Villa Rosa Nursing And Rehabilitation, LLC

cite:Based on record review and interviews, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to resident who was discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 1 resident (#11) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 01/14/2026 at 2:15 PM, a review of the facility's SNF Beneficiary Protection Notification Review Worksheet indicated that 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.

cite:Based on observation and interview, it was determined that the facility failed to ensure adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment. This was evident during the Infection Control review conducted as part of the annual survey. This deficiency has the potential to affect all residents.The findings include:On 01/12/2026 at 10:55 AM, this surveyor observed a large hole in the ceiling in the Laundry room, in the clean clothes drying area. The hole exposed pipes, dust, and drywall. Photographs of the observation were taken at this time.On 01/12/2026 at 11:29 AM, this surveyor observed a large hole in the ceiling in the clean linen folding room. There was a ceiling fan near the edge of the hole, and the hole exposed pipes, dust, and drywall. Photographs of the observation were taken at this time.On 01/14/2026 at 09:45 AM, this surveyor conducted an interview with the Maintenance Director regarding building maintenance and plumbing concerns. The Maintenance Director reported that he has observed ongoing leaks in the…

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

Based on observations, interview and record review, it was determined that the facility failed to ensure that 1) an allegation of neglect was reported to the Office of Health Care Quality no later than 2 hours after the allegation was made. This was evident for 1 (Resident #61) out of 6 residents reviewed for neglect allegations and 2) to report the malfunction of the HVAC heating system to the State Agency the Office of Health Care Quality (OHCQ) in a timely manner. This was found to be evident for 1 out 8 Facility Reported Incidents (FRI) reviewed during the recertification survey.The findings include: 1) On 01/05/2026 at 3:15 PM, this surveyor conducted an interview with Resident #61. When asked whether the Resident had ever felt mistreated by a staff member, Resident #61 reported mistreatment by Geriatric Nursing Assistant (GNA) #5. Resident #61 stated that this concern was communicated to a family member, who then reported the concern to the facility, although the Resident was unsure to whom the report was made. On 01/07/2026 at 11:01 AM, this surveyor conducted a record review…

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

cite:Based on record review and interview, it was determined that the facility failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. This was found to be evident for 1 (Resident #61) out of 6 residents reviewed for allegation of neglect. The findings include:On 01/07/2026 at 11:01 AM, a record review of the facility's investigation file for a facility-reported incident of alleged neglect involving Resident #61 by Geriatric Nursing Assistant (GNA) #5 was conducted. The review showed that the initial report of the allegation was submitted to the Office of Health Care Quality on 10/29/2025 by the Administrator. The final investigation report was submitted to the Office of Health Care Quality on 11/04/2025, also by the Administrator. The report indicated that GNA #5 was suspended on 10/29/2025 and returned to work on 11/01/2025.A continued record review of the investigation file on 01/07/2026 at approximately 11:35 AM showed that the file included a statement from the Registered Nurse (RN) Unit Manager, dated 11/04/2025,…

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 record reviews and facility staff interview, it was determined that the facility failed to ensure 1) the resident/resident representative received the bed hold notification form in writing. This was evident for 1 (resident #79) of 2 residents reviewed for transfers during the recertification survey and 2) the local ombudsman was notified of facility discharges. This was evident for 2 (Residents #76 & #80) of 2 residents reviewed for discharges during the recertification survey. The facility implemented effective and thorough corrective measures after discovering the delay in ombudsman reporting prior to the start of this survey. Therefore, this deficiency was found to be past noncompliant with a compliance date of [DATE]. The findings Include: 1) On [DATE] at 1:00 PM, a review of the Facility Reported Incident (FRI) #2598892 investigation revealed Resident #79 fell while self transferring out of the wheelchair to the toilet in the bathroom. 911 was activated and the Resident was transferred to 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 review of records and interviews, it was determined that the facility failed to ensure a comprehensive care plan was developed and implemented for 1 (Resident #7) out of 1 residents reviewed for care plans during the recertification survey. The findings include:Care plans provide direction for individualized care of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 01/12/2026 at 9:58 AM, review of Resident #7 records revealed medical orders for: Encourage oral fluid intake 300 ML(milliliters) every shift. Fluids to be provided by a Licensed Nurse every shift. Activities of daily living are basic routine tasks that most healthy individuals can perform without assistance. These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. 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 interview and record review it was determined that the facility failed to ensure a resident was provided quarterly care plan meetings. This was evident for 3 (Resident#35,# 8 and #1) out of 26 Residents reviewed for care plan meetings during the recertification survey. The findings include: A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse with responsibility for the resident, nursing assistant with responsibility for the resident, dietary services, the resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly and as needed. 1) During an interview with Resident #35 on 1/05/2026 at 2:20 PM he/she denied having any recent care plan meetings. During a 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 medical record reviews, observations and interviews it was determined that the facility staff failed to follow procedures during wound care to a resident with a pressure ulcer. This was evident for 1 (#22) out of 5 residents reviewed for pressure ulcer care during the recertification survey.The findings include: A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on 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) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). 1. During a medical record review 1/06/26 at 1:41 PM it was revealed that Resident #22 had a Stage IV sacral pressure ulcer (PU) since 12/2024 and was receiving wound care…

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.

cite:Based on medication administration observation, medical record review, and staff interviews, it was determined that licensed facility staff failed to maintain a medication error rate of less than five percent during the medication pass observation. This was evident for 2 Residents (#85 and #16) of 10 residents observed. A total of 29 medication administration opportunities were reviewed, resulting in a medication error rate of 10.34%. The findings include:On 01/08/2026 at 6:26 AM, during a medication administration observation with Registered Nurse (RN) #17, was observed crushing Resident #16's medications; Tylenol 325 mg, two (2) tablets, and pantoprazole 40 mg, one (1) tablet and administering them mixed in applesauce. On 01/08/2026 at 6:30 AM, during reconciliation of Resident #16's Medication Administration Record (MAR), the physician's orders indicated Tylenol 325 mg, two (2) tablets by mouth at 6:00 a.m., and Pantoprazole 40 mg, one (1) tablet by mouth at 6:00 a.m. There were no orders to crush the medications or mix them in applesauce. On 01/08/2026 at 6:40 AM, review of…

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

citeBased on observation and staff interviews, it was determined that the facility failed to properly store medications, as evidenced by medications not being properly labeled or dated. This was evident in 1 of 2 medication rooms and 4 of 4 medication carts observed during the recertification and complaint survey. The findings include: On 01/12/2026 at 6:17 AM, during a medication cart observation on the 1st floor C and D-Wing with Registered Nurse (RN) #26, the surveyor observed opened medications without documented open dates or resident identification. Resident-specific medications included Resident #70's Albuterol and Ellipta inhalers, Resident #10's Albuterol inhaler, Resident #9's Simethicone (1 fl oz/30 mL), and Resident #1's Albuterol inhaler. Additional opened medications stored without identification or documented open dates included Calcium + D3 (1 bottle), Vitamin C 1000 mg (1 bottle), Vitamin D 125 mg (1 bottle), and Tylenol 500 mg (1 bottle). One Glucagon Emergency Kit with the label torn off was also observed without resident identification or a documented open date.…

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 resident medical records and facility staff interviews, it was determined the facility failed to maintain an accurate medical record. This was evident for 1 (Resident #56) of 1 resident reviewed during the annual recertification survey. The findings include:Diabetes Mellitus (DM) II : Is a condition characterized by high blood glucose (blood sugar) levels caused by either a lack of insulin or the body's inability to use insulin efficientlyOn 01/07/2026 at 9:48 AM, a review of Resident #56's Medical Record confirmed a diagnosis of Diabetes Mellitus (DM) II. Finger stick: A way to check your blood glucose level (BGL) using a lancet to prick the side of a fingertip (often the middle or ring finger), collecting a drop of blood on a test strip, and inserting the strip into a glucose meter to get a reading in seconds. BGL is measured in milligrams per deciliter, or mg/dL.On 01/07/2026 at 9:50 AM, a review of Resident #56's Treatment Administration Record (TAR) showed an order for: Check finger stick blood sugar (FSBS) before breakfast and Dinner call Medical Doctor (MD)…

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 the environmental equipment was functional. This was found to be evident for 2 out of 2 Solariums observed during the recertification survey.The findings include: On 01/05/2026 at 7:30 AM the Survey team conducted an unannounced entry of the facility to conduct a recertification and complaint survey. The night Registered Nurse (RN) #17 advised the team to have a seat because he needed to contact the Administrator and Maintenance Director to assign the Survey team a room because the usual room (1st floor B-wing Solarium) did not have heat. At 8:19 AM Licensed Practical Nurse (LPN) #4 met the Survey team and moved the team from the lobby of the facility to a room on the second floor C-wing. On 01/05/2025 at 8:30 AM the Assistant Director of Nursing (ADON) met with the team and explained that the room that is usually assigned to the Surveyors did not have heat and that the Maintenance Director was working on the heat. On 01/05/2026 at the end of the day the Survey team was moved…

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

Based on observations and interviews it was determined that the facility failed to provide residents with reasonable accommodations of needs. This was found evident of 5 (Resident #18, #11, #66, #81 & #2) out of 62 residents reviewed. The finding include: 1a) On 5/15/24 at 8:18 AM, the surveyor, along with Geriatric Nursing Assistant (GNA) Staff # 43, observed Resident #18 laying in bed. The surveyor asked Resident #18 where his/her call light was in case he/she needed to call for assistance. Resident #18 stated he/she did not know. At this time Staff #43 picks up the call light cord from behind Resident #18's bed and clips it to Resident 18's bed. Staff #43 confirmed that the call light was out of reach and should have been placed back in bed after it was removed. On 5/15/24 at 12:15 AM, the surveyor reviewed a progress note written on 2/24/24 by Licensed Practical Nurse (LPN) Staff #46. The note stated Resident #18 was a new admission adjusting well. It further stated Resident #18 demonstrates appropriate use of the call bell this day. On 5/16/24 at 9:59 AM, the surveyor informed…

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 facility staff interview it was determined the facility failed to maintain a safe, clean and comfortable home like environment free of possible hazards. This was evident for 5 residents ( # 40, #67, #24, #85, & #542) out of 62 residents observed for home like environment and 4 out of 6 shower and bathing environments observed in the facility. The findings include: During tour of the facility on 05/13/24 at 9:215 AM, surveyors observed: In Resident # 40's room: - Extensive paint damage on all walls (peeled/removed). - One green Geri- chair (a large padded chair with a wheeled base, designed to assist seniors with limited mobility) a the resident's -bedside with tattered arm rests, inner material visible. - A mattress air flow device attached to the foot of the resident's bed, with it's black power cord on the floor, plugged into an electrical wall socket located a the base of the wall opposite the resident's bed; the cord covered a distance of approximately 3 feet, cord approximately 10…

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

Based on medical record review and interview, it was determined that the facility staff failed to timely report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation was made. This was evident for 5 (Resident #57, #34, #93, #51, and #19) out of 30 residents reviewed for facility self-report incidents during an annual survey. The findings include: 1). Review, on 05/29/24 at 10:25 AM, of the facility's self-report investigation file revealed that the Assistant Director of Nursing (ADoN) documented on the Facility's Incident Investigation Form in reference to Resident #57 incident the time was on 06/28/23 at 3:00 PM. Based on the allegation of abuse/harm, the facility's self-report (MD00193871) had to be sent to the State agency no later than 2 hours after the incident had occurred or was reported. Further review revealed that staff had sent the facility self-report to the State agency, on 06/28/23 at 5:37 PM, 2 hours and 37 minutes later. During the interview, on 5/30/24 at 09:30 AM, the…

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

Based on record review, and interviews, it was determined that the facility failed to: 1) thoroughly investigate alleged violations of abuse, and 2) prevent further potential of abuse while an investigation was in process. This was found evident of 6 (Resident #91, #108, #2, #19, #93, & #21) of 30 residents investigated for Facility Reported Incidents(FRI). The findings include: 1a) On 5/14/24 at 10:33 AM, the surveyor reviewed Resident #91's medical record. The review revealed that Resident #91 was admitted to the facility in late 2022 and had a past medical history that included, but not limited to, bilateral primary osteoarthritis of knee, adult failure to thrive, unspecified protein-calorie malnutrition, signs involving cognitive functions and awareness, difficulty in walking, and muscle weakness (generalized). Further review revealed Resident #91 was assessed with a Brief Interview for Mental Status (BIMS) assessment and received a score of 15, the highest score, indicating he/she was cognitively intact. On 5/14/24 at 11:12 AM, the surveyor reviewed the investigation report 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 interviews and medical record review it was determined the facility failed to provide notification to the Ombudsman and the Responsible Party of the residents that transferred to the hospital. This was evident for 7 residents (#19, #44, #6, #41, #62, #71, and #40) out of 7 residents reviewed for hospitalizations. The findings include: 1) During a phone interview on 5/15/24 at 11:43 AM with Resident #19's daughter, the daughter stated that Resident #19 has had 2 hospitalizations recently. On 5/21/24 at 7:45 am the surveyor reviewed Resident #19's medical record. The review of the medical record revealed that Resident #19 was transferred to the hospital on March 4, 2024, and May 4, 2024. Further review of Resident #19's medical record revealed that there was no documentation that the facility Ombudsman was notified of Resident #19's transfer to the hospital on 3/4/24 or on 5/4/24. The Director of Nursing at 11:20 am on 5/23/24 conveyed to the surveyor that they are unable to locate documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 4 (#41, #62, #71, and #40) of 7 residents reviewed for hospitalizations during the annual survey. The findings include: 1. On 05/22/2024 at 06:55 AM, an interview conducted with the Director of Nursing (DON) revealed that the staff responsible for keeping record of written bed hold notices from 2019-2023 no longer works at facility. The DON further stated that the current Business Manager is new to the facility and is not familiar with where records of the bed hold notices are kept. On 05/28/2024 at 09:15 AM, a review of Resident #41's electronic medical record revealed that Resident #41 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 06/02/2023, 03/26/2024 and 05/21/2024. Further review of Resident #41'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 clinical record review and staff interview it was determined that the facility staff failed to ensure a baseline care plan was created within the required 2 days and ensure a written summary of the baseline care was provided to the resident/resident representative. This was evident for 4 Residents (#542, #41, #58, and #71) out of 62 residents in the survey sample. The findings include: The baseline care plan must be completed within 48 hours of admission. It must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission. 1. A review of Resident #542's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for: 1) residents with a history of seizure disorder currently taking medication for the condition, 2) a resident prescribed opioids for pain relief, and 3) a resident's pressure ulcer and a fungal skin infection. This was evident for 4 residents (Residents #60, #65, #96 and #64) out of 62 residents with care plans reviewed during the annual survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. 1a.On 5/23/2024 at 1:18 PM, during review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, it was determined that the facility failed to ensure care plans were reviewed and revised after 1) a resident's hospitalization and quarterly assessment and 2) a resident whose medication for depression was discontinued. This was found to be evident for 2 residents ( Res. #60 and Res. #64) out of 8 residents reviewed for care plans during the annual survey. The findings include: 1) A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. On 5/23/2024 at 1:18 PM, During review of Resident #60 electronic medical record, the Surveyor discovered that the resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, it was determined that the facility failed to provide on-going personalized activities to meet the resident's needs and failed to inform or offer a resident the opportunity to attend facility activities. This was evident for 4 (Resident #34, #60, #65, & #542) out of 6 residents reviewed for the personalized activities during the annual survey. The findings include: 1) Observation, on 5/14/24 at 09:43 AM and 5/15/24 at 10:05AM for over an hour each time, found that Resident#4 was able to feed herself, change his/her position from side to side and clean her bedside table. However, the resident was confined to his/her room, dozing off after breakfast with the TV on. During another observation and interview, on 05/14/24 at 1:00 PM, Resident #34 stated I would like to go for group activity sometimes. There was no evidence that the activity staff provided any social group or one-to-one activity adequate provision of personalized activities. Record review, 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 employee record reviews and interviews it was determined that the facility failed to ensure that the required Geriatric Nursing Assistant performance reviews were completed. This was evident in 4 out of 4 Geriatric Nursing Assistants (GNA) #6,12, 23 and 24 employee files reviewed for required performance reviews. The findings include: On 5/30/24 at 9:57 AM, the surveyor reviewed 4 Geriatric Nursing Assistant (GNA) employee files #6,12, 23 and 24. During the review of the 4 employee files the surveyor discovered that the facility did not have current performance reviews in the employee files for all 4 GNAs #6,12, 23 and 24 for 2023 and 2024. At 12:30 PM on 5/31/24 the surveyor interviewed the Director of Human Resources #37 and the Interim Nursing Home Administrator (NHA). During the interview the surveyor informed the Director of Human Resources and the Interim NHA that the 4 GNAs #6,12, 23 and 24 employee files did not contain any performance reviews for 2023 and 2024. The Director of Human Resources confirmed that the 4 GNA employee files #6,12, 23 and 24 did not have…

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 interviews, it was determined that the facility staff failed to ensure the safety of food products and food service areas. This was evident for food storage areas reviewed during an annual survey. The findings include: During observation of the facility kitchen on 05/13/24, the surveyor observed vanilla flavoring boxes with a handwritten date of 1/11/22. During an interview with Staff #49 on 5/13/24 at 9:30 AM, she was asked about the date written on the vanilla flavoring boxes and the shelf life. Staff #49 stated that's the date it came in, then confirmed it, she said she thought they lasted a couple of years but was unsure. During observation of the facility kitchen on 5/14/24 the surveyor observed two busted cans of ginger ale that were in the stand up freezers and were split almost in half. They were sitting in a container of frozen lemon ice cups. During observation of the facility kitchen on 5/14/24, the surveyor observed a jar of grape jelly opened to 3/4 full in a dry storage room. The label recommended refrigeration after opening. During an…

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

Based on employee record reviews and interviews it was determined that the facility failed to ensure that the required in-service training for Geriatric Nursing Assistants was completed. This was evident in 2 (Geriatric Nursing Assistants (GNA) #23 and #24) out of 4 employee files reviewed for required in-service training records. The findings include: On 5/30/24 at 9:57 am, the surveyor conducted a record review for 4 Geriatric Nursing Assistant (GNA) employee files #6, 12, 23 and 24. During the review of the 4 employee files the surveyor discovered that the facility had incomplete required in-service training for 2023 and 2024 for 2 GNAs #23 and #24. At 12:30 pm on 5/31/24 the surveyor interviewed the Interim Nursing Home Administrator (NHA). During the interview the surveyor informed the Interim NHA that GNA employee files had incomplete in-service training for 2023 and 2024 for 2 GNAs #23 and #24. The Interim NHA confirmed that there was incomplete in-service training for the 2 GNAs #23 and #24 for 2023 and 2024. The Interim Nursing Home Administrator stated that she would look…

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

Based on observation, record review, and interview with residents and staff it was determined that the facility failed to maintain and enhance the dignity of residents. This was evident for 1 (Resident #81) out of 3 residents reviewed for dignity during the annual survey. The findings include: A Hoyer lift is a mechanical lifting device that allows a person to be lifted and transferred to the bed or chair with a minimum of physical effort. On 5/14/2024 at 1:37 PM, during a tour of the first floor B Unit, the Surveyor noted Resident #81 in the doorway of his/her room, sitting in a wheelchair with a Hoyer pad underneath him, and his head down. The resident's call bell was alarming. The Surveyor conducted an interview with the resident and discovered that he/she had been sitting there for over 40 minutes waiting for someone to assist him/her back to bed. The resident stated that a Geriatric Nursing Assistant (GNA) left him/her there to locate a Hoyer lift to transfer him/her back to bed. Resident #81 mentioned that he/she had not been happy lately and was very upset because finding a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff it was determined that the facility failed to support resident choices. This was evident for 2 (Resident #85 and #542) out of 4 residents reviewed for choices during the annual survey. The findings include: Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. During an interview conducted on 5/14/2024 at 9:04 AM, Resident #60 informed the Surveyor that he/she would like to go to Mass services in the morning, but he/she must wait for the Geriatric Nursing Assistant (GNA) to finish up with the other residents before they can assist him/her with ADLs for the day. The resident stated he/she must wait until about 11:00 AM before the GNA can get to him/her. The resident also mentioned that, on the days of Mass, he/she would like to be assisted with ADLs first thing in the morning so he/she can attend services. While…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to protect a resident, who was dependent on staff for turning and repositioning, from falling out of bed during care. This was evident for 1(Resident #65) of 1 resident reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological, and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It also outlines what needs to be done to plan, assess, and manage care. This helps to evaluate the effectiveness of the resident's care. Activities 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 medical record review and interviews, it was determined that the facility staff failed to initiate appropriate bladder and bowel interventions to maintain dignity for (Resident #85). This was evident for 1 of 61 residents reviewed during an annual survey. The findings include: During an interview with Resident #85 on 05/13/24 at 11:13 AM, the resident stated that he/she could walk but had consistently worn a brief since admitted to the facility. He/she expressed the desire to use the bathroom. Resident #85 stated that he/she walks to therapy and other areas in the facility using a walker. During an interview with GNA #35 on 05/21/24 at 09:59 AM they were asked about the care she provided for Resident #85. GNA #35 stated she gave him/her a shower, oral care, and assisted with transfer to wheelchair. She also stated the resident stays in the room, he/she uses a walker to transfer to a wheelchair, and he/she would try to get to the bathroom. GNA #35 confirmed the resident wore briefs and occasionally used a urinal but she cleaned him/her up during her morning shift. GNA #35…

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 label and store medications appropriately. This was evident in 1 (Resident #27) out of 1 Resident for medication labeling and storage. The findings include: During the initial tour of the second floor Nursing Unit A at 7:49 AM on 5/14/24 the surveyors observed Resident #27 in bed with medications at his/her bedside. The surveyors observed 2 medication cups, one sat inside the other on the overbed tray table. There were 2 small white tablets in one of the medication cups and an orange-colored tablet in the other medication cup. The surveyors interviewed Licensed Practical Nurse (LPN) #1 at 8:09 AM on 5/14/24 who observed the medications at the bedside, 2 small white tablets and an orange-colored tablet in the medication cups. LPN #1 stated to the surveyors that she was unsure of what the medications were and that she had not given the medications to Resident #27. LPN #1 further indicated that she did observe Resident #27 take the 8:00 AM medications that were scheduled to be…

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

Based on record review and interview with residents and staff, it was determined that the facility failed to ensure a resident requesting dental services received a timely appointment. This was evident for 1 (Resident #60) out of 2 residents investigated for dental services during the annual survey. The findings include: During an interview conducted on 5/14/2024 at 9:00 AM with Resident #60, the resident stated, I need to go to the dentist. The resident informed the Surveyor that he/she has not received any dental services while residing at the facility. On 5/24/2024 at 8:15 AM, review of Resident #60's electronic medical record revealed a nursing progress note written on 10/03/2023 at 12:08 PM written by Licensed Practical Nurse (LPN) #56 stating that the resident was requesting for [Company] dental. Additional record review revealed a nursing progress note dated 2/25/2024 at 8:33 AM written by LPN # 57 which stated Resident #60 was complaining of a toothache and another nursing progress note dated 2/25/2024 at 3:05 PM, stated that an order for pain relief medication and an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure medical records were complete by voiding old MOLST forms when new MOLST forms were completed. This was evident for 1 (Resident #60) of 62 residents reviewed during the annual survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. A full code provides full support, including CPR, and allows all interventions needed to restore breathing and/or heart functioning. During review of Resident #60's electronic medical record on [DATE] at 9:20 AM, the Surveyor discovered the 2 MOLST forms. The first completed MOLST form was signed and dated [DATE], certifying 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.

The facility failed to ensure that a staff member implemented appropriate processes related to handling and storing of a shared resident medical equipment. As a result, the potential existed for transmission of organisms between residents who received assessments of their blood pressure during medication observation. This was evident for 2 Residents (#2 and #68) of 5 observed during medication administration. The findings include: On 05/30/24 at 11:02 AM a Licensed Practical Nurse (LPN), Staff #19, was observed during medication administration to remove a blood pressure machine from the medication cart, apply the blood pressure cuff onto Resident #68's left arm, and place the attached digital screen on the resident's bedside table. After completing the assessment, Staff #19 placed the machine on the medication cart. On 5/30/24 at 11:18 AM surveyors conducted an interview with Staff # 19 promptly after the observation which revealed that Staff #19 confirmed that the blood pressure machine was for use with all residents for whom she was assigned. Staff #19 confirmed that she 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 observation and interview, it was determined that the facility staff failed to maintain an adequate functioning call system in resident bathrooms. This was evident for 2 (Resident #85 and #542) of 62 residents reviewed during the annual survey. The findings include: During observation of Resident #85's room on 05/13/24 at 11:13 AM, surveyor observation determined an inadequate call system in Resident #85's bathroom. The call system was missing the string that is to be pulled for residents to access. During observation of Resident #542's room on 05/13/24 at 11:21 AM, surveyor observation determined an inadequate call system in Resident #542's bathroom. The call system was missing the pull cord used for emergencies. During interview with Maintenance Director (Staff # 17) on 05/21/24 at 01:07 PM, he was asked about what the resident bathroom call system configuration consisted of in the facility. Staff #17 confirmed he is new to the facility, some of them have strings, some have chains, and he was not familiar with call systems. He stated he would have to ask the nurses, he…

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 that a handrail was secure. This was found to be evident for 1 out of 5 handrails tested during the annual survey. The findings include: During an observation on 05/16/2024 at 10:08 AM, the surveyor observed that the handrail to the left of the 1C Bath door was lose on the wall. The Maintenance Director was shown where the rail was loose from the wall on 05/16/2024 at 10:15 AM. The Maintenance Director stated he would fix it right away. The Administrator was shown the loose handrail on 05/16/2024 at 12:23 PM. She stated they would get it repaired as soon as possible. The surveyor and the Administrator observed that the handrail was tighter but still loose on 05/31/2024 at 8:57 AM. The Administrator called the Maintenance Director who stated he would fix it right away. The Administrator showed the surveyor at 05/31/2024 at 9:09 AM that the siderail was secure and stated the Maintenance Director was inspecting the remaining siderails in the building.

Based on observation, interview, and record review, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of a pest in the hallway. This was found to be evident for the 1B hallway. The findings include: On 05/15/2024 at 7:46 AM, the surveyor and GNA #2 observed a cockroach crawl up the wall and behind a picture outside of room B130. The surveyor pointed to the wall and asked what's that? GNA #2 responded, That's a cockroach crawling up the wall. She further stated, we do see cockroaches here and there. More upstairs than down. The residents upstairs have more stuff in their rooms because they are long term. The surveyor asked if she had seen any other pests and GNA #2 stated, I have never seen any mice or other pests. On 05/15/2024 at 11:30 AM, the Administrator informed the surveyor that the pest management company would be coming to do an additional treatment that day. The surveyor observed the pest management company treating the facility on 05/15/2024 at 1:29 PM.

Based on record review, and interviews it was determined that the facility failed to accurately assess a resident. This was found evident of 1 (Resident #96) out of 62 residents reviewed during an annual and complaint survey. The findings include: On 5/15/24 at 10:47 AM, the surveyor reviewed Resident #96's medical record. The review revealed that Resident #96 was admitted to the facility in late February 2023 and had a past medical history of, but not limited to, difficulty walking, muscle weakness, seizures, and cerebral infarction (stroke). The surveyor further reviewed the hospital admission history and physical dated January 31st 2023. In the assessment and plan section seizures were listed. It further stated seizures resulted from an anterior cerebral artery (aca) stroke. The plan further stated, continue home lamotrigine 150 mg twice daily (a medication prescribed to prevent seizures) and sertraline 75 mg daily (a medication prescribed to treat depression). On 5/22/24 at 12:04 PM, the surveyor reviewed the Medication Administration Record (MAR) for Resident #96. The review…

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

Based on record review, and interviews it was determined that the facility failed to accurately dispense and record medications as per scheduled ordered time. This was found evident of 1 (Resident #103) of 5 Residents reviewed for pain management. The finding include: On 5/14/24 at 11:41 AM, the surveyor reviewed Resident #103's medical record. The review revealed that Resident #103 was admitted in early November 2022. Further review revealed that Resident #103 was prescribed a pain medication, oxycodone, on 11/3/22. The order was for oxycodone 5 mg every 6 hours as needed for pain. In review of the progress note dated, 11/7/22, Licensed Practical Nurse (LPN) Staff #30 wrote; Resident continues to complain of pain to his/her right knee. It further stated the Medical Director evaluated Resident #103 and wrote orders for routine oxycodone to be given at 7 AM along with the as needed oxycodone. On 5/15/24 at 7:56 AM, the surveyor reviewed Resident #103's Medication Administration Record (MAR). The review revealed that oxycodone 5 mg was scheduled to be given at 8 AM starting 11/8/22.…

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.