] B where Resident # 1 resides. When this surveyor entered the room, trash was all over the floor such as wrappers, Kleenex, hair brush and food. Left over food and crumbs were all over the bedside table for Resident #1 and his roommate. There was also stuck on food on the cushion that was in the wheelchair. The floor mat was dirty and the corners in the room were dusty and dirty as well. This surveyor showed this to the Charge Nurse staff # 7 and the Director of Nursing (DON) staff # 2. Staff # 7 stated that Resident # 1 is a messy eater and gets food everywhere. This may be true, but the roommate's side of the bedroom was just as dirty. The Administrator was made aware.

Based on medical record review and interview, the facility staff failed to provide treatment/services as ordered to prevent/heal pressures ulcers (Resident #5). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.The findings included: A pressure ulcer also known as 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). Review of Resident #5's medical record on 2/3/26 revealed the Resident was admitted to the facility in 2024 with a diagnosis to include adult…

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 implement the Dietitian's recommendations for residents with weight loss (Resident #5 and #10) and failed to follow up on a physician's report for a resident evaluated for weight loss (Resident #5). This was evident for 2 of 3 residents reviewed for weight loss during a complaint survey. The findings include:1.Review of Resident #5's medical record on 2/3/26 revealed the Resident was admitted to the facility in 2024 with a diagnosis to include adult failure to thrive. Failure to thrive (FTT) in adults, particularly the elderly, is a syndrome marked by unintentional weight loss, decreased appetite, poor nutrition, and physical inactivity. Further review of Resident #5's medical record revealed the Resident was assessed by the Dietitian on 4/10/25 for nutritional follow up. The Dietitian documented that the Resident continues to experience weight loss despite supplementation and assistance during meals. His/her diagnoses of dementia, adult failure to thrive, mild protein-calorie malnutrition,…

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 obtain a diagnostic test as ordered for a resident (Resident #5). This was evident for 1 of 11 residents reviewed during a complaint survey. The findings include:Review of Resident #5's medical record on 2/3/26 revealed the Resident was admitted to the facility in 2024 with a diagnosis to include goiter. Goiter is an enlargement of the thyroid gland.Further review of Resident #5's medical record revealed the Resident had a chest X-ray completed on 3/3/25 to rule out pneumonia. Review of the X-ray results revealed it stated: a nonspecific superior mediastinal widening. Overall findings are worse compared to 4/22/2024. CT recommended. A CT (computed tomography) scan is a quick, painless, and non-invasive medical imaging test using X-rays to create detailed 3D, cross-sectional slices of bones, blood vessels and soft tissues. Review of Resident #5's physician orders revealed the order for the CT scan was not placed until 3/28/25. The 3/28/25 ordered was updated on 4/3/25 to include 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 investigation of intakes #314675 and #314688, review of facility documents, and interviews it was determined the facility failed to maintain an effective Grievance system. This was evident for 5 of 6 months of Grievance forms from the months of April through September of 2025 reviewed during the complaint survey. The findings include:On 10/06/2025 a review of intakes # 314675 and #314688 was completed, alleged by complainant's from Resident #101 and Resident #102. The Complainant for Resident # 101 alleged had 160.00 worth of clothes missing. The Complainant for Resident #102 alleged that she called the facility to voice concerns and never received a call return. On 10/07/2025 at 2:57 PM, in review of Facility Grievance forms from the last 6 months (April through September of 2025), provided to the Surveyor by the Administrator revealed the following:Grievance forms were unavailable for four out of six months in 2025: April, June, July, and August. Continued review of the Grievance forms revealed, for the month of May of 2025 revealed 4 grievance forms with dates 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 complaint intakes, observations, and staff interviews, it was determined that the facility failed to provide quality of care services to their residents by not having clean towels or wash clothes used for washing up. This was evident for 3 (#314683, #314678 and #314685) of 5 complaint intakes reviewed during a complaint survey.The findings include:On 1/7/25 at 10:14 AM review of incident #314683 alleged that Resident #105 was frequently left in their soiled adult briefs for extended periods, sometimes for over two hours. During their first three days at the facility, the resident was left in bed without being bathed. When family members attempted to clean the resident, they were informed there were no clean towels or wash-clothes available. They had to go to a local store to purchase these items to care for the resident themselves.Review of intake #314678 also alleged that the facility never had wipes, towels and wash clothes for the residents and were always running out hindering staff from doing their jobs. When aides tell the facility there's no linen, they suggest…

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 investigation of Intake #314680, observation, and interviews with facility staff it was determined the facility failed to provide an environment that promotes resident respect and dignity. This was evident for 1 (Resident #117) of 1 resident reviewed for dignity during the complaint survey. The findings include:On 10/08/2025 at 11:06 AM, during an interview with Geriatric Nursing Assistant (GNA) #12, when asked why so many residents were seen wearing hospital gowns, Staff #12 replied, they don't have clothes.On 10/08/2025 at 11:13 AM, during an observation of Resident #117, he/she ambulated down 100 hallway in a hospital gown. The gown was hanging off Resident #117's right shoulder, halfway down the arm, and exposing his/her back. On 10/08/2025 at 11:26 AM, during an interview with Registered Nurse (RN) Staff #14, stated that the Geriatric Nursing Assistant (GNA) needed to check the laundry for Resident #117's clothes. With the surveyor present, Staff #14 opened Resident #117's closet, which revealed only one sweatshirt. At that time, Staff #14 confirmed that Resident #117…

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 interviews it was determined that the facility failed to honor a resident's preference to receive a shower instead of a bed bath. This was evident for 1 (Resident #116) of 1 resident reviewed for preferences during the complaint survey.On 10/06/2025 at 9:40 AM, during an interview with Resident #116 stated, he/she has not had a shower in over 2 years, his/her preference is a shower, but has only received bed baths. Resident #116 continued to state, the shower room on the unit he/she resides on has not been in use and is used to store wheelchairs. On 10/06/2025 at 12:30 PM, during a review of Resident #116's medical record revealed the following: A Physician order dated 2/20/2023 weekly shower schedule on Wednesday and Saturdays on 7-3 shift.A Care plan with an initiated date of 07/29/2025 for maintenance that stated, Resident #116 is a long-term care or respite resident and requires assistance with their ADL's related to inability to perform ADLs independently, Parkinson's Disease. With an intervention that was initiated on the date of 07/29/2025,…

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 during tours of the facility and investigations into intakes #314685 and #314689, it was determined that the facility staff failed to ensure the facility was free from odors. This was evident for 2 out of the 4 nursing units observed during the complaint survey. The findings include:This surveyor reviewed intakes #314685 and #314689 on 10/6/25 and 10/7/25. The first was from an anonymous complainant and the second one was from family members. Both alleged bad odors, especially the smell of urine, being very noticeable in the facility. This surveyor toured the facility on 10/6/25 at 8:10 AM and observed the smell of urine and a foul odor that was possibly body odor. This was evidence at the far end of the 300 unit. This surveyor toured the facility on 10/7/25 at 10:30 AM and observed the smell of urine and a foul odor, possibly body odor, at the far end of the 300 unit. This surveyor toured the facility on 10/8/25 at 7:50 AM and observed the smell of urine and a foul odor, possibly body odor,…

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, investigation of facility reports, and interviews, it was determined that the facility failed to conduct a thorough investigation of 1) and allegation of abuse and 2) an accident with a serious injury. This was evident for 2 (Residents #106, #114) of 25 residents reviewed during the complaint survey.The findings include:1) On 10/7/25 at 8:40 AM review of a facility report #2560996 had that Resident #106 fell at the facility and was sent out to the hospital, there s/he was found to have a rib fracture and pneumothorax (air in Lungs), a chest tube was placed to drain the air out. The resident told the hospital staff that they were pushed by an unknown person resulting in the fall with injury. The hospital staff made the facility aware of the abuse allegation. The resident was later discharged back to the facility on 7/10/25. When resident came back, the abuse allegation was investigated by the facility but was not substantiated. Further review of the investigative report did not…

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 #2596795, record reviews, and interviews, it was determined that the facility failed to develop an impaired mobility care plan as required. This deficiency was observed in 1 (Resident #108) of 4 care plans reviewed for mobility needs during the complaint survey.The findings included:A care plan serves as a crucial tool to summarize a resident's healthcare needs, treatments, and care goals.On 10/9/2025, a review of complaint #2596795 alleged that the facility did not have operational Hoyer lifts in August 2025. The surveyor subsequently requested a list of Hoyer lift-dependent residents, selected and examined 4 residents' charts (#108, #123, #124 and #125) including their respective care plans.On 10/9/2025 at approximately 1:00 pm, a review of Resident #108's medical records indicated a history of left-sided paralysis and left-sided weakness. The resident's care plan also revealed dependence for activity of daily living (ADL) including mobility or transfer needs; however, there was no documented evidence to support the facility's development of a resident-specific…

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 investigation of intakes, record review, observation, and interview, it was determined that the facility failed to 1) provide incontinence care timely, 2) provide showers for dependent residents, and 3) provide incontinence care in a professional manner. This as evidence for 4 residents (Residents #119, #105, #121, #112) out of 25 residents reviewed during the complaint survey.The findings include: 1) Intakes #314680, #314688, and #314675 were reviewed on [DATE] and [DATE]. All 3 intakes had alleged an extended wait time to receive incontinence care. On [DATE] at 11:40 AM, during an observation, the surveyor overheard Resident #119's complainant inform Geriatric Nursing Assistant (GNA) Staff #7 that Resident #119 needed to be changed and had been waiting 30 minutes. Staff #7 responded she would return or find someone. On [DATE] at 11:42 AM, during an interview with the complainant for Resident #119, stated he/she arrived at the facility at 11:00 AM. At that time a therapist (Staff #8) brought Resident…

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

Based on clinical record review and an investigation of intake #314682 it was determined that the facility staff failed to conduct a thorough investigation into an accident thereby denying facility staff the ability to adequately evaluate possible cause(s) to this and future accidents. This was evident for 1 (Resident #113) out of 1 resident reviewed for accidents during the complaint survey.The findings include:A review of Resident #113's clinical record was conducted on 10/7/25 at 10:00 AM as well as the review of the allegations made in intake #314682. It was revealed that on 2/23/25 the resident was found on the floor of the resident's room. Nursing staff observed that the resident had a hematoma (localized collection of blood the pools similar to a bruise) and a laceration over the left eyebrow as well as a large amount of bleeding. Staff assisted the resident to bed, applied ice to the hematoma, and a pressure dressing was applied over the left eyebrow to control the bleeding. 911 was called and the resident was sent to the hospital. Further review of the clinical record on…

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

Based on observation of a test tray and information provided from intakes, it was determined that the facility staff failed to ensure food was served in a palatable manner. This was evident for 1 out of 2 test trays sampled.The findings include:A test tray was provided to the survey team on 10/9/25 at 8:30 AM. The scrambled eggs and the bacon tested at a palatable level. The cream cheese was 53.9 F, the milk was 52.8 F, the apple juice was 49.6 F. All three were above the 41-degree limit for cold food. The survey team informed the facility administrative team at the exit conference.

Based on investigation of intake #314675, observation, and interview it was determined the facility failed to properly verify pertinent information prior to meal service. This was evident for 1 (Resident #118) of 1 reviewed for meal service during the complaint survey.The findings include:On 10/08/2025 at 1:12 PM, during an observation and interview of meal service on 300 Hall, the surveyor requested the test tray (a sample meal requested by surveyors to evaluate the quality and temperature of the food served to residents) from the 300-meal cart. Geriatric Nursing Assistant (GNA) Staff #18 confirmed she had served the test tray to Resident #118. Upon entering Resident #118's room, the surveyor, with GNA Staff #18 present, observed that the meal tray lacked a meal ticket. GNA Staff #18 acknowledged the absence of a meal ticket (a slip containing information that contains the resident's name, room number, diet type, food texture, liquid consistency, and allergies) and admitted that she should not have served the meal without verifying the information. On 10/08/2025 at 1:40 PM, during…

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 clinical record review, investigation of intake #314679, staff interview, and interview with complainant, it was determined that the facility staff failed to ensure medical records were complete with all communication flow sheets with the dialysis center. This was evident for 1 (Resident #114) resident out of 25 residents that were part of the survey sample.The findings include: The surveyor reviewed intake #314679 on 10/6/25 at 8:30 AM. According to the complainant, Resident #114 arrived at the dialysis center on 11/22/24 and complained of leg pain. The Resident's leg was noted to be swollen. Resident #114 was asked what happened and the resident said they were dropped at the facility. The dialysis center nurse called the facility and informed them of the resident's complaint of pain and the swelling. Dialysis nurse said she documented the conversation with the facility nurse, the vital signs, and signed her name on the flow sheet. The dialysis nurse alleged that when the resident returned on Monday, the communication flow sheet that was sent to the facility on Friday no…

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 facility staff interview, it was determined that the facility failed to have a safe/clean/comfortable/homelike environment. This was found to be evident in 6 out of 8 Resident rooms observed by the surveyors during the tours of the facility. The findings include: 1. During the tour of the facility on 9/30/2024 at 10:45 AM the surveyor observed the following items in need of repair: the sink faucet in room [ROOM NUMBER] was missing a handle for the warm water, the cove basing in room [ROOM NUMBER] was not secure to the wall underneath the sink, one of the closets in room [ROOM NUMBER] was missing a drawer, and the walls marred in rooms 100, 112 and 114. At 9:20 AM on 10/7/2024 the surveyor toured nursing unit 100 with the Nursing Home Administrator (NHA) and the Maintenance Director. The NHA and the Maintenance Director observed room [ROOM NUMBER] and room [ROOM NUMBER] with the surveyor and acknowledged that these two areas required repair for the missing drawer and the unsecured cove…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and medical record review it was determined that the facility failed to provide notification to the Ombudsman of Residents that transferred to the hospital and discharged from the facility. This was found to be evident in 9 out of 9 Residents (#4, #8, #24, #32, #33, #41, #60, #105 and #118) reviewed for hospitalizations. The findings include: 1. During an interview with Resident #8 on 10/01/2024 at 08:57 AM, the Resident stated to the surveyor that he/she was hospitalized at Greater Baltimore Medical Center in April of this year. The surveyor reviewed Resident #8's medical record on 10/7/24 at 08:10 AM and the medical record review revealed that Resident #8 was hospitalized on [DATE]. The surveyor interviewed the Nursing Home Administrator (NHA) at 01:13 PM on 10/7/2024 and requested documentation of notification to the Ombudsman when a Resident is transferred to the hospital. The NHA stated that notification to the Ombudsman has not been completed up until a few months ago. 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, staff interview and clinical record review, it was determined that the facility staff failed to ensure that MDS (Minimum Data Set) assessments were coded accurately for Residents. This was found to be evident for 5 Residents (#41, #77, #119, #133 and #118) out of 5 Residents reviewed for accuracy of MDS assessments. The findings include: 1) The surveyor observed Resident #41 sitting on the side of her bed on 10/1/2024 at 10:16 AM with a Foley catheter in use. Resident #41 stated to the surveyor that he/she has a catheter. The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of Long-Term Care Nursing Facilities. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. A record review of Resident #41's medical record 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 staff interview, clinical record review, and an investigation into Intake #MD00205003, it was determined that the facility staff failed to ensure residents right to determine who speaks for them is respected. This was evident for 1 (#128) out 44 residents in the survey sample. The findings include: A review of Resident #128's clinical record revealed the resident was admitted to the facility with the assistance of a granddaughter. The facility was informed that the resident had a Medical Power of Attorney form that was signed on 3/15/24 appointing the granddaughter as the Health Care Agent. The granddaughter got a second signature on 3/18/24. The facility as of 3/20/24 was still contacting the resident's son. Social services wrote a late note on 3/21/24 at 09:13 AM detailing the recent family history of the resident and the note makes it clear that the resident wants support from the granddaughter not the son. This surveyor interviewed the Regional Director of Clinical Services prior to the survey team's exit from the facility and we discussed the importance of ensuring…

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, review of complaint intake MD 00209581 and staff interview, it was determined that the facility failed to implement the grievance process as evidenced by the failure to initiate grievances and to resolve complaints. Additionally, the facility staff failed to ensure the residents' right to voice grievances with respect to care/ treatments and the concerns of staffs' behaviors regarding their facility stay. This was evident for 1 (Resident# 144) out of 20 residents reviewed for facility complaint reviews during an annual survey. The findings include: Record review, on 10/11/24 at 10:55 AM, revealed that Resident #144 filed a complaint to the Office of Health Care Quality (OHCQ) with MD 00209581 and emailed the Administrator at the same time, on 9/9/24, about staff concerns during the weekend. The resident indicated that a meeting was scheduled for 9/10/24 and he/she did meet with the Administrator about the grievances. However, there was no action taken and the resident was discharged on 9/13/2024. During the interview, on 10/11/24 at 02:00 PM, 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 medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 2 (Residents #32 and #91) of 44 residents selected for investigation during the survey process. 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. Resident #32 was admitted on [DATE] with diagnoses including Acquired Absence of Left Leg Below Knee, Hemiplegia and Hemiparesis following Cerebral Infraction affecting Left Non-Dominant Side, Acquired Absence Right Leg above Knee. 1) On [DATE] at 07:41 AM the surveyor reviewed Resident # 32's care plan for Fall which was initiated on [DATE] with the Focus - Resident had an actual fall and remains at risk for falls relating to Deconditioning, Right AKA (Above the Knee Amputee), Left BKA (below the Knee…

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 medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 2 Residents (#8 and # 57) out of 3 residents that were reviewed for respiratory care and services. The findings include: 1a) On 9/30/2024 at 11:18 AM the surveyor conducted a tour of Unit 100 and observed Resident #8 with oxygen in use and the oxygen tubing was not dated/labeled. In addition, the oxygen humidifier bottle that was attached to the oxygen delivery system did not have any water in the bottle and was dated 9/20/2024. The surveyor interviewed the Registered Nurse (RN) #11 who observed the humidifier bottle empty and asked what the expectation was for the oxygen humidifier bottle, and RN #11 stated that she would replace the humidifier bottle. On 10/4/24 at 10:00 AM the surveyor observed Resident #8 in bed with oxygen in place to his/her nostrils and the oxygen humidifier bottle and the oxygen tubing was dated 10/03/2024. The surveyor conducted a record review of Resident #8's 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, interviews and medical record review it was determined that the facility failed to store medications appropriately. This was found to be evident in 1 (Resident #8) out of 1 resident for medication storage. The findings include: During the initial tour of Nursing Unit 100 at 11:18 AM on 9/30/2024 the surveyor observed two respiratory medication inhalers at Resident #8's bedside. The surveyor notified Registered Nurse (RN) #11 of Resident #8 with medications at the bedside and RN #11 observed the two respiratory inhalers at the bedside and stated that one of them was Albuterol and that Resident #8 had a locked drawer. The surveyor conducted a record review of Resident #8's medical record on 10/4/2024 at 07:44 AM and the review of the medical record revealed that there was not an order for medications/inhalers at the bedside. A self-administration medication assessment was completed by the nursing staff on 10/2/2024 for Resident #8. On 10/1/2024 at 08:45 AM the surveyor observed Resident #8 with five tablets in a medication cup on the meal tray on the resident'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 observation and staff interview it was determined that the facility staff failed to ensure food products were properly labeled and disposed of when they are past their expiration dates. This was observed on two tours of the kitchen. The findings include: On 9/30/24 at 8:10 AM a tour of the kitchen revealed there were several items that were either past an expiration date or their labeling was incomplete. The walk-in cooler had a container of mustard with a label indicating it was opened on 7/4 and to use by 8/4. The year was not present, but it appears to have been past the use by date. There were two containers of ricotta cheese that had expiration dates of 9/27/24. One 1-gallon container of coleslaw dressing that had a label that both a use by date and expiration date of 8/12. A second container of coleslaw dressing that was not labelled. One container of teriyaki with a use by date of 7/30. There were 4 boxes of sun cups that had a warning on the box to serve within 10 days but there was no label 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 clinical record review and staff interview it was determined that the facility staff failed to ensure clinical records were maintained in an accurate manner. This was evident for 1 (#4) out of 44 residents in the survey sample. The findings include: The Activity Director (Staff #25) was interviewed on 10/7/24 at 9:22 AM. The team asked her where to find Activity logs documenting participation. She said they switched to putting Activities information into the computer. This surveyor requested Activity logs for Resident #4. Activity logs were brought to the survey team on 10/7/24 at 12:15 PM. This surveyor reviewed the activity logs on 10/7/24 at 12:45 PM and activity staff documented that the resident was participating in activities on 7/11/24, 7/15/24, 7/17/24, and 7/19/24. Further review of the clinical records revealed the resident was in the hospital from 7/10 to 7/22/24. This surveyor interviewed the Administrator and Regional Director of Clinical Services on 10/11/24 at 12:13 PM. The Surveyor showed them the activity logs. They confirmed that there are activities…

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 provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evidenced by: 1) Staff failing to perform hand hygiene before entering the room of a resident with enhanced barrier precautions 2) Failure to keep contaminated pillows separate and away from clean pillows in the laundry room The findings include: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1) On 10/3/24 at 8:20AM during rounds, on the unit with rooms 500-514, the surveyor observed Enhanced Barrier Precautions (EBP) signage…

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 keep a sanitary environment. This was found evident on 1 of 3 floors observed in the laundry room area. The findings include: On 10/07/24 at 08:48AM the surveyor did a walk through the laundry room. Staff #22 and Housekeeping Director, Staff #21 were present. The surveyor observed the floor tiles in the room with the washing machines were visually dirty and sticky with a brown colored substance. On the floor in front of the washing machines were two large, rusty drain pit covers. Surrounding the drain pit covers were an accumulation of dirt. Chemicals for the washing machines were in buckets attached to hoses sitting on a platform covered with thick powder like white substance. The thick white substance was also scattered on the floor next to the platform. In an interview regarding the condition of the room Staff #22 agreed that the room needed cleaning. On 10/08/24 at 08:10 AM the surveyor did a second observation of the laundry room with the Maintenance Director and the Administrator. The room 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 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 4 out of 5 personnel files reviewed. The findings include: A random review of GNA personnel files was conducted on 10/28/19 at 2:00 PM with the Human Resources Director. 1) Review of Staff #17's employee personnel file documented a date of hire (DOH) of 9/16/15. The Human Resources Director did not have any yearly performance evaluation for this employee. She did imply that a past years performance review could be in a stack of boxes on the floor in her office. 2) Review of Staff #18's employee personnel file documented a DOH of 5/16/18. The yearly performance review was not performed. 3) Review of Staff #20's employee personnel file documented a DOH of 5/25/15. The last yearly performance review on file was dated 7/18/17 and it was not signed by the employee. 4) Review of Staff #21's employee personnel file documented a DOH of 2/8/17. The last yearly performance review was dated 3/14/18.

Based on record review and staff interview it was determined that the facility staff failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by; 1) reading Tuberculosis Skin Test (TST) results outside of the specified time frame and 2) failed to update Infection Prevention and Control Program Policy (IPCP) annually. This was true for 3 (#95, #368, #427) of 3 residents reviewed for infection control and for 2 of 3 policy's reviewed for infection control. These deficient practices have the potential to affect all residents, visitors and staff in the facility. The findings include: The TST helps determine if someone has developed a response to the bacteria that causes tuberculosis (TB). The TST consist of two separate tests (steps). Each one is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm. A licensed nurse will look for (read) a reaction on the resident's arm within 48 to 72 hours. 1). On 10/28/19 at 9:27 AM a record review of Resident #368 revealed that the First Step…

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 the facility staff failed to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair including the grounds. This was evident throughout the survey 1) the outside grounds; 2) on 3(200, 300, and 500) of 4 hallways; and 3) in 4 (506, 509, 505, 502) of 6 resident rooms. The findings include: 1) A tour of the grounds was conducted with the maintenance director on 10/25/19 at 10:10 AM. Exiting through the back doors of the facility, the grounds were not noted to be clean, neat, and attractive. There was an extensive collection of unused possessions that included mattresses, beds, bed parts, Geri chairs, air conditioning units, a large horizontal freezer, a shower stretcher, Hoyer lifts and/or other manufacture lifts, at least 5 wheelchairs, wheelchair parts and numerous walkers in the back of the facility. The maintenance director provided explanations for some of the accumulated…

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 the facility failed to: notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 5 (#74, #105, #19, #70, #69) of 8 residents reviewed for hospitalization. The findings include: 1) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse documented a change in Resident #74's medical condition, 911 was called and Resident #74 was transported to the hospital emergency room for evaluation. Continued review of the medical record failed to reveal documentation the Resident #105 and/or the resident's representative was notified in writing of the transfer along with the reason why the resident was transferred to the hospital. The Director of Nurses (DON) was made aware of these findings on 10/23/19 at 3:00 PM. 2) On 10/24/19 at 10:48 AM, a review of Resident #105's medical record 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.

Based on medical record review and staff interview it was determined 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 8 (#69, #111, #83, #119, #74, #105, #19, and #70 ) of 8 residents reviewed for hospitalization. The findings include: 1)Review of the medical record for resident #69 on 10/22/19 documented that on 7/9/19 resident #69 was having difficulty breathing, was evaluated and transferred out to an acute care facility at 8:15 PM 2) Review of the medical record for resident #111 on 10/22/19 documented that on 9/21/19 at 3:12 PM the resident was found on the floor and sent to the emergency room. 3) Review of the medical record for resident #83 on 10/25/19 documented that on 9/9/19 at 11:45 AM resident #83 had complained of chest pain. The nursing progress note was simply written as Resident went to ER (emergency room) with right hearing aid in his ear. 4) Review of the medical record for Resident #119 on 10/29/19/19 documented that on 7/29/19 at 5:28 PM 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 and staff interview it was determined the facility staff failed to give the written bed hold policy to the resident or resident representative upon transfer/discharge of a resident to an acute care facility. This was evident for 4 (#74, #105, #19, #70) of 8 residents reviewed for hospitalization. The findings include: 1) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse documented a change in Resident #74's medical condition, 911 was called and Resident #74 was transported to the hospital emergency room for evaluation. Continued review of the medical record failed to reveal documentation that the resident and/or the resident's representative was given the written bed hold policy upon the resident's transfer to the hospital. The Director of Nurses (DON) was made aware of these findings on 10/23/19 at 3:00 PM 2) On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed documentation 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 and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#118, #105, #19, and #77) of 34 resident investigations during the survey. 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 those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) A review of the medical record for Resident #118 was conducted on 10/28/19 documents that resident #118 was discharge to the community/home on 8/30/19. Review of the MDS assessment with an assessment reference date (ARD) of 8/30/19 indicated that the resident was discharged to the hospital. The MDS assessment for Discharge Status at A2100 was inaccurately coded on…

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

Based on resident representative and resident interview, observation, medical record review and staff interview it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#105) of 1 residents reviewed for urinary tract infections and 1 (#72) of 6 residents reviewed for accidents. 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. 1) On 10/21/19 at 11:24 AM, during an interview, Resident #105 stated that he/she had a history of urinary tract infections (UTI) and just finished taking antibiotics for a UTI last week. On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed on 9/20/19 at 11:50 PM, in a progress note, the physician documented that he/she was seeing Resident #105 following the resident's hospitalization and readmission to the facility. The physician documented the resident was hospitalized for a change in mental status and a urinary tract infection.…

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 maintain complete and accurate medical records by: 1) failing to void MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST has been created, 2) failing to ensure a resident's Preadmission Screening and Resident Review (PASRR) Level I ID Screen for Mental Illness and Intellectual Disability or related conditions were retained in the resident's medical record, 3) failing to accurately document a resident's refusal to wear a soft helmet, 4) allowing the Social Service Director to sign notes in the electronic medical records as a LCSW (licensed clinical social worker) in the absence of having a social work license, and 5) failing to ensure the in-house nurse practitioner's notes were available on the medical record for review and failed to ensure the practitioner's notes were accurately documented. This was evident for 6 (#70, #74, #105, #19, #320, and #319) of 32 residents reviewed during…

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

Based on interview and record review, it was determined that the facility staff failed to, in the presence of a resident - to - resident altercation, provide immediate intervention to ensure the safety and wellbeing of the resident. This was evident for 1 (#39) of 7 residents reviewed for abuse. The findings include: During an interview with Resident #39 on 10/21/19 at 11:04 AM, the resident reported that his/her roommate (Resident #100) was calling his/her mother names and talked about her. Resident #39 stated, I have told social services many times about this and that I wanted a room change or I would bust him/her (the roommate) in the mouth. Resident reported they (facility staff) kept telling me that I have to be on a wait list and I am not sure why. Resident stated this issue had been going on since being moved to the room in 12/2018. An interview with Licensed Practical Nurse (LPN) #35 revealed that the roommate Resident #100 was abusive to staff and frequently called them names, but not aware of issue with the roommates. During an interview with Social Services Director (SSD)…

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

Based on interview and record review it was determined that the facility failed to report allegation of abuse to the Office of Health Care Quality. This was evident for 1 (#39) of 7 Residents reviewed for abuse. The findings include: During an interview with Resident #39 on 10/21/19 at 11:04 AM, the resident reported that his/her roommate (Resident #100) was calling his/her mother names and talking about her. The resident reported this has been going on since he was moved into the room and that facility staff were aware. On 10/24/19 at 3:16 PM, during an interview with Director of Social Work (DSS) Staff #1 stated she was aware of Resident #39's request to change rooms and provided the concern form dated 10/16/19. An interview with Staff #24 on 10/28/19 at 11:48 PM, revealed she was informed on 10/16/19, by Resident #39 that he/she wanted a room change because the roommate (Resident #100) was cursing at him/her. She gave the concern form to DSS Staff #1 and reported what the resident had said to her the same day. Staff #24 and #1 failed to report this as abuse. The Administrator 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 record review and interview it was determined that the facility failed to initiate an investigation of an alleged violation of abuse was reported to staff. This was evident for 1 (#39) of 7 residents reviewed for abuse. The findings include: A record review of the roommate (Resident #100) on 10/29/19 at 1:35 PM, revealed a care plan that was revised on 9/5/19, documented, Resident (#100) cursing and screaming at roommate (Resident #39) and staff member. However, the interventions did not include how to address the resident - to - resident altercation. A record review on 10/25/19 at 12:03 PM, for Resident #39 revealed the resident had filed a concern form with Staff #24 on 10/16/19, requesting a room change. There was no evidence that staff recognized the abuse and initiated an investigation. Furthermore, no action was taken to prevent further incidence of abuse until surveyor intervened on 10/24/19. An interview with the Administrator on 10/24/19 at 3:30 PM, revealed he was not aware of the reason for the room change requested by Resident #39. An interview with Staff #24 on…

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

Based on medical record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of the Assessment reference date (ARD). This was identified for 1 (#7) of 2 residents reviewed for pressure ulcers. 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 those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include. Review of Resident #7's medical record on 10/23/19 revealed that an annual MDS assessment with an ARD of 10/3/2019 was in progress, with the name of the MDS assessor. An interview was conducted with the MDS Assessor (staff #11) at 2:45 PM on 10/23/19, she had indicated that she knows that the assessment is greater that 14 days after the assessment reference…

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 the medical records, and resident and staff interviews it was determined the facility failed to perform appropriate revisions to the care plan interventions as resident care needs became apparent or changed over time as evidenced by failure to update interventions on an incontinence plan of care. This was evident for 1 (#69) of 2 residents reviewed for sensory (vision) concerns. 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 findings include: 1) An Initial interview was conducted with resident #69 on 10/21/19. Resident #69 indicated that s/he does not get toileted and does not utilize a bed pan. Resident #69 indicated that a disposable bed mat is utilized as resident requested for bowel movements. The disposable bed pad is discarded, and s/he is cleaned up after each evacuation. Resident #69 indicated that s/he was continent of bowel and urine. Resident #69 could express his/her needs as warranted. Resident #69's medical record was reviewed on 10/24/19.…

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, medical record, observation, and interview it was determined that the facility failed to provide care and treatment in accordance with professional standards as evidenced by: 1)failure to ensure medications were ordered and administered as indicated; 2) failure to complete a thorough physical assessment after a fall 3) failure to provide activity of daily living (ADL) care as needed 4) failed to render care in accordance with the resident's care plan and failed to apply prescribed/ ordered treatments. This was found to be evident for 1 (#39) of 3 residents reviewed for 5 day hospice respite admissions, and for 1 (#7) of 2 residents reviewed for pressure ulcers. The findings include: 1) On 10/24/19 review of Resident #319's medical record revealed the resident had been admitted to the facility in May 2019 for a five day hospice respite stay. The resident's diagnosis included but was not limited to chronic pain, dementia with behavioral disturbances, anxiety, major depressive disorder and agitation. Review of MD00142554 revealed concerns that that the…

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

Based on observation, record review, and staff interview it was determined that the facility failed to follow a physician's order for oxygen administration for a resident. This was evident for 1 (#39) of 2 residents reviewed for respiratory care. The findings include: During the initial pool process on 10/21/19 at 11:07 AM, an observation of Resident #39 revealed they were wearing a nasal cannula (delivers oxygen through the nose) and the oxygen (O2) level was set between 1 and 1.5 liters per minute. A second observation was made on 10/24/19 at 10:49 AM, revealed the resident was wearing a nasal cannula and the O2 level was set between 1 and 1.5 liters per minute. On 10/24/19 at 12:54 PM, a record review of the physician's order summary for 10/2019, revealed that Resident #39 had an order for O2 3L via nasal cannula continuous for SOB dated 1/29/19. The resident was receiving less than half the amount that was ordered. During an interview with Licensed Practical Nurse (LPN) #35, she confirmed with surveyor that the O2 was set at 1.5 liters per minute. She stated she was not sure…

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 a physician and a certified registered nurse practitioner (CRNP) failed to write, sign and date medical visit progress notes in resident medical records the day the resident was seen. This was evident for 2 (#83, #119) of 8 residents reviewed for hospitalization. The findings include: 1) A review of the medical record for Resident #83 on 10/25/19 revealed multiple occasions when the resident's attending physician failed to document in the resident's medical record on the day of the visit. A physician progress notes with a date of service (DOS) of 8/2/19 was documented as electronically signed on 8/9/19 and faxed to the facility on 8/12/19. Physician note with a DOS of 8/23/19 was faxed to the facility on 8/26/19. Physician note with a DOS of 9/11/19 was faxed to the facility on 9/15/19. 2) Resident of resident #119 closed record on 10/28/19 revealed that this resident was discharged from the facility on 8/14/19. The medical record was absent of a discharge summary. The Medical records director (staff #7) 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.

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 assure that residents are seen by a physician at least every 30 days for the first 90 days after a resident's admission. This was evident for 1 (#83) of 8 residents reviewed for hospitalization. The findings include. Resident #83 was admitted to the facility on [DATE]. Review of Resident #83's medical record on 10/24/19 revealed that the last physician progress note had a Date of service as 9/11/19. The medical records director (staff #7) was interviewed on 10/24/19 at 11:10 AM. She had indicated that the resident's attending physician did not have any outstanding progress notes. On 10/25/19 at 11:14 AM the VP of clinical services was informed of the late physician's progress note/visitation. The Nursing home administrator confirmed at 1:30 PM the lack of any additional notes from resident #83's attending physician. As of 10/25/19 the physician visit for Resident #83 was two weeks overdue.

Based on medical record review it was determined that the facility failed to ensure the pharmacist identified medication order irregularities during the monthly pharmacy review. This was found to be evident for one out of three (Resident #319) resident's reviewed for 5 day hospice respite admission. The findings include: On 10/24/19 review of Resident #319's medical record revealed two seperate orders for Haldol concentrate 2 mg/ml both of which were put into the electronic health record on 5/24/19 at 1:22 PM. One order read: Give 0.5ml by mouth every 8 hours for agitation [0.5ml would provide 1 mg of the Haldol]; the other order read: Give 1 milligram by mouth every 8 hours for agitation. Both orders were for 1 mg every 8 hours but written in slightly different format. Review of the MAR for these two Haldol orders revealed both doses of Haldol were administered on 7 occassions prior to the second of the orders being discontinued on 5/28 at 12:13 PM. On 5/25, 5/26 and 5/28 the doses due at 8:00 AM were coded as 9 which indicates other /see progress notes. No corresponding progress…

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.

2) On 10/28/19 at 11:34 AM, review of Resident #19's October 2019 MAR (medication administration record) revealed had 2 orders for narcotic medication to be given by mouth as needed for pain with no clear indication as to which medication to give first. The resident had an order Oxycodone (narcotic) 0.5 MG (milligram) tablet give 0.5 tablet every 4 hours as needed for pain and an order for Morphine Sulfate (concentrate) Solution 20 MG/ML (milliliter) give 0.5 MG by mouth every 6 hours as needed for pain/resp. Also, the morphine order should have been clarified with the physician as the morphine dose of 0.5 MG (0.025 ML) was not a recommended adult dose per the FDA (Federal Drug Administration) and the dose, 0.025 ML (0.5 MG), would not be accurately measurable in its current form. On 10/28/19 at 3:47 PM, during an interview, when asked how you would know which medication, the Oxycodone or the Morphine, to give if the resident was having pain, Staff #15 (RN) indicated he/she would not know which one to give and confirmed the orders did not have clear parameters to identify which one…

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 interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 2 errors observed during the medication observation of 32 opportunities for errors resulting in a medication error rate of 6.25. This was found to be evident for two (Resident #425 and #426) out of four residents observed during the medication administration observation. The findings include: 1) On 10/23/19 at 8:37 AM surveyor observed licensed practical nurse (LPN) #5 prepare and administer medications for Resident #425. The nurse reported that an antibiotic was due but was not available on the medication cart at this time. The nurse informed the resident about the antibiotic and the resident stated that it was finished on the 22nd. The nurse informed the resident that she had checked the computer and that the medication was due to end on the 23rd. After administering the other medications the nurse was observed obtaining Cefadroxil [an antibiotic] 500 mg capsule from the medication room. At approximately 9:15 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 review of medical record and interview it was determined that the facility failed to ensure that narcotic medication that was removed from the resident's supply was administered to the resident. This was found to be evident for one (Resident #319) out of 3 residents reviewed for 5 day hospice respite admission. The findings include: On 10/24/19 review of Resident #319's medical record revealed that on 5/24/19 Oxycodone 5 mg tablet every 4 hours as needed for pain was ordered. Review of the MAR and the nursing notes failed to reveal documentation that the resident received any Oxycodone during the May admission. On 10/28/19 review of the narcotic control sheet for the Oxycodone 5 mg tablets revealed a total of 4 doses of the medication had been removed from the resident's supply on 5/29/19. One dose at 8:00 AM, one dose at 12 noon, and two additional doses after the 12 noon dose were removed with a notation of wasted. Review of the nursing note dated 5/29/19 at 9:00 AM revealed the resident had a change in condition and was unable to swallow, was listless and responsive only…

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 interviews and observations of the kitchen with the testing of a food tray it was determined that the facility failed to serve food at a preferable temperature. This was identified on the unit that is the last to be served food. The findings include. Initial observations of the kitchen tray line food service on 10/21/19 at 7:40 AM revealed that there were not any plates in the plate warmer. The plate warmer was on and heat was felt. There were approximately 2 dozen plates sitting in the bottom plastic plate insulator behind the person that initiates the tray line. The plates were not handled appropriately to maintain heat prior to plating of the breakfast items. Interview of resident #105 on 10/21/19 at 11:12 AM, stated that this is the last unit to get food cart and sometime the people in charge of getting the food out take their time and the food comes cold or lukewarm. Interview of resident #46 on 10/21/19 at 12:57 PM indicated when s/he eats in the room the food is cold. During lunch time…

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