Lorien Health Systems Mt Airy

Based on review of facility documentation and interview, it was determined the facility staff failed to have a social service director and a medical director participate monthly in the facility's Quality Assessment Performance Improvement (QAPI) committee meetings.The findings include:Review of the monthly QAPI sign-in sheet for August 2024, the medical director signature block indicated Leave of Absence (LOA) and March 2025 and June 2025, the social service director signature block indicated Leave of Absence (LOA).During an interview on 08/13/2025 at 11:41 AM with the Director of Nursing (DON), and staff # 4, the DON stated that there is no designated person for the Medical director, and the facility had one social services worker, who is the director. Staff #4 stated that he/she would discuss the information from the QAPI meeting during the risk management meeting with the members who were absent from the QAPI committee meeting.On 08/13/2025 at 11:48 AM staff #4 stated that he/she acted as the designee for the Social Services Director and the facility had a covering 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 interview, record review, document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal abuse perpetrated by staff. This deficient practice affected 2 (Resident #3 and Resident #5) of 18 sampled residents. Findings included: A facility policy titled, Abuse Policy, revised 02/06/2025, indicated, It is the policy of [facility name] to: Maintain a ZERO tolerance of ANY form of abuse or neglect of a resident. The policy specified, Verbal Abuse - The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. 1. An admission Record indicated the facility admitted Resident #3 on 05/12/2022. According to the admission Record, the resident had a medical history that included diagnoses of pulmonary embolism, cognitive communication deficit, hypertension, and history of falling. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 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 the review of a facility reported incident, record review, interview with staff and observations, it was determined that the facility failed to administer medications to residents according to facility policy and standard nursing practice for resident medication rights. This was evident for 1(Resident #8) of 3 residents reviewed related to medication administration. The findings include: According to the state nurse practice act the five main medication rights to ensure as a licensed nurse that medications are administered safely are to verify prior to administration the; right person, medication, dose, time and route. Review of the facility reported incident MD00190869 on 2/18/25 at 10:37 AM revealed a concern related to an RN, identified as staff #108, who admitted that on 4/2/23 she prepared medications for 2 different Residents, 8 and #12 at the same time. RN #108 then proceeded to the room of Resident #108 with both medicine cups, respectively labeled for each resident. According to the statement from staff #108 included in the facility investigation packet, as she…

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

Based on the review of a complaint, medical records, facility policy and procedures and interview with staff, it was determined that the facility failed to have processes in place to ensure for the daily care and potential complications of residents' percutaneous endoscopic gastrostomy tubes (PEG inserting a feeding tube directly into the stomach through the abdominal wall). This was evident during the review of 5 (Residents #4, #6, #16, #17, #18) of 6 residents with PEG tubes secondary to a complaint during a complaint survey. The findings include: Review of the complaint #MD00203009 on 2/18/25 at 12:53 revealed concerns related to the care of and replacement of a PEG tube for Resident #6 after it inadvertently came out. After the replacement of Resident #6's PEG tube on 2/3/24, the complainant reported that according to the hospital, there was too much water in the balloon and that s/he was vomiting repeatedly, that's why the family requested the x-ray. Further review currently revealed diagnosis of Resident #6 including admission post anoxic brain injury (a condition where the…

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

Based on the review of a facility reported incident, record review, interview with staff and observations, it was determined that the facility failed to administer medications to residents without any significant medication errors. This was evident for 1(Resident #8) of 3 residents reviewed related to medication administration. The findings include: Review of the facility reported incident MD00190869 on 2/18/25 at 10:37 AM revealed a concern related to an RN, identified as staff #108, who admitted that on 4/2/23 she prepared medications for 2 different residents, #8 and #12 at the same time. RN #108 then proceeded to the room of Resident #8 with both medicine cups, respectively labeled for each resident. According to the statement from staff #108 included in the facility investigation packet, as she left the room for Resident #8 and proceeded to the room for Resident #12, it was then she realized that she still had the medicine for Resident #8 and that she had administered the medication for Resident #12 to Resident #8. Medical record review for Resident #8 revealed diagnosis 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations and staff interviews it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the nursing unit and resident rooms in clean and good repair. This was evident during environmental tours conducted on 2 of 2 nursing units during the annual survey. The findings include: On 12/14/22 at 9:13 AM an environmental tour was conducted with the Director of Maintenance, Staff #36. The following environmental and housekeeping observations were shown to Staff #36 and discussed: The ceiling tile outside of room [ROOM NUMBER] in the hallway had an approximate 6 inch brown circular stain. In room [ROOM NUMBER] the wall to the right of the door and under the window had areas of spackle over the paint. In the bathroom the over the toilet riser was rusted in the front by the seat and by the back hinge. In room [ROOM NUMBER]A the privacy curtain had many stained marks and there was paint peeling above the door by the ceiling. There were areas 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 the medical record review and staff interview, it was determined that the facility failed to provide treatment/services to maintain vision. This was evident for 2 (#16, #29) of 3 residents selected for reviews of vision care during the annual survey. The findings include: 1) A review of Resident #16's medical record on 12/07/22 revealed that Resident #16 was seen and assessed by the facility's eye physician on the following days and prescribed medications to treat the following conditions: a) on 07/19/22, Resident #16's eye physician documented that Resident #16 suffered from a history of Corneal neovascularization of the right eye, had Conjunctival hyperemia in both the right and left eyes that were getting worse, and that both eyes have long-standing tenderness that comes and goes, and both are light sensitive. Resident #16's eye physician documented these findings in a consultation note and indicated the plan was to administer in a New Medication Order, 1) Ocuoft Lid Scrubs Plus Pads, apply 1, Both eyes, twice daily indefinitely. Apply with eyes closed, go from inside 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 medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure parameters for administering Carvedilol and Midodrine, blood pressure medications, and physician ordered glucose parameters for Levemir, which is a long acting insulin that helps control blood sugar levels. This was evident for 2 (#3, #21) of 7 residents reviewed for unnecessary drugs during the annual survey. The findings include: 1) On 12/13/22 at 10:09 AM a review was conducted of Resident #3's medical record. Review of physician's orders that were written on 7/13/22 revealed the order, Carvedilol 12.5 mg. give 1 tablet enterally (via tube) in the morning for Afib (atrial fibrillation). Hold for SBP (systolic blood pressure) less than 110, HR (heart rate) below 80. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and documentation review, it was determined the facility failed to ensure that, 1) equipment was maintained in proper working condition, 2) sanitary practices were followed while preparing food, and 3) food temperatures were consistently monitored and documented. This was evident during 2 of 2 visits to the facility kitchen during the annual survey. The findings include: 1a. On 12/5/22 at 9:20 AM a tour of the kitchen with the Certified Dietary Manager (CDM) #5 was conducted. Observation was made of the freezer that had small ice mounds on the ceiling in front of the 2 condenser fans. CDM #5 stated that they have had the freezer checked a couple of times. A second observation was made of the freezer on 12/9/22 at 11:59 AM with Staff #41. There were ice mounds on the ceiling and were starting to spread towards the door. Staff #41 stated that the company for the freezer had been notified a few weeks ago and they were still waiting for a callback. Staff #41 stated that the freezer…

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 the reviews of a medical record, observation, and interviews with staff, it was determined that the facility staff failed to maintain a medical record in the most accurate form. This was evident for 4 (#16, #48, #20, #21) of 34 residents reviewed for medical record accuracy during an annual recertification survey. The findings include: A medical record is an official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) A review of Resident #16's December medication administration record (MAR) on 12/12/22 at 9:22 AM, revealed an order instructing the nursing staff to apply a Calcium Alginate Dressing, to the right buttock, topically, every day shift for wound care. First, cleanse with normal saline, pat dry and apply treatment, cover with dry, protective, dressing (DPD), to start on 10/12/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident was offered the opportunity to develop an advance directive for 2 (#22, #55) of 2 sampled residents for advance directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will be made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining…

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 facility staff failed to protect Resident #261's right to confidentiality of his/her medical record. This was evident during a random observation on 1 of 2 nursing units. The findings include: On 12/14/22 at 8:57 AM observation was made of an unlocked and unattended medication cart sitting in the hallway on the Prospect nursing unit. There was a laptop computer sitting on the top of the medication cart that was opened and displayed Resident #261's medication administration record (MAR). The surveyor stood at the medication cart until 9:00 AM when Staff #34 walked up to the medication cart. The surveyor asked Staff #34 if she knew that she left the resident's information on the computer screen open and on display. Staff #34 stated that she just went down the hall to get something for the resident. The surveyor asked where she was down the hall and Staff #34 stated she was down the hall and around the corner, out of sight of the medication cart. Staff #34 stated that she didn't mean to leave the medication cart unlocked and 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 the reviews of a medical record, observation, and interviews with staff, it was determined that the facility staff failed to revise the physician wound care orders. This was evident for 1 (#16) of 5 residents reviewed for pressure sores during an annual recertification survey. The findings include: 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 to 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). A review of Resident #16's December medication administration record (MAR) on 12/12/22 at 9:22 AM, revealed 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 medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in the resident's drug regimen to the physician, facility's medical director and the director of nursing. This was evident for 1 (#3) of 7 residents reviewed for unnecessary medications. The findings include: On 12/13/22 at 10:09 AM a review was conducted of Resident #3's medical record. Review of physician's orders that were written on 7/13/22 revealed the order, Carvedilol 12.5 mg. give 1 tablet enterally (via tube) in the morning for Afib (atrial fibrillation). Hold for SBP (systolic blood pressure) less than 110, HR (heart rate) below 80. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. The order was not clear as it did not state if the medication should be held when both parameters were not met, or just 1…

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

Based on observation, staff interview, and documentation review, it was determined facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 2 nursing units observed during the annual survey. The findings include: On 12/14/22 at 8:57 AM observation was made of an unattended and unlocked medication cart sitting in the hallway on the Prospect nursing unit. On top of the medication cart was a 30 ml. plastic medicine cup with 7 pills in the cup. The computer screen on top of the medication cart was opened to Resident #261's Medication Administration Record (MAR). The surveyor was able to open all the drawers in the medication cart. In the second drawer observation was made of 2 plastic 30 ml. medication cups. The bottom cup contained 3 pills and the second medication cup, which was sitting inside the other medication cup contained 1 pill. At 9:00 AM Staff #34 walked up to the medication cart and the surveyor asked her if she realized she left the cart unlocked while unattended. Staff #34 stated she just went down the hall to get a tube of cream. The…

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

Based on observation and staff interviews it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to follow infection control guidelines during the handling of linens. This was evident for random observations made during the tour of the Prospect unit. The findings include: 1) Observation was made of the Prospect Unit on 12/5/22 at 9:15 AM. The surveyor observed Geriatric Nursing Assistant, GNA #7, attempting to pull out clean linens from a linen cart that was in the hallway by room N09, but the linen she pulled out of the cart fell on to the floor. GNA #7 picked up the linen from the floor and using the same hand reached into the clean linen cart and pulled out more linen. She then placed them on top of the ones she picked up from the floor and using the same hand picked up a piece of paper that was laying on the floor. GNA #7 then went into room N09 and placed the linen on the windowsill. Without…

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 with facility staff, it was determined that the facility staff failed to develop and implement a comprehensive, resident-centered care plans to meet the distinct needs of residents with dementia. This was evident for 2 (#48 and #22) of 27 resident reviewed during this survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) A medical record review, on 6/3/19 at 8:19 AM, for Resident #48, revealed the resident was admitted with a diagnosis of dementia, however, staff failed to have a care plan for dementia. 2) On 5/30/19 at 7:13 AM, a medical record review for Resident #22, revealed the resident was admitted with dementia with behavioral outburst. Review of the care plan revealed a focus of impaired brain function, because of the dementia, with a goal that stated, I (the resident) will be able to communicate basic needs on a daily basis through the review date and the interventions were standard, such as keep…

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

Based on observation and medical record review, it was determined that facility staff failed to treat residents with dignity and respect by failing to provide mealtime assistance to eat in timely manner to a resident who was dependent on staff . This was evident for 1 (#44) of 27 residents in the final sample. The findings include: During an observation of a resident dining experience, on 5/28/19 at 12:32 PM, there were 2 Geriatric Nursing Assistants (GNA) #13 and GNA #14 in the dining room to assist residents. Resident #44 sat at a table of 7 residents. It was noted that the resident's food remained uncovered and sitting in front of him for 15 minutes until more staff arrived to help feed the other residents. During a review of this resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/19 on 5/28/19 at 1:00 PM, revealed resident was totally dependent on staff. Director of Nursing was made aware of these findings on 6/3/19 at 11:20 AM.

Based on resident interview, medical record review, and staff interview, it was determined that the facility failed to have a process in place to provide prior notice of care plan meetings to the resident. This was evident for 1 (#49) of 27 residents reviewed for care plans during the survey. The findings include: An interview with Resident #49 on 5/31/19 at 11:53 PM, revealed the resident was unaware of the purpose of and their right to attend a care planning meeting. Resident reports he/she has never been to a care planning meeting. During a review of the resident's medical record on 5/31/19 at 10:56 AM, it was noted that the baseline care plan meeting roster did not have a signature for the resident. An interview was conducted with Registered Nurse (RN) #10 on 5/31/19 at 11:10 AM. RN #10 reported that the family had invited the resident, but s/he declined to come. RN #10 added that although she never interviewed him/her, the resident was confused and would not have been able to make good decisions regarding their care. An interview on 5/31/19 at 12:50 PM, with the Social Work…

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, the facility failed to 1) ensure that resident records remained secure and confidential, and 2) provide privacy for a resident while they were receiving care. This was evident for 1 of 3 observations of medication administration and for 1 (#49) of 1 resident reviewed for privacy. The findings include: 1) A medication observation took place on 5/31/19 at 7:50 AM. During the observation, Licensed Practical Nurse (LPN) #1 stated that s/he needed to return to the nurse's station to obtain medication for Resident #23 that was not available at the medication cart. LPN #1 left the medication cart at 7:53 AM but did not lock the screen, leaving Resident #23's protected health information visible on the screen. The cart was sitting in front of room [ROOM NUMBER] and the screen, fully open, faced into the room. LPN #1 returned to the cart at 7:54 AM. LPN #1 continued to prepare medication for Resident #23 and again stated that s/he needed to return to the nurse's station to obtain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to document accurately the medication administered to a resident on the Minimum Data Set (MDS). This was evident for 1 (#32) of 27 residents reviewed during the survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: Review of Resident #32 medical record on 5/31/19 at 1:00 PM, revealed the resident was ordered Xarelto 20mg (milligram) by mouth daily for chronic Atrial fibrillation. Xarelto is a blood thinner medication or anticoagulant. Further review of the medical record revealed on 1/30/19, the medication was placed on hold due to vaginal bleeding until lab results were obtained. Continued review of the medical record revealed the lab results were…

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 record and interview with staff, it was determined that the facility staff failed to develop a baseline care plan and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 1 (#49) of 27 residents reviewed for care plans. 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. A record review for Resident #49 on 5/31/19 at 10:56 AM, revealed that the resident was admitted with a feeding tube (tube in the stomach to receive nutrition), aspiration precautions, pacemaker, and skin breakdown. However, the baseline did not include guidance to the care team regarding these medical issues and the specialized care for this resident. An interview with Registered Nurse (RN) #10, revealed that she does not consistently print baseline care plan and medication list to give to the resident/representative in 48 hours. She states, I will take the hit on this one because she…

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

Based on observation, medical record review, and staff interview, it was determined that facility staff failed to evaluate and update a resident's care plan to reflect current needs and preferences. This was evident for 1 (#22) of 27 residents reviewed for care plans. 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. During an observation of Resident #22 on 5/29/19 at 10:32 AM, Resident #22 was seated in the dining room, while the Activities Aide Staff #6 was playing a game of bingo. Resident's back was to Staff #6 as he called the Bingo numbers and resident was not engaged. A review of the resident's medical record on 5/30/19 at 7:13 AM, revealed that a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/19 had been completed. However, review of the1/26/18 care plan revealed a focus for activities with a goal that resident would like music programs, 1:30 PM church services, and special events. The interventions were initiated in…

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 records and interview with facility staff, it was determined that the facility failed to ensure that residents remained free of accidents while being transferred by facility staff. This was evident for 1 (#1) of 3 residents reviewed for accidents. The findings include: Resident #1's medical record was reviewed on 5/31/19 at 9:28 AM. During the review, a note was found that had been written in early November, 2018, that stated, Resident received bump at right forehead from Hoyer arm when transferring by Hoyer from bed into shower chair today. Attending physician in building at the time, assessed [him/her] right away . Pressure dressing and ice applied. Neuro checks have been stable per bedside nurse since incident. Resident also has reddened sclera of left eye. Attending physician stated it is a ruptured vessel, and is expected to resolve without intervention. A Hoyer lift is an assistive device that lifts a resident out of bed using a sling that is placed under the resident. It is used for residents who are completely dependent on staff to exit the bed.…

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 what the physician documented in the resident's progress notes, did not accurately reflect what was in the resident's medical records. This was evident for 2 (#12, #32) of 27 residents reviewed in final sample. The findings include: 1.Review of resident #12's medical record on 5/30/19 at 2pm, revealed two physician's progress notes, dated 4/28/19 and 5/11/19. Both physician progress notes revealed that the physician documented the resident was receiving Lorazepam 0.25mg (milligrams) by mouth twice a day for Anxiety. Further review of the medical record revealed a physician order, dated 4/16/19, and clarified on 4/20/19, to decrease the resident's Lorazepam 0.5mg to Lorazepam 0.25mg three times a day due to excessive sedation. During interview with the physician on 6/1/19 at 4pm, s/he stated, the nursing staff informed me that the resident was receiving the medication twice a day. 2. Review of resident #32 medical record, on 5/31/19 at 10am, revealed a physician order, dated 1/11/19, to administer Xarelto 20mg…

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, it was determined that the facility failed to develop a plan of care that addressed the needs of a resident with dementia. This was evident for 2 (#37 and #48) of 6 residents reviewed for dementia care. 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. Dementia is a general term used to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells. 1) Resident #37's electronic medical record was reviewed on 5/30/19 at 9:50 AM. During the review, it was found that the resident was diagnosed with unspecified dementia with behavioral disturbance, and was receiving medication treating that diagnosis. The resident's care plan was reviewed for inclusion of goals and interventions that addressed the resident's needs related to his/her dementia diagnosis. No care plan topic was found…

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 determine that the facility staff failed to follow through on a pharmacy recommendation. This was evident for 1 (#48) of 6 residents reviewed for unnecessary medications during the investigation phase of the survey. The findings include: A medical record review for Resident #48 on 6/3/19 at 9:30 AM, revealed a pharmacy recommendation, dated 5/12/19, which documented that staff needed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment related to antipsychotic use and to stop a blood thinner. A resident with long term use of an antipsychotic is at risk for developing abnormal involuntary movement that can be a permanent side effect. AIMS is an effective tool to monitor side effects. However, at the time of this medical record review, on 6/3/19, the attending physician had not completed the documentation regarding her/his agreement with, or disagreement with the recommendations made. An interview with the Director of Nursing, Unit Manager Staff #9, and the Infection Control Preventionist on 6/3/19 at 11:30 AM,…

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

Based on review of medical record and interview with facility staff, it was determined that the facility staff ordered and administered an excessive amount of Coumadin to Resident. This was evident for 1 (#12) of 5 residents reviewed for unnecessary medications. The findings include: The facility staff ordered and administered an excessive amount of Coumadin to Resident (#12). Coumadin is a blood thinner. It can treat and prevent blood clots. Review of the medical record, on 5/31/19 at 10am, for resident #12 revealed a physician's order to administer 2.5mg (milligrams) of Coumadin on Monday, Tuesday, Wednesday, Thursday, Friday and 3mg on Saturday and Sunday. On 5/20/19 the resident had a scheduled PT and INR drawn which resulted in the following: PT 46 (normal range according to this lab was 9-12) and INR 4.59 (critical high)- (normal range according to this lab was 2-3). The PT stands for prothrombin time. The INR stands International Normalized Ratio. Physicians measure patients' INR level during a PT-INR test. The test measures how much time it takes for a patient's blood 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 review of the medical record and interview with facility staff, it was determined the facility failed to ensure that residents receiving psychoactive medication received behavioral and mood monitoring for the conditions that the psychoactive medications were prescribed for. This was evident for 1 (Resident #37) of 6 residents reviewed for unnecessary medication. The findings include: Resident #37's medical record was reviewed on 6/3/19 at 1:35 PM. During the review, it was found that the resident was receiving an antipsychotic medication for the diagnosis, other specified depressive episodes. Review of orders for the resident failed to reveal an order to monitor for specific behaviors related to that diagnosis. Prior to his/her hospitalization in May, 2019, Resident #37's medication management notes from the psychiatric consulting service at the facility demonstrated that the resident had been prescribed more psychiatric medication at that time: two antipsychotic medications, one antidepressant medication, one prescription sleeping aid, and one medication with significant…

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, it was determined that the facility failed to have a medication error rate of greater than 5%. This was based on 2 errors occurring over 31 opportunities for error during 3 observations of medication administration. The findings include: During a medication observation that took place on 5/31/19 at 7:42 AM, with Licensed Practical Nurse (LPN) #1, LPN #1 was noted to have touched medication with his/her bare hands prior to administering those medications to residents. This occurred once during administration of medication to Resident #159 and again during administration to Resident #23. This resulted in 2 medication errors occurring over 31 opportunities for error, resulting in a medication error rate of 6.45%. Cross Reference F880.

Based on observation, interviews with facility staff and resident, it was determined the facility failed to ensure that there was not greater than 14 hours between the resident receiving his/her last meal for the evening and the next scheduled meal. This was found to be evident 1 (#32) of 27 residents reveiwed during the facility's annual Medicare/Medicaid survey observation rounds. Findings include: During observation rounds on /28/19 at 10:30am, Resident # 32 said, s/he had not received breakfast yet. Additionally, the resident reported that the facility does not always wake him/her up for breakfast. The Unit Manager and the Dietary manager was made aware at 10:45am. An interview was conducted with the Dietary Manager on 5/28/19 at 11am, and s/he stated, the resident tray was sent to the unit and returned on the cart. I am not sure if the meal was touched. S/he stated, Another tray will be sent to the resident. At 12:30pm during dining observation rounds, the resident still had not received a breakfast tray. The resident's lunch was being delivered by GNA #1 at that time. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, the facility 1) failed to ensure that medications were administered in a sanitary manner, and 2) failed to follow infection control practices by handing residents' food in a safe and sanitary manner. This was evident for 1 of 3 medication administration observations for 2 residents (#159, #23) and 3 (#44, #22, and #24) of 7 residents at a table chosen for dining observation. These practices had the potential to affect all residents at the facility. The findings include: A medication observation was performed, on 5/31/19 at 7:42 AM, during which Licensed Practical Nurse (LPN) #1 administered oral medication to Resident #159. After preparing and explaining the medication to the resident, LPN #1 handed the small plastic cup of 10 tablets to the resident who was able to take and swallow the medicine with only supervision. While tipping tablets into his/her mouth, one unknown tablet fell from the plastic cup onto Resident #159's chest. The resident attempted…

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.