Mount Airy Nursing and Rehab Center

Based on observation, interview, and record review it was determined that the facility failed to use proper infection control strategies. This was evident for 1) one of two laundry rooms observed, and 2) while providing feeding assistance to a resident(s). The findings include: 1). A review of the facility's laundry policy and procedure revealed a statement that read, in part, “employees should don appropriate PPE (e.g. tear resistant reusable gloves, gown/apron, and/or face shield/goggles) prior to collecting, transporting, or sorting soiled linens.” On 8/25/25 at 8:35 AM during an observation of the soiled laundry room in A building, laundry aide (Staff #4) was observed in front of the washing machine with the door open. She was not wearing any PPE. When interviewed, she said her normal process was to wear gown and gloves and she pointed in the room to where they were stored but said she was busy and so did not put them on. She said she knew that she was supposed to do so. She also said she had worked at the facility for 38 years. On 8/25/25 at 8:40 AM an interview was conducted…

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 ensure call systems devices were within reach and available to the residents. This was evident for one (Resident # 60,) in a random observation during a survey.The findings include: On 8/19/25 at 10:39 AM an observation was made in Resident # 60s room. The observation revealed that the resident's call system device was hooked over the wall light behind the resident's bed, approximately 5 feet off the floor. The call light was beyond the resident's reach and not accessible to the resident.On 8/19/25 at 1:52 PM a second observation was made in Resident # 60s room. The observation revealed the call light in the same place as observed at 10:39 AM. Which was out of reach for the residents and not accessible to them.On 8/19/25 at 1: 53 PM the above observation was confirmed by the infection control nurse (Staff #8). Staff #8 removed the call light from above the wall light and placed the call system on the bed within reach of resident #60.On 8/21/25 at 2:55 PM the surveyor shared this information with the…

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

Based on resident and staff interviews it was determined that the facility did not ensure that residents received mail on the weekend. This has the potential to affect all residents. The findings include. On 4/24/23 at 10:15 AM, an interview was conducted with a select sample of resident council members for the B-building and the activities director. The resident council members were asked if mail is delivered on Saturdays. The B-building resident council president responded No. The activities director (staff #7) was asked who gives out the mail on Saturdays, she responded that she did not know. An interview was conducted with the NHA administrator on 4/26/23 at 9 AM. She was asked who distributes mail to the residents. She indicated that the activity staff give out the mail and are responsible for distributing it on weekends. She was informed that the activity staff did not know who distributes the mail on weekends. On 5/2/23 at 11:43 AM activities staff (#34) was asked who gives out the mail to residents and she responded that she did not know.

Based on review of facility records and interview with staff it was determined the facility failed to establish and implement a grievance policy to ensure resolution of all grievances and evidence demonstrating that the result of all grievances were maintained for no less than 3 years. This was evident during review of 1 (#MD00186812) of 8 complaints reviewed during the survey and had the potential to affect all residents in the facility. The findings include: Complaint #MD00186812 was reviewed on 5/1/23 at 1:02 PM. The complaint included concerns related to residents entering another resident's personal space and taking snacks and drinks in November or December 2022. The Nursing Home Administrator (NHA) was asked to provide the grievance logs for November and December 2022. On 5/1/23 at 1:34 PM the NHA reported that there were no grievance logs for that time frame and explained that the Social Worker would have been responsible for investigating grievances however, the facility did not have a Social Worker at that time. On 5/2/23 at 9:15 AM the NHA was asked to provide 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 interview, the facility failed to post the required Names, addresses, and telephone numbers for all pertinent State agencies and advocacy groups, such as the State Survey Agency. This was identified in one of the two facility buildings affecting up to 32 residents at the time of the survey. The findings include. Observation of the entire A-building conducted on 4/21/23 did not reveal any required postings related to contact agencies for Abuse and Nursing Home complaints. At 11:33 AM on 4/21/23, the nursing home administrator was asked where the required posting are, listing the Office of Health Care Quality and the local Office on Aging. She asked the medical records person staff # 4 and they both confirmed that there were not any of the required postings of the contact agencies in the A-building. An empty bulletin board by the nursing station was identified as where the required posting should have been found. Observations of the B-building at 11:50 AM (4/21/23) found the required posting of the agencies to contact for Abuse and nursing home complaints.

Based on record review and staff interviews it was determined that the facility failed to have a system in place for notifying residents and their representatives in writing of their remaining Medicare benefit days. This was evident for 1 of (#39) of 3 residents reviewed for beneficiary notice. The findings include: On 4/26/23 at 9:14 AM, a review of Resident #39's Beneficiary Protection Notification revealed that the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted and that notifications were made by phone to the residents' representatives. The Business office manager Staff #33 was asked on 4/26/23 at 10:44 AM about the process for Beneficiary Notification. She explained that Notifications were made by phone calls to resident's representatives and that three staff members (Social Services Designee #32, Minimum Data Set Coordinator #10, and Social Worker #8) were responsible for providing the notifications. The Social Worker SW staff #8 was asked on 4/26/23 at 11:15 AM to explain how Resident #39's representatives were notified. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean, and comfortable environment. This was evident in 1 of 2 buildings observed during the annual survey. The findings include: On 4/18/23 at 10:25 AM, observation was made of building A, room [ROOM NUMBER]/104 shared bathroom, and revealed a crack in the paint behind the toilet. The water supply pipe extending through the wall to the toilet was damp, there was an approximately 1/2-inch-wide gap in the wall around the pipe. The wall below the pipe was soft and damp and the floor below the pipe was wet. Black rubber trim approximately 4 inches tall was located along the base of the bathroom walls. At the base of the wall to the left of the toilet, a 10-12-inch-long section of trim was pushed approximately 3 inches into the wall. Approximately 3-4 white clumps of what appeared to be wet toilet paper were located on the floor in front of the damaged area. A…

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

Based on medical record review and staff interview, it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was identified for 4 (Resident #11, #34, #44, and #72) of 10 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 4/20/23 at 11:45 AM a review of Resident #34's medical record was conducted. Review of a nursing note written on 3/3/23 at 9:14 AM indicated a nurse practitioner ordered to send the resident out for oxygen deficiency. The next nursing note timed for 9:23 AM indicated that resident #34 was picked up by two EMT staff at 9:23 AM and was sent to a local hospital. The next note on 3/3/23 at 9:28 AM was an SBAR (Situation, Background, Assessment, Recommendation) summary for providers. Ongoing review of the medical record did not reveal documentation that the resident or the resident's responsible party was informed in writing related to the transfer to the hospital. It was noted that there was not a…

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

Based on medical record review and staff interview 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 identified for 4 (Resident #11, #34, #44, and #72, ) of 10 residents reviewed for hospitalization during the annual survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) On 4/20/23 at 11:45 AM a review of Resident #34's medical record was conducted. Review of a nursing note written on 3/3/23 at 9:14 AM indicated a nurse practitioner ordered to send the resident out for oxygen deficiency. The next nursing note timed for 9:23 AM indicated that resident #34 was picked up by two EMT staff at 9:23 AM and was sent to a local hospital. The next note on 3/3/23 at 9:28 AM was an SBAR (Situation, Background, Assessment, Recommendation) summary for providers. There was no written documentation 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 a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan and 2) failed to update a resident's care plan to reflect food preferences. This was evident for 3 (#39, #43, #58) of 57 residents reviewed during the annual survey. The findings include: Care plans address the unique needs of each resident, are developed and used plan, assess, and evaluate the effectiveness of the residents' care. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) On 4/17/23 at 8:30 AM, observation…

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 reviews of a medical record and staff interview, it was determined that the facility nursing staff failed to document a resident's care in the resident's medical record per nursing standards. This was evident for 1) 1 (Residents #11) of 8 residents reviewed for accurate medical records; and 2) for 1 (#1) of 5 residents reviewed for Advance directives during an annual recertification survey. The findings include: 1) A review of Resident #11's medical record on 04/26/23 at 9 AM, revealed that Resident #11 has a history of multiple sclerosis, stroke with lasting paralysis, slurred speech, and anxiety. A review of Resident #11's Activity of Daily Living (ADL) care plan revealed that Resident #11 requires 2 staff members' assistance when providing care and requires dependent assistance with bed mobility. A review of Resident #11's 12/10/22 Fall Risk Observation Tool, indicated Resident #11 was non-ambulatory and is totally dependent on the nursing staff for his/her care. A review of Resident #11's medical record on 04/26/23 revealed GNA documentation indicating Resident #11 was…

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

Based on observation and staff interviews, it was determined that the facility staff failed to 1) maintain a resident's call bell within reach of the resident, 2) maintain the resident call system in working order in the B-building, and 3) identify a resident's nonfunctioning call bell and a missing restroom call bell cable. This was identified for the entire B-building that was observed during an annual recertification survey. The findings include: 1) During an interview and observation with Resident #14 on 04/18/23 at 11:27 AM, Resident #14 stated S/he was unable to locate his/her call bell to summon the nursing staff for assistance. The surveyor observed Resident #14's call bell located on the floor behind Resident #14's bed. Staff member #26 was made aware of Resident #14's call bell location and replaced the call bell within Resident #14's reach. 2) During an observation of the facility B-building nursing unit on 04/18/23 at 4:15 PM, the nurse surveyor observed the B-building nursing unit main resident call bell enunciator was nonfunctioning. Some resident call bell lights 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and reviews of a medical record, it was determined that the facility staff failed to treat each resident in a dignified manner by pulling a resident backward down the hallway. This was evident for 1 (Resident #6) resident reviewed for dignity during the Long Term Care Survey Process annual recertification survey. The findings include: During an observation of Resident #6 on 4/18/23 at 4:55 PM, the surveyor observed GNA #27 pulling Resident #6 backward down the hallway to his/her room, while seated in his/her wheelchair. Resident #6 was admitted to the facility on [DATE] with diagnoses that included a cerebrovascular accident with paralysis to one side of the body and dementia. A review of Resident #6's annual MDS assessment, dated 1/10/2023, revealed that Resident #6 is totally dependent upon the nursing staff for transfers and locomotion on the unit. Resident #6 also received a Brief Interview for Mental Status (BIMS) on 1/10/23 in which Resident scored 2 out of 15 which indicates severe…

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 1) failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive; 2) failed to ensure that 2 physicians' certificates of incapacity were obtained for residents; and 3) failed to have a copy of the Advance Directive readily accessible in the medical record. This was evident for 3 (#41, #43, and #1) of 5 residents reviewed for advance directives during the annual survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used…

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 reviews of a complaint, a closed medical record, administrative records, and staff interviews, it was determined that the facility staff failed to notify a resident's physician and family member regarding new complaints of pain in the right leg. This was evident for 1 (Resident #180) of 3 residents reviewed for pain management during the Long Term Care Survey Process annual recertification survey. The findings include: A review of complaint MD00178602 on 4/27/23 revealed an allegation Resident #180 was sent to the emergency room for a suspicious injury of unknown origin. In the emergency room, Resident #180 was confirmed with a distal right fractured femur on 3/10/22. A review of the facility's Pain Management and Assessment policy on 4/27/23 revealed a definition of breakthrough pain for the purpose of this policy, which is generally associated with cancer and is severe pain that erupts while the resident is already medicated with long-acting pain medications. The facility's Pain Management and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 1 (Resident #40) of 14 residents reviewed for abuse during a long-term care survey process recertification survey. The findings are: A review of facility-reported incident #MD00185114 on 5/1/23 revealed that the facility reported an allegation of staff-to-resident abuse on 11/1/23 in which a Geriatric Nursing Assistant (GNA) Staff #46 was observed to hit resident #40 in the head twice with a closed fist. The facility also reported that the local police were notified and conducted an onsite investigation. The resident's physician and responsible party were also made aware of the allegations. Resident #40 was transferred to the emergency room for evaluation without identification of actual injuries to the resident. A review of the facility's Abuse, Neglect, and Misappropriation…

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

Based on record review and staff interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (#36 and #381) of 14 residents reviewed for abuse during the annual survey. The findings include: 1. Review of complaint MD0000143102, the self-report submitted to OHCQ on 7/23/19, on 4/26/23 at 10:52 AM, revealed Resident #36 reported to the charge nurse regarding his/her roommate calling staff members the N-word and statements that two staff members were in his/her room on 6/23/19 stating we should come back and beat the shit out of him/her and might as well get [the resident's name] while we're at it. Further review of the facility investigation documentation revealed that the previous Nursing Home Administrator (staff #35) identified this incident while she reviewed another reported incident on 7/22/19 and started investigating, including submitting a self-report to OHCQ. On 4/26/23 at 12:50 PM, the surveyor requested medical records for Resident…

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

Based on a review of medical records, investigative documentation, and interviews, it was determined that the facility failed to have an effective system in place to ensure abuse allegations were thoroughly investigated to determine if abuse occurred and take appropriate action. This was evident for 5 (Resident #70, #36, #28, #430, and #65) out of 14 residents reviewed for abuse during the survey. The findings include: 1) Review of facility-reported incident MD00179136 on 4/28/23 at 9:24 AM revealed that on 6/04/22, Resident #70 had a fall with pain on the left side leg and back. X-ray (thoracic spine, lower thoracic vertebrae, lumbosacral spine, left femur, and bilateral hips including pelvic) was obtained for the resident, and no negative result, including fracture or dislocation reported. On 6/16/22, an occupational therapist noted Resident #70 exhibited pain in the left shoulder with bluish discoloration of the left scapula. The x-ray of the left shoulder and scapula resulted in a left clavicle fracture. Further review of the facility investigation which was provided by 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 medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#34) of 10 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 4/20/23 at 11:45 AM a review of Resident #34's medical record was conducted. Review of a nursing note written on 3/3/23 at 9:14 AM indicated a nurse practitioner ordered to send the resident out for oxygen deficiency. The next nursing note timed for 9:23 AM indicated that resident #34 was picked up by two EMT staff at 9:23 AM and was sent to a local hospital. The next note on 3/3/23 at 9:28 AM was an SBAR (Situation, Background, Assessment, Recommendation) summary for providers, indicating resident #34 was administered oxygen and a nurse practitioner ordered to transfer the resident to the hospital. There was no documentation in the medical record of the preparation of the resident and if the resident was informed of the transfer and understood why he/she was being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#43) of 5 residents reviewed for activities of daily living during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 4/17/23 at 8:30 AM, observation was made of Resident #43 lying in bed with head elevated with tube feeding infusing, noted vulnerable condition. On 4/20/23 at 9:20 AM, a medical record review was conducted for Resident #43 and revealed the resident was admitted 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 medical record reviews and staff interviews, it was determined that the facility social work department failed to obtain a state-designated evaluation for a resident who was determined to have a mental disorder (MD) or intellectual disability (ID), or related condition. This was evident for 1 (Resident #12) of 2 residents reviewed for PASARR screening during the Long Term Care Survey Process annual recertification survey. The findings include: The intent of this regulatory requirement is to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, or within 30 days, and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. A review of Resident #12's medical record on 04/17/23 at 1:45 PM, revealed a positive Preadmission Screening and Resident Review (PASARR) that was completed on 09/30/22. The nurse surveyor was unable to determine if a Level II evaluation had been obtained at that time. In an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide residents with a copy of their baseline care plan and their admission medications. This was evident for 1 (#41) of 1 newly admitted resident reviewed for baseline care plans during the annual survey. This has the potential to affect all residents that are newly admitted to the facility. The findings include: The baseline care plan is to be developed within 48 hours of a resident's admission with a variety of detailed components of the care that the facility intends to provide to that resident. The facility is required to provide the resident and the representative with a written summary of the baseline line care plan including a list of current medications, dietary instructions, and services to be administered by the facility and personnel acting on behalf of the facility. Resident #41 was admitted to the facility on [DATE]. An interview with the resident on 4/18/23 at 11:28 AM revealed that resident #41 had not received…

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 develop and initiate comprehensive, resident-centered care plans for residents timely. This was evident for 1 (#43) of 57 residents reviewed during the annual 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. On 4/17/23 at 8:30 AM, observation was made of Resident #43 lying in bed with head elevated with tube feeding infusing, noted vulnerable condition. On 4/20/23 at 9:20 AM, a medical record review was conducted for Resident #43 and revealed the resident was admitted to the facility in April 2022 with diagnoses including catatonic schizophrenia, dysphagia, epilepsy, and altered mental status. During an interview with a Licensed Practical Nurse (LPN #26) on 4/20/23 at 11:39 AM, he confirmed that Resident #43's current medical condition had been the same as his/her initial admission as bedridden, nonverbal, and totally dependent.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint, reviews of active and closed records, and staff interviews, it was determined that the facility staff failed to 1) document the nurse practitioner wound care orders and implement the wound orders for a resident, 2) and 3) administer an antibiotic to 2 residents as prescribed by the resident's physician. This was evident for 3 (Resident #180, #33, #12) of 3 residents reviewed for quality of care during an annual recertification survey. The findings include: 1) A review of complaint MD00178602 on 04/27/23 revealed an allegation Resident #180 was sent to the emergency room for a suspicious injury of unknown origin and a pressure ulcer on 03/11/22. A review of Resident #180's closed medical record on 04/27/23 revealed that Resident #180 had been readmitted from the hospital on [DATE] after being treated for a urinary tract infection. On 03/07/22, the facility wound consultant assessed Resident #180's skin and identified Resident #180 with a fungal rash in the groin area. The wound consultant…

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, staff interview, and observation, it was determined that the facility failed to provide/document foley catheter care. This was evident for 1 (#43) of 1 resident reviewed for Foley catheters during the annual survey. The findings include: A suprapubic catheter is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow. On 4/17/23 at 12:35 PM, a review of Resident #43's medical record revealed that the resident was admitted to the facility in April 2022 with diagnoses including catatonic schizophrenia, dysphagia, epilepsy, and altered mental status. Further review revealed that the resident was discharged to an acute care facility on 3/02/23 to evaluate the change of condition and readmitted to the facility on [DATE] with a suprapubic catheter for urethral stricture. The resident had repeated transfers to the hospital and readmissions and stayed stable since the last readmit…

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

Based on observation, record review, and staff interviews, it was determined that the facility failed to label oxygen and nebulizer tubing with a date. This was evident for 1 (#71) of 3 residents reviewed for respiratory care. The findings include: Observation of Resident #71 on 4/17/23 at 10:15 AM revealed that the resident was on oxygen therapy connected to an oxygen concentrator (an electric machine that concentrates oxygen from the room air). The nasal cannula, which is a tubing used to deliver oxygen through the nose, was not dated as to when it was changed. A second nasal cannula tubing was connected to a portable oxygen tank. The tank was in a tank holder, mounted on the back of Resident #71's wheelchair. The second oxygen tubing did not have a date on it. A nebulizer, which is a small machine that turns liquid medication into a mist for easy inhalation, was observed on the overbed table. It was connected via tubing to a nebulizer mask. The mask/tubing were not dated. A review of the physician order on 4/20/24 at 8:03 AM revealed orders written on 1/13/23 for change oxygen…

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 review of a complaint, closed medical record review, administrative record review, and staff interviews, it was determined that the facility staff failed to address a resident's new complaint of pain in the right leg. This was evident for 1 (Resident #180) of 3 residents reviewed for pain management during the Long Term Care Survey Process annual recertification survey. The findings include: A review of complaint MD00178602 on 04/27/23 revealed an allegation Resident #180 was sent to the emergency room for a suspicious injury of unknown origin. In the emergency room, Resident #180 was confirmed with a distal right fractured femur on 03/10/22. A review of the facility's Pain Management and Assessment policy on 04/27/23 revealed a definition of breakthrough pain for the purpose of this policy, which is generally associated with cancer and is severe pain that erupts while the resident is already medicated with long-acting pain medications. The facility's Pain Management and Assessment policy on 04/27/23…

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 reviews of presurvey payroll-based journal staff data reports, reviews of facility administrative records, and staff interviews, it was determined that the facility failed to have a Registered Nurse for at least 8 consecutive hours in a 24-hour period for 4 out of 17 days reviewed for sufficient and competent nursing staff during an annual recertification survey. The findings include: Reviews of the presurvey documents revealed payroll-based journal (PBJ) staff data reports that indicated there were days the facility failed to minimally have a registered nurse (RN) for 8 consecutive hours a day seven days a week. In an interview with the facility Administrator and Director of Nurses (DON) on 05/01/23 at 1:46 PM, the facility Administrator confirmed that the facility did not have any Federal or State nursing staffing waivers and that currently the facility is not using and contracted or agency nursing staff. The Administrator confirmed that the facility is sending staffing information quarterly to CMS. The facility DON confirmed that S/he has not had to work on the nursing…

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 employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistants (GNA) were given a yearly performance review. This was evident for 1 of 6 GNA employee records (Staff #50) reviewed during the review for sufficient and competent nursing staffing task during an annual recertification survey. The findings include: Interview with the facility assistant director of nurses (ADON) on 05/02/23 at 1:58 PM, the facility ADON stated that he/she was unable to produce documentation that indicated 6 sampled GNA staff members received the following training and performance review. The ADON also stated that S/he was unable to locate any education prior to 01/01/2022 when the new ownership took over the facility: Staff member #50, with a hire date of 06/27/2005, had not received a performance review in the last 12 months. A review of the Facility Assessment on 05/02/23 revealed section 3.4. Staff Training/education and Competencies that: 1) Required in-service training for nurse aides. Inservice training…

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

Based on record review, and staff interviews, it was determined that the facility failed to accommodate residents' food preferences. This was evident for 1 (#58) of 3 residents reviewed for nutrition during the annual survey. The findings include: During an interview on 4/17/24 at 1:29 PM Resident #58's family member revealed that the resident was served spicy foods, meat, and fish which the resident disliked, and the resident had lost a lot of weight because she/he would not eat certain foods. The family member indicated that he/she spoke to the Dietitian a couple of weeks ago and provided her with the resident's food preference list. A review of Resident #58's electronic medical record on 4/19 23 at 1:11 PM revealed a progress note dated 2/13/23 at 13:35 by Staff #37, the Dietitian. The note indicated that she had spoken to the resident's family member regarding Resident #58's food preferences. She indicated that the resident's family member provided a list of foods that the resident would eat. The list included fried egg sandwiches, grilled cheese, cheese, milk, fruit, ice cream,…

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

Based on record review and staff interview, it was determined that the facility failed to document education was provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to staff who had not received the COVID-19 vaccine. This was evident for 3 (Staff #18, #19, and #20) out of 8 facility staff members reviewed for COVID-19 vaccinations during the survey. The findings include: A review of COVID-19 vaccination records for 8 facility staff members was conducted on 4/20/23 at 10:40 AM. The review revealed that staff #18, #19, and #20 were hired in January 2022 as direct resident care staff. The three staff did not receive COVID-19 vaccination with religious exceptions. Further review of Staff #18, #19, and #20's records revealed that the documents did not contain education regarding COVID-19 vaccination benefits, risks, and potential side effects. An interview was conducted with an Infection Control Preventionist (ICP, also Director of Nursing) on 4/26/23 at 11:21 AM. The ICP confirmed that the facility had three COVID-19 unvaccinated staff…

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

Based on observation and staff interview it was determined the facility failed to keep a freezer unit in the A-building kitchen in safe operating condition. This was evident during the initial tour of the kitchen and during a subsequent visit. The findings include: 1) On 4/17/23 at 8:47 AM during the initial tour of the kitchen revealed the tall freezer was noted with mounds of ice covering both fans on the ceiling of the freezer unit and ice/frost was mounding on the items below the fans. The Culinary Director (staff #6) was interviewed on 4/20/23 at 12:20 PM and informed of the observed ice covering the fan units and products. She indicated when she returned on 4/19/23, she chipped away the ice mounds. On 4/24/23 at 10 AM repeat observation of the same tall freezer revealed ice mounds on the two fan units. The Culinary Director was informed of the observations, and she indicated that she would have to remove the ice again and have the freezer serviced/looked at.

Based on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistant's (GNA) were given 1) dementia management training, 2) a yearly performance review, and 3) training for GNA's that provide services to residents with cognitive impairments. This was evident for 6 of 6 GNA employee records (Staff #13, #23, #48, #49, #50, and #41) reviewed during the sufficient and competent nursing staffing task during an annual recertification survey. The findings include: Interview with the facility assistant director of nurses (ADON) on 05/02/23 at 1:58 PM, the facility ADON stated that he/she was unable to produce documentation that indicated 6 sampled GNA staff members received the following training and performance review. The ADON also stated that S/he was unable to locate any education prior to 01/01/2022 when the new ownership took over the facility: 1) Staff member #23, with a hire date of 12/27/2022. Staff member #51, with a hire date of 01/10/2023. These staff members had not received dementia…

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 failed to ensure that care plans were developed in a way that was person-centered, contained measurable goals, and accurately reflected the needs of each resident. This was evident for 8 (#5, #50, #7, #40, #4, #53, #82 and #62) of 29 residents reviewed during the investigation phase of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) Record review of Resident #5's care plan (last reviewed by facility on 12/18/18) on 02/27/19 at 10:46 AM, failed to capture a diet order for pureed foods with nectar thick liquids and for aspiration precautions. Resident #5's medical record contained a physician's order, dated 2/1/19, indicating that this resident may have unthickened carbonated liquids by single cup sips or spoon sips. Further review revealed a physician order for aspiration precautions. This was not noted on the care plan. Observation 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 interview, it was determined that the facility staff failed to evaluate the effectiveness of care plans, including residents' progress or lack of progress toward reaching the care plan goals. This was evident for 7 (#13, #46, #82, #53, #4, #30 and #40) of 29 residents reviewed during the investigative stage of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) On 2/19/19 at 9:59 AM, during an interview with a surveyor, Resident #13 indicated he/she currently did not wear eye glasses. On 2/25/19, review of Resident #13's most recent MDS (minimal data set) assessment, with a reference date of 12/18/18, documented the resident did not wear corrective lenses. On 2/25/19 at 2:45 PM, during an interview, Staff #5 stated he had been employed at the facility for many years and had never seen the resident wearing eye glasses. A 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.

Based on interview with the facility's resident councils, interview with facility staff, and review of resident council minutes, it was determined that the facility failed to demonstrate that a response was given for grievances and recommendations made by the resident councils. This practice has the potential to affect all residents. The findings include: Members of the resident council of Building A were brought together and interviewed by the surveyor on 2/22/19 at 11:05 AM. The members present included Residents #30, #47, #26, and #78. As part of the resident council task, the residents were asked if facility officials respond to the concerns of the resident council, and both Resident #26 and Resident #47 stated sometimes. Members of the resident council of Building B were interviewed in a similar way on 2/25/19 at 2:06 PM and including Residents #46 & #21. Resident #46 answered the same question, They don't always get back to us about what comes up during the meeting. Some of them try to, but sometimes we never hear anything. Permission was obtained to review resident council…

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 staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed in both buildings of the facility. The findings include: 1. Initial environment concerns were made by multiple surveyors upon initiation of the survey on 2/19/19. On 2/28/19 at 11:00 AM, the concerns were reviewed with the maintenance director (Staff #12) and nursing home administrator. While in the A-building, it was noted that there were many resident bedroom door frames with missing/chipped-off paint with exposure of the previous paint color. It was identified while in the hallway that there were numerous suspended ceiling tiles with stains. Noted in the B-building hallway was stained ceiling tiles near the nursing station. In room [ROOM NUMBER], an insulated pipe running vertically was shown to have a gouge/rip in the insulation approximately…

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 surveyor observation, review of the medical record and interview with facility staff it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to date label oxygen administration equipment, failing to maintain a nasal cannula in a sanitary manner, failing to administer oxygen as prescribed and failing to develop and update plans of care to address the resident's respiratory needs. This was evident for 3 (#7, #32 and #5) of 3 residents reviewed for Respiratory Care. The findings include: 1) On 2/19/19 at 10:18 AM, the surveyor observed an oxygen concentrator (a machine that provides oxygen from room air) at Resident #7's bedside. The oxygen concentrator humidification bottle and oxygen tubing were not labeled as to when they were put into use or should be replaced. The nasal cannula was lying on the floor between the bed and the concentrator. Staff #1 entered the room at 10:45 AM picked up the nasal cannula, placed it on top of the concentrator and turned the concentrator off. He/She was asked how staff would know…

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

Based on staff interview, observations and review of medical record it was determined that the facility staff failed to have an effective quality assessment and assurance (QAA) program based on repeat deficiencies related to development and revision of care plans, medication storage, infection control and medical record accuracy. This was evident during the survey process and review of the Quality Assurance Program. The findings include: On 2/28/19, review of the Quality Assurance Program with Staff #9 revealed that effective process had not been put in place regarding repeat deficiencies. The facility's action plans did not resolve quality deficiencies identified during the last re-certification survey which was concluded on 10/18/17 with a plan of correction date of 12/15/17. Development of comprehensive care plans, revision of care plans, drug storage, infection control and medical record accuracy were cited during the annual survey, 10/18/17. During an interview, when asked about the QA process put into place following the prior deficiencies, Staff #9 indicated he/she ran 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 surveyor observation and interview with staff, it was determined that the facility staff 1) failed to date label oxygen administration equipment for 2 (#7 & #32) of 2 residents reviewed for respiratory care, and 2) failed to label and store personal equipment in a hygienic manner in 3 of 5 resident bathrooms in building A. The findings include: 1A) On 2/19/19 at 10:18 AM, the surveyor observed an oxygen concentrator (a machine that concentrates oxygen from the room air) at Resident #7s bedside. The oxygen concentrator humidification bottle and oxygen tubing were not labeled as to when they were put into use or should be replaced. During an interview at 10:45 AM Staff #1 was asked how staff know when the tubing and humidification bottle was changed. He/She stated, I cleaned the filter and the concentrator myself yesterday. He/She confirmed that the humidification bottle and tubing would be changed more often than the filter and concentrator cleaning but did not indicate the frequency. He/She added that…

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

Based on observation, record review and staff/resident interview, it was determined that the facility staff failed to allow residents to choose a schedule for sleeping and waking. Additionally, Resident #4 had a goal that scheduled activities of daily living (ADL) without consideration of the resident's preference. This was evident for 1 (#4) out of 54 residents reviewed for care plans. The finding include: On 2/21/19 at 8:40 AM, Geriatric Nursing Assistant (GNA) #17 was in Resident #4's room and attempted to awaken the resident to eat his/her breakfast. GNA Staff #17 stated, You must have had a late night last night. You know I cannot leave your breakfast tray here for much longer. During an interview with GNA #51 on 2/22/19 11:51 AM, he/she stated that Resident #4 was a 'night owl 'and preferred to stay up all night and sleep all day. On 2/22/19 at 12:09 PM, a review of a care plan for the resident revealed: Sleep pattern disturbance related to preferences as evidenced by staying awake most of the night and sleeping most of the day and refusing to awaken for ADLs (activity 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 record review and interview with facility staff, it was determined that the facility failed to ensure that physicians were notified of changes in resident conditions. This was evident for 1 (#62) of 5 residents reviewed for unnecessary medications. The findings include: Resident #62's medical record was reviewed on 2/21/19 at 2:30 PM. During the review, an order was found to obtain finger stick blood glucose levels before meals and every evening. The order included the statement, Call MD if [glucose] <(less than) 60 and greater than 250. The order date was 5/24/18. Resident #62's medication administration logs were reviewed concurrently for the months of December, 2018 and January and February, 2019. During those three months, a glucose value of greater than 250 milligrams per deciliter (mg/dl) was obtained and documented 14 times. The Director of Nursing (DON) was interviewed on 2/26/19 at 1:35 PM and stated that a nursing note or a change in condition assessment should be documented in the medical record to demonstrate that the physician had been notified appropriately…

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

Based on interviews with the resident and staff, and review of the resident's record it was determined that the facility 1) failed to report a resident's allegation of missing property and report the results of their investigation to the state survey agency for 1 (#7) of 2 residents reviewed for Personal Property and 2) failed to report injuries of unknown origin to the state agency for 1 (#8) of 8 residents reviewed for activities of daily living. The findings include: 1) During an interview on 2/19/19 at 10:54 AM Resident #7 indicated that he/she had a gold colored metal wedding band that went missing a couple of months ago, that he/she reported it to the facility staff. The resident indicated that someone said it was locked in a safe at the facility and someone else said it went missing when he/she was hospitalized , but he/she was never told if it was found. During an interview on 2/22/19 at approximately 10:30 AM Staff #4 indicated that the resident reported the missing ring within the last week or so. Staff #4 was asked for the facility's investigation and documented…

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

2) A record review conducted on 2/26/19 revealed an entry made by LPN #2, on 2/3/19, that Resident #8 had a bruise noted to the left leg. Further review failed to find evidence that an investigation was conducted to determine the cause/origin of the injury. Further review found an entry made by LPN #5 on 2/4/19, revealed that the resident had a purplish discoloration on the right side of the vaginal area discovered by staff members during care, that day. However, further record review failed to find documentation that a thorough investigation was completed. The Director of Nursing (DON) and the Administrator acknowledged surveyor's findings on 2/26/19, prior to the exit meeting. Cross reference F 609 Based on interviews with the resident and staff, and review of the resident's record it was determined that the facility 1) failed to thoroughly investigate an allegation of misappropriation of property for 1 (#7) of 2 residents reviewed for Personal Property and 2) failed to complete an investigation and maintain documentation for an injury of unknown origin for 1 (#8) of 8 residents…

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 the facility failed to orient, prepare, and document a resident's preparation for transfer to the hospital. This was evident for 2 (#46, #59) of 6 residents reviewed for hospitalization. The findings include: 1) On 2/26/19, a review of Resident #46's medical record revealed that, on 1/8/19 at 9:26 PM, in a progress note, the nurse documented that the resident was sent to the emergency department for evaluation following a fall. There was no documentation in the medical record that the resident had been prepared and oriented to the transfer. 2) On 2/26/19, a review of Resident #59's medical record revealed the resident was transferred to an acute care facility following a fall in the facility that occurred in early October 2018. There was no documentation in the medical record that an assessment of the resident had been done prior to transfer to the hospital. There was no documentation in the medical record that the resident had been prepared and oriented to the transfer. On 2/26/19 at 4:34 PM, the Director 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 observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#50, #79) of 3 residents reviewed for activities. The findings include: The MDS is part of the Resident Assessment and is a set of assessment screening items that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident 1) On 2/22/19, a review of Resident #79's December 2018 MAR (medication administration record) revealed the resident received one anxiolytic (anti-anxiety) medication every day. The MAR documented that Resident #79 received Ativan (Lorazepam) by mouth two times a day for anxiety. Review of Resident #79's annual MDS with an ARD (assessment reference date) of 12/18/18 revealed Section I, Active Diagnosis, Psychiatric/Mood Disorder 15700. Anxiety Disorder was blank. 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 the medical record and interview with facility staff it was determined the facility staff failed to provide necessary behavioral healthcare and services to maintain the highest practicable well being for a resident with behavioral problems. This was evident for 1 (#7) of 4 residents reviewed for behavioral concerns. The findings include: During an interview on 2/19/19 at 11:16 AM Resident #7 indicated that he/she had been involved in several altercations with other residents. Resident #7's medical record was reviewed on 2/22/19 at 2:56 PM. Plan of care comment sheets included notations on 1/30/19: Resident to Resident incident, hit another resident and 2/24/19 Resident hit another resident on the right shoulder. Facility incident reports for resident to resident altercations involving Resident #7 in the past year were reviewed. The reports revealed that Resident #7 was involved in 7 altercations between 2/7/18 and 2/24/19. Review of Resident #7's care plans revealed that Resident #7 had a plan of care for physically abusive towards others that was resolved on…

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

Based on observation and review resident medical records, it was determined that the facility failed to monitor residents with dementia for specific behaviors related to their dementia diagnosis. This was evident for 1 (#62) of 4 residents reviewed for dementia care. The findings include: 1) Resident #62's medical record was reviewed on 2/22/19 at 9:25 AM. The review revealed that the resident's care plan did not include a specific care area related to dementia, but that dementia was involved in five other care areas: antipsychotic medication use, disordered thinking / awareness, impaired decision-making, anticonvulsant medication use, and antidepressant medication use. Of these five areas, behavior monitoring was mentioned only once: monitor behavior every shift and document was an intervention for the antipsychotic medication use care area. No specific behaviors to monitor were described. Physician orders were reviewed concurrently and no active orders could be found that specified which behaviors required monitoring for dementia.

Based on medical record review the pharmacy failed to clarify the indications for use of 3 psychotropic medications during monthly medication review for 1 (#91) of 7 sampled residents for unnecessary medications. The findings include: Review of Resident #91's physician's orders on 2/27/19 at 9:40 AM, revealed an order for the following medications: -Trazadone 100mg (milligrams), by mouth, at 8 PM (Used for major depressive disorder and may be used for insomnia), -Depakote sprinkles 125mg capsule, give 4 caps (capsules) to equal 500mg, by mouth, 8 AM & 8 PM (for seizures and mood stabilizer), -and Seroquel (Quetiapine Fumarate) 25mg, by mouth, two times a day (Antipsychotic medication used to treat schizophrenia and bipolar disorder). The diagnoses for all 3 of the medications was listed as Dementia in other diseases, classified elsewhere with behavioral disturbance. Further review of the record revealed that Resident #91 was seen by Psychiatric Services and the clinical indications used for the medications were the following: Trazadone for sleep, Seroquel for delusions and anxiety…

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

Based on medical record review and staff interview it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure medication orders had adequate parameters to indicate when to administer as needed medications for pain. This was evident for 1 (#50) of 2 residents reviewed for pain management. The findings include: On 2/26/19, review of Resident #50's February 2019 MAR (medication administration record) revealed a 10/10/18 order for Tylenol ES (Acetaminophen) (extended release) 500 mg (milligrams) every 4 hours PRN (as needed) for pain and a 10/10/18 order for Norco 325 mg-5 mg (Acetaminophen/Hydrocodone) by mouth every 6 hours PRN for pain. The orders were unclear as to which medication to give first for pain. The Director of Nurses was made aware of these findings on 2/28/19 at 11:44 AM.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication by failing to adequately monitor a resident for behavior, side effects, or adverse consequences related to psychotropic medication use. This was evident for 2 (#46 and #4) of 6 residents reviewed for accidents. The facility also failed to adequately monitor residents for behaviors related to psychotropic medication use for 1 (#4) of 7 residents reviewed for unnecessary medications. The findings include: 1) On 2/26/19, Resident #46's February 2019 MAR (medication administration record) was reviewed. The MAR documented that Resident #46 received Ativan (Lorazepam) (anxiolytic) by mouth three times a day for anxiety, Risperdal (Risperidone) (antipsychotic) by mouth one time a day for bipolar disorder, Trazodone (antidepressant) by mouth every day at bedtime for insomnia, and Zoloft (Sertraline) (antidepressant) every day for bipolar disorder. Continued review of the medical record failed 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 observation and staff interview it was determined the facility failed to properly store medications as evidenced by 1) failing to ensure that medication was properly labeled and dated in 1 of 2 medication rooms; and 2) failed to ensure medications were properly secured when unattended for 1 of 4 medication carts observed during the survey. The findings include 1) On [DATE] at 10:10 AM observation of A building medication room refrigerator revealed a small Lantus Insulin (insulin glargine) imprinted box had a pharmacy label with Resident #45's name. Hand written on box was an opened date of [DATE] and an expiration date of [DATE], indicating the Lantus vial in the box expired in 43 day. Per manufacturer recommendation, Lantus insulin should be discarded 28 days after opening. Inside the box was an opened vial of Lantus Insulin, with [DATE] hand written on the vial and not labeled with a resident's name. The date on the vial of insulin did not match the dates on the box the insulin was stored in. The…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that residents receiving therapeutic mechanically altered diets were given food of the correct consistency based on the physician order. This was evident for 1 of 3 meal observations performed during the survey. The findings include: During a dining observation that took place on 2/19/19 at 11:55 AM, the surveyor noted that residents receiving a pureed diet had been given a brown meat-based entree with solid pieces in it the size of tiny beads. A sample of the entree was obtained and tasted by the survey team who found that the particles were solid and discretely perceptible in the mouth. A pureed diet is used for residents who are not able to bite or chew their food or who have difficulty swallowing. A pureed diet should have a smooth texture with no lumps. Failure to ensure a thoroughly smooth texture poses a risk that residents with a swallowing disorder could have food pass down the airway instead of the esophagus when eating. On 2/21/19 at 10:36 AM, Staff #16 provided 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 resident observation, record review, and interview with facility staff, it was determined that the facility failed to maintain accurate resident medical records by 1) failing to have an order to discontinue a treatment that the resident was no longer receiving, 2) failing to clarify discrepancies for indications for use of 3 psychotropic medications and failing to document the reason for continuing current medication doses despite pharmacy recommendations to decrease the dose. This was evident for 3(#62, #4, and #91) of 54 residents reviewed during the investigation phase of the survey. The findings include: 1) Resident #62 was observed on 2/27/19 at 8:54 AM. During the observation, it was noted that the resident was not wearing any protective headgear. Protective headgear is used for residents who are at risk for falling and requires a physician's order to place on the resident. Resident #62's medical record was reviewed on 2/27/19 at 9:05 AM. An order was found stating Resident to wear helmet at all times except hygiene care. This order was dated 11/16/18. Further 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.