Autumn Lake Healthcare At Pikesville

Based on facility documentation review and interview, the facility staff failed to provide evidence the facility had purchased a surety bond to assure the security of all the residents' personal funds deposited with the facility. This was evident during the investigation of facility tasks during an annual survey. The findings include: On 8/9/22 at 11:45 AM, an inquiry was made with lobby receptionist (Staff #47) as to where the business office was located. It was revealed that the facility did not have a business office and she was responsible for passing out resident funds. Upon further questioning she indicated that she receives a weekly ledger listing the individual residents' current personal funds balances for the residents that have their personal funds managed by the facility. The receptionist showed the balance dated 8/3/22 of all residents' personal funds held by the facility was $59,541.00. She was asked as the total amount of the Surety bond. She expressed that she was unaware of a Surety bond. Surety bond is an agreement between the principal (the facility), the surety…

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/responsible party was offered the opportunity to develop an advanced directive for 15 (#46, #76, #17, #87, #18, #28, #67, #1, #22, #49, #61, #95, #24, #75, #307) of 16 sampled residents for advanced directives. 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 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…

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 interviews, it was determined that the facility failed to maintain a safe and clean environment as evidenced by 1) sagging ceiling tiles in resident rooms, 2) stained ceiling tiles, 3) walls in resident rooms that were in disrepair, 4) soiled linen and trash/debris on the floor and, 5) a rusted tube feeding pole. This was found to be evident throughout both floors of the facility. The findings include: 1) During the facility tours from 7/21/22 to 8/4/22, surveyors observed several resident rooms that had sagging ceiling tiles in their rooms. (Sagging ceiling tiles meant there was a space between the two attached tiles, and it looked like it was stuck down convexly.) -room [ROOM NUMBER] above bed B: the second ceiling tiles from the wall had sagging ceiling tiles. -room [ROOM NUMBER]: sagging tiles were observed above the bathroom entrance on the hallway side. -room [ROOM NUMBER]: sagging tiles were observed above the sink. -room [ROOM NUMBER]: sagging tiles were observed above bed A. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care that were resident specific with measurable objectives and goals. This was evident for 17 (#46, #58, #80, #208, #84, #251, #17, #76, #53, #401, #307, #95, #89, #311, #1, #49, #152 ) of 38 residents reviewed during the annual survey, however affected all residents as only samples were provided in this citation. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 7/27/22 at 8:04 AM Resident #46's medical record was reviewed and revealed a diagnosis of unspecified dementia. Review of Resident #46's care plan, has mood problem r/t Disease process cognitive decline will have improved mood state (Specify: happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date was not specific to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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) review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident for 2 (#67, #401) of 4 residents reviewed for care plan meetings and 7 (#46, #84, #1, #27, 49, 152, #89) of 38 residents reviewed during the annual survey, however affected all residents on units that did not have a unit manager. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. 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…

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 employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) are evaluated annually and provided appropriate re-education based on the outcome of these evaluations. This was found to be true for 5 of 5 GNA employees (Staff #68, #69, #70, #71, #72) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility. The findings include: On 8/10/22, the Human Resources (HR) Director (staff #78) provided a requested list of the facility's Geriatric Nursing Assistants (GNAs) with hire dates. Out of a list of 23 GNAs, 5 employee files were selected at random. A meeting was held with HR at 10:00 AM on 8/10/22 to review the GNA employment files for education and yearly performance Appraisals. 1) Review for GNA (staff #68) with a Date of hire (DOH) 8/1/18 revealed an incomplete employee Job performance appraisal dated 8/1/21. The form showed 11 areas that each employee was evaluated with a number system from 4 = Excellent to…

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

Based on observation and interview, it was determined the facility failed to consistently maintain a sanitary environment in the kitchen. This was evident during the initial tour of the kitchen and during 2 subsequent visits. The findings include: 1) Dietary staff failed to utilize personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread during an active COVID-19 outbreak in the facility. Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear source control while at work. 1a) Observation was made on 7/21/22 at 8:01 AM, during the initial tour of the kitchen, of Staff #3 at the food service table plating breakfast with her mask below her chin. Staff #4 was also at the plating table with her mask below her nose. 1b) Observation was made on 7/26/22 at 11:07 AM of lunch being prepared in the kitchen. During an interview with Staff #50, Staff #50 wore her…

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 pertinent documentation, observation and interview it was determined that the facility administration failed to 1) ensure that all staff, including agency staff, were educated on elopement prevention, 2) update the facility assessment to address elopement and COVID-19, 3) correct deficiencies from a previous complaint survey and 4) obtain and utilize resources necessary to provide for the needs of the residents. This was evident from 7/21/22 to 8/11/22 (16 days) of the annual survey which resulted in 52 Federal citations and identification of an Immediate Jeopardy. The findings include: 1) After an elopement in May 2021 facility administration failed to ensure that all staff were educated regarding elopement and failed to have a process in place to educate agency staff which resulted in an Immediate Jeopardy being identified on 8/2/22 at 9:40 AM. On 8/1/22 a review of facility-reported incident MD00167212 revealed on 5/10/21 at 6:58 AM, Resident #208 eloped from the facility and was brought back to the facility by police at about 8:30 AM on 5/10/21. During 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 facility records and interview with staff, it was determined the facility failed to conduct and document an accurate facility-wide assessment that was up to date. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was provided at the initiation of the survey. The Date of the assessment or Update was 6/30/22. Date assessment reviewed with QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance and Performance Improvement committee) was 7/19/22. On 8/11/22 at 1:07 PM an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, reviews of facility and resident records, and current survey findings it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) plan to ensure care and services are maintained at acceptable levels of performance and continually improved. This had the potential to affect all residents within the facility. The findings include. A copy of the facility's Quality Assessment Performance Improvement (QAPI) plan was received at the initiation of the survey. The undated QAPI plan was reviewed, and per the plan, there was no indication that the plan was refined and revisited. Much of the plan was written in generalizations such as Under the section titled Feedback, Data systems and Monitoring the plan stated the facility will put in place systems to monitor care and service, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. Under the section titled…

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, reviews of facility and resident records, current survey findings and the facility's prior complaint surveys it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) program to develop and implement effective plans of action to correct identified quality deficiencies. This failure resulted in 4 repeat deficiencies found during the current annual survey. This was evident during the survey process and review of the Quality Assurance Program. The findings include: On 7/22/22 a review of the survey binder revealed a plan of correction for a complaint survey that ended on 7/29/21. Citation F623 was cited as the facility failed to give a written copy of a resident's transfer notice to the resident/resident representative (RP). The corrective action that the facility stated they were taking was to put measures in place to prevent re-occurrence and that residents would receive a copy of the transfer notice at the time of transfer. The facility documented the RP would be sent a copy of the transfer paper in writing…

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 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 1) failing to keep contact/isolation room door closed on the 1st East unit. This was evident for 1 (Resident #401) of 15 residents' rooms observed, 2) failing to provide education and convey updates to staff on COVID-19. This was evidenced by 49 out of 115 staff who did not receive COVID-19 education in November 2021, 3) failing to change oxygen tubing and label when changed. This was evidenced by 1 (#76) of 3 residents reviewed for respiratory care and 4) failed to follow infection control practices in the laundry room and kitchen. This was evident for 5 staff (#3, #4, #51, #15 and #16) observed in the kitchen and laundry room during survey. These practices had the potential to affect all residents. The findings include: 1) During 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 observation and staff interview it was determined the facility failed to keep the second walk-in freezer and dishwasher in the kitchen in safe operating condition. This was evident during the initial tour of the kitchen and during 2 subsequent visits. The findings include: 1) On 7/21/22 at 8:07 AM observation was made of the second walk-in freezer during the initial tour of the kitchen. There were small mounds of ice covering the inside ceiling of the freezer. Staff #2, the dietary manager stated, when it gets hot and humid in here and when the door is open there is ice build-up. On 7/26/22 at 11:29 AM a second observation was made of the second walk-in freezer. The ceiling had small mounds of ice scattered throughout the ceiling. The District Manager was with the surveyor during the observation and stated, we have had problems for a while with the freezer and that is why the fans are here. There were industrial size fans in the kitchen by the outside of the freezer. 2) Observation was made on 8/5/22 at 10:35 AM in the kitchen of the commercial dish washer running 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 and staff interviews, it was determined that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, evidenced by 1) ongoing renovation construction in the facility building since October 2019, 2) uncapped sides of handrails at the 2-East wing, 3) broken wall behind the water purifier on the second floor near between 2-West nursing station and medication storage room, and 4) approximately 1.5 cm x 0.5 cm size, rusty, flat metal piece with one side that was sharpened and the other side was flat found on the hallway on the 2nd floor of the facility. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: 1) Surveyors conducted a facility tour on 7/21/22 at 8:10 AM. During a tour of the facility's second-floor units, surveyors observed carpet on the hallways that was covered with debris from paint, wall scrapings, and wallpaper that was on the entire second floor. At 8:40…

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, observation, and documentation review it was determined the facility failed to ensure an adequate amount of potable emergency water was always available. This was evident during a tour of the kitchen during the annual survey. This had the potential to affect all residents. The findings include: On 7/21/22 at 8:01 AM an interview was conducted with Staff #50 while in the kitchen. Staff #50 was asked where the emergency water was located. Staff #50 stated the water was in the basement and proceeded to walk with the surveyors to the basement storage room. Observation was made in the basement storage room of 16 cases of water with 4 gallons in each case. There were an additional 26 cases of water on the other side of the room containing 4 gallons each. The total number of gallons of water on hand was 168 gallons. Potable water on hand is calculated at 1 gallon per resident (total bed capacity) x 3 days. The bed capacity for the facility on 7/21/22 was 140 residents. The facility should have had 420 gallons of water on hand to cover 140 residents for 3 days. 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 employee file documentation and interview it was determined that the facility failed to have a process to ensure all Geriatric Nursing Assistants (GNAs) have no less than 12 hours of education per year and the education included annual dementia management training and resident abuse prevention training. This is evident for 5 of 5 GNA employment files reviewed and 1 (staff #69) of 5 GNAs that did not have abuse prevention training. This is evident for 5 (#68, #69, #70, #71, #72) of 5 GNA employment files reviewed and 1 (staff #69) of 5 GNAs that did not have abuse prevention training. The findings include: On 8/10/22, the Human Resources (HR) Director (staff #78) provided a requested list of the facility's Geriatric Nursing Assistants (GNAs) with hire dates. Out of a list of 23 GNAs, 5 employee files were selected at random. A meeting was held with the HR at 10 AM on 8/10/22 to review the GNA employment files for education and yearly performance Appraisals. The HR director did not have access to employee education files but was requested to obtain staffing…

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 staff interview it was determined the facility staff 1) failed to notify the physician that a medication for an elevated potassium level was unavailable and 2) failed to have a system in place to notify the physician when residents' weight loss was identified. This was evident for 1 (Resident #251) of 1 resident reviewed for an unexpected death and 3 (Resident #73, #67, #402) of 7 residents reviewed for weight loss. The findings include: 1) On 8/4/22 at 7:30 AM a review of Resident #251's medical record revealed a 12/17/21 physician's history and physical that documented the resident was admitted to the facility on [DATE] from an acute care facility for subacute rehabilitation due to deconditioning. Resident #251 had diagnoses that included, but were not limited to hypertension, chronic obstructive pulmonary disease exacerbation complicated by pneumonia, aortic stenosis, atrial fibrillation, and heart failure. A review of a 1/4/22 physician's note documented that Resident #251 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 interview and medical record review it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident or with the reason for the transfer. This was evident for 3 (#57, #61, #83) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) Resident #57 was initially interviewed on 7/21/22 at 10:37 AM. Resident #57 revealed that he/she was transferred to the hospital on multiple occasions in the past year. A review of resident #57's medical record on 8/3/22 revealed that he/she was transferred to a hospital on the following dates and more 8/24/21, 11/24/21, 2/3/22, 3/24/22, and 7/19/22. Further review of the medical record did not reveal documentation that the resident was informed in writing related to transfers to the hospital on 8/24/21, 11/24/21, and 2/3/22. On 8/3/22 at 2:23 PM an interview was conducted with the unit manager (staff # 48). She was asked, where is the written notifications of transfer. She responded that her previous employer/facility owner kept the…

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

Based on interview and medical record review it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 ( #57, #61, #83) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) Resident #57 was initially interviewed on 7/21/22 at 10:37 AM. Resident #57 revealed that he/she was transferred to the hospital on multiple occasions in the past year. A review of resident #57's medical record on 8/3/22 revealed that he/she was transferred to a hospital on the following dates and more 8/24/21, 11/24/21, 2/3/22, 3/24/22, and 7/19/22. Further review of the medical record did not reveal copies of the bed hold policy that was to be provided to the resident at the time of each transfer. On 8/3/22 at 2:23 PM an interview was conducted with the unit manager (staff # 48). She confirmed that a copy of the bed hold policy for each transfer was not in the medical record. She added that her previous employer/facility owner kept…

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 conduct a complete assessment by failing to assess a resident's cognition and mood on quarterly MDS assessments. This was evident for 5 (#4, #7, #98, #47 #28) of 38 residents reviewed during the annual survey. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 7/21/22 at 12:30 PM Resident #4's medical record was reviewed and revealed an incomplete quarterly MDS. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 4/10/22, Section C, Cognitive Patterns, Brief Interview of Mental Status, was not done, however Section C0700, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 10 (#53, #87, #57, #58, #80, #208, #251, #28, #67, #311,) of 38 residents reviewed 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. 1) On 7/27/22 at 10:30 AM a record review of Resident #53's quarterly MDS with an assessment reference date (ARD) of 6/6/22, Section N, Medications, documented that the resident received an anti-coagulant for 7 days during the lookback period. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission and failed to accurately assess the resident. This was evident for 6 (#58, #208, #251, #416, #307, #89) of 38 residents reviewed during the annual survey. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is to be given to the resident and/or resident representative and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1) On 7/28/22 at 7:47 AM a review of Resident #58's…

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

Based on observation, interview, and record review it was determined the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 (#17, #53, #55) of 6 residents reviewed for positioning and mobility during the annual survey. The findings include: 1) On 7/25/22 at 12:00 PM an observation was made of Resident #17 sitting in a chair with a right palm protector in place. On 7/26/22 at 10:08 AM a second observation was made of Resident #17 lying in bed without anything in the right hand. Resident #17's right hand was in a fist. On 7/25/22 at 12:00 PM Resident #17's daughter was interviewed and stated that Resident #17's hands were not always like they are now. On 7/27/22 at 1:24 PM Resident #17's medical record was reviewed. Resident #17 was admitted to the facility in December 2018 with diagnoses including but not limited to early onset Alzheimer's disease. Review of physician's orders revealed an order for, Right palm protector continuous wear, that 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 medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 5 (#46, #80, #55, #67, #65,) of 38 residents reviewed during the annual survey. The findings include: 1) On 7/27/22 at 8:04 AM a record review was done for Resident #46. Review of the paper and electronic medical record revealed the last physician's note found in the medical record was from an 8/4/21 visit with an upload to the electronic medical record on 8/11/21. 2) On 7/9/22 at 9:30 AM a review of Resident #80's medical record revealed the last physician's visit that was in the medical record was dated 11/28/21 with an upload date of 12/22/21. The previous note was dated 5/18/21. There were no physician visits noted in-between those 2 notes. A physician's note dated 5/17/22 was found in the labeled other section of the electronic record that was uploaded on 6/13/22. In that note there is documentation of visits dated 12/14/21, 1/18/22, 2/8/22, 3/8/22, 4/15/22, and 5/17/22, however they 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 review of facility records and interview with staff, it was determined the facility failed 1) ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs and 2) failed to ensure all nursing staff had the specific competencies and skill sets necessary to care for residents with a Nephrostomy tube. This was evident for 2 (Staff #71 and #72) of 5 randomly selected GNAs reviewed for competency review and 2 (# 89 and #83) out of 2 residents with Nephrostomy tubes reviewed. The findings include: Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as resident Rights, person centered care, communication, basic nursing skills, basic restorative services, skin and wound care, medication management, pain management, Infection control, Identification of changes in condition, and cultural competency. 1) A meeting was held with the Human Resource (HR) Director (staff #78) 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.

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 1) monitor the blood pressure and heart rate prior to administering a blood pressure medication and 2) follow physician ordered blood pressure parameters for administering Metoprolol, a blood pressure medication. This was evident for 1 (#80) of 7 residents reviewed for unnecessary drugs during the annual survey. The findings include: On 7/29/22 at 7:43 AM a review was conducted of Resident #80's medical record. Review of July 2022 physician's orders revealed the order Metoprolol 25 mg. 1/2 tablet every 12 hours at 8 AM and 8 PM. The order stated to hold the medication if SBP (systolic blood pressure) was less than 110 or HR (heart rate). 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.…

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 facility staff 1) failed to keep medication carts locked when unattended and 2) failed to date medication and biologicals when opened, and failed to discard insulin, food supplements, inhalers, and oral medications when expired. This was evident on 2 of 4 nursing units observed during the annual survey. The findings include: 1) On 7/21/22 at 09:01 AM observation was made of an unlocked and unattended medication cart in the hallway outside of room # 208. The surveyor was able to open the drawers to the medication cart to observe insulin, eye drops and resident medications. When LPN #1 came out of a resident's room, the surveyors asked about the unlocked and unattended medication cart. LPN #1 stated, I was right here. I only stepped into the room. The other nurse called me and closed the door. The Director of Nursing (DON) was informed of the observation. 2) On 7/22/22 at 8:07 AM observation was made of a medication room on the first-floor nursing unit.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility failed to have quality laboratory supplies for resident diagnostic testing in 1 of 2 medication rooms observed during the annual survey. The findings include: Observation was made on [DATE] at 8:07 AM in the first-floor medication room by 2 surveyors of the following expired blood collection tubes that were observed in a light blue bin labeled lab specimen supplies: (14) purple blood collection tubes, Lot #9315422 exp (expiration) 3/31 (13) blue top collection tubes, Lot #0009468 exp [DATE] (3) orange top collection tubes, Lot #0240566 exp [DATE] (5) red top collection tubes, Lot #0218175 exp [DATE] (3) purple top collection tubes, Lot #226552 exp [DATE] (3) blue top collection tubes, Lot # 0184336 exp [DATE] Licensed Practical Nurse (LPN) #9 was in the medication room at the time of the observation and was asked if the nurses drew blood for residents. LPN #9 stated, when the lab can't get here. On [DATE] at 10:41 AM 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 medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 10 (#251, #84, #76, #53, #18, #28, #61, #401, #73, #24 ) of 38 residents reviewed in the investigative stage of the annual survey. The findings include: A medical record is the 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. 1a) On 8/4/22 at 7:30 AM a review of Resident #251's medical record revealed a 1/4/22 physician's note, Lab work today is being ordered stat. A review of the written physician's orders sheet dated 1/4/22 had the order, give Lokelma 10 gm x 1 for hyperkalemia. The order sheet did not have a time that the order was written. Review of the electronic order in the facility's electronic medical record system…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, complaints from anonymous staff, and facility documentation review, it was determined that facility staff failed to maintain an effective pest control program, so the facility was free of pests. This practice had the potential to affect all residents, staff, and visitors. The findings include: During multiple observations in the facility building from 7/25/22 to 7/29/22, the surveyor observed dead bugs, crawling bugs, and flying bugs. -On 7/25/22 at 10:44 AM, a black, pinky nail-sized, smashed dead bug was found in front of room [ROOM NUMBER]. -On 7/25/22 at 7:49 AM, a dark brown, about 1.5 inches long, a smashed bug was found between room [ROOM NUMBER] and the medication room. -On 7/26/22 at 7:28 AM, a brown, pinky nail size dead bug was found on the 1st floor in front of the women's locker room. -On 7/26/22 at 8:39 AM, a dark brown, ring fingernail size, dead bug was found on the right side of the nursing office's director. -On 7/27/22 at 6:47 AM, a pinky finger size,…

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, interview, and record review it was determined that the facility staff failed to: 1) protect and value resident's private space by failing to knock and request permission before entering a resident's room, and 2) ensure a urine collection bag had a privacy cover and was out of sight of the public. This was evident but not limited to 1 of 7 residents (Resident #57) reviewed on the 1 [NAME] Unit and 1 (#83) of 4 residents reviewed for urinary catheters during the annual survey. The findings include: 1) An interview was conducted with Resident #57 in the resident's room with the door closed on 8/3/22. At 1:41 PM a couple of knocks were heard and without any acknowledgement from resident #57 an employee entered the room. The employee did not excuse herself, interrupted the interview and proceed to place supplies into a dresser drawer. Upon the employee's exit from the room, resident #57 identified the employee (Staff # 75) from central supply. Resident #57 commented and implied that the staff entering the room unannounced is routine. The unit manager…

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 complaint MD00177146, medical record review, observations, and interviews with the resident, and facility staff, it was determined that the facility 1) failed to optimize the living environment for a resident with a request to add weather-stripping to the bottom of the resident's bedroom door and 2) failed to ensure access to the nurse call bell for residents residing in the facility. This was evident for 1 (complaint MD00177146) of 4 complaints reviewed for Resident #50 and 1 (Resident #53) of 32 residents reviewed during the initial stage of the annual survey. The findings include: 1) Review of complaint MD00177146 revealed a concern that the facility did not meet an agreed upon request to install weather stripping along the bottom of the resident's door to accommodate resident #50's request to maintain the air quality in the room. Review of resident #50's medical record on 8/2/22 revealed a social service Care Plan: quarterly resident meeting note dated 6/17/22 with the following statement: Resident request structural adjustment to the bottom of his/her…

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 policy and facility documentation review and interviews it was determined that the facility failed to implement their policy regarding reporting allegations of abuse, neglect, and exploitation of residents and misappropriation of resident property. This was evident for 2 (#58, #412) of 8 residents reviewed for abuse during the annual survey. The findings include: 1) On 7/29/22 at 7:50 AM a review of the Abuse, Neglect and Exploitation policy dated 7/21/21, Section V B6. reads, providing complete and thorough documentation of the investigation. Review of facility reported incident MD00178644 on 7/29/22 at 8:00 AM revealed on 6/9/22 Resident #58 alleged that there was money missing from his/her nightstand drawer. Review of the facility investigation that was provided by the Nursing Home Administrator (NHA) included (2) employee interviews and the resident interview. It was also noted on the front page of the report that law enforcement was notified. The facility documented that police were unable 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 that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#57, #61) of 5 residents reviewed for hospitalization during an annual certification survey. The findings include. 1) Review of Resident #57's electronic and paper medical record on 08/03/22 at 11:31 AM revealed a change in condition note dated 8/24/21 for 6:09 PM that was written as Change in Condition Note Text: Brief Synopsis of Change: Hematuria and lethargy Summary of Change in Condition: Pt was lethargic and had Hematuria. Transferred out to [hospital name] Hospital. There was no documentation as to what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why. An interview was conducted with the unit manager (staff #48) at 2:23 PM on 8/3/22. She read the change in condition note dated 8/24/21 6:09 PM (as above) and acknowledged that the note was brief. At 3:03 PM on 8/3/22 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 staff failed to conduct an accurate, comprehensive assessment by failing to assess a resident's mood and cognitive status on comprehensive and quarterly MDS (Minimum Data Set) assessments. This was evident for 3 (#27, #46, #28) of 38 residents reviewed 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 7/21/22 at 10:04 AM a review of Resident #31's medical record revealed a comprehensive MDS assessment with an assessment reference date (ARD) of 1/3/22 was not complete. Section C, Cognitive Patterns and Section D, Mood was not assessed. 2) On 7/27/22 at 8:04 AM a…

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

Based on observation, medical record review, and staff interview, it was determined the facility failed to follow a physician's ordered treatment. This was evident for 1 (Resident#61) of 1 resident reviewed for non-pressure skin condition. The findings include. Review of resident #61's medical record on 7/26/22 revealed that the resident had multiple chronic vascular bilateral lower extremity wounds. Review of the physician order's revealed that there was multiple treatment wound orders prescribed for daily dressing changes with various treatments to each wound. On 8/4/22 at 9:14 AM, an agency Licensed Practical Nurse (LPN) staff #86, was observed to provide wound care and replace the wound dressing to the multiple areas on resident #61's feet and legs. Upon completion of the observed wound treatments, resident #61's medical record was reviewed to reconcile the physician orders to the observed wound care. Based on the medical record review it was discovered that the nurse staff #86 failed to provide the prescribed treatment ordered as Wound location: right medial plantar great toe…

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

Based on observation, medical record review, and interview, it was determined the facility 1) failed to properly date label oxygen tubing when changed, 2) failed to follow physician's orders for the administration of oxygen, and 3) failed to develop and implement a person centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 2 (#307 and #76) of 3 residents reviewed for respiratory care during the annual survey. The findings include: On 7/22/22 at 8:10 AM, the surveyor observed Resident #307 lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the right side of the resident's bed. The resident was wearing a nasal cannula (oxygen tube with nose prongs) that was connected to the concentrator. The tubing was not date labeled to indicate when it was last changed. When asked, the resident was unable to recall when it was last changed. During a review of Resident #307's medical record conducted on 8/1/22 at 8:12 AM, surveyor noted an active physician order dated 7/22/22…

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

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 (#80) of 7 residents reviewed for unnecessary medications. The findings include: On 7/29/22 at 7:43 AM a review was conducted of Resident #80's medical record. Review of the July 2022 physician's orders revealed the order Metoprolol 25 mg. 1/2 tablet every 12 hours at 8 AM and 8 PM. The order stated to hold the medication if SBP (systolic blood pressure) was less than 110 or HR (heart rate) less than 60. Metoprolol is a beta-blocker used to treat hypertension. 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. Review of Resident #80's July 2022 Medication Administration Record (MAR)…

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 interviews, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications if outside of physician ordered parameters. This was evident for 1 (#251) of 5 residents reviewed for medication pass observation and 1 (#151) of 2 residents reviewed for death during the annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). 1) On 7/26/22 at 7:58 AM observation was made of medication administration for Resident #151. After the medication administration observation, the resident's medical record was reviewed. Review of Resident #151's July 2022…

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

Based on medical record review and interview it was determined that facility staff failed to provide timely dental care. This was evident for 1 (#28) of 3 residents reviewed for dental during the annual survey. The findings include: On 7/28/22 at 7:54 AM a review of Resident #28's medical record revealed a progress note dated 4/7/22 at 11:22 AM that documented that a fax request was made for dental services for Resident #28. A 5/9/22 at 11:51 AM progress note stated that Resident #28 was complaining that when s/he eats the upper teeth that broke were sharp and hurting his/her gum. The Nurse Practitioner (NP) was notified and an order was given to have dental consult. A 6/30/22 at 1:49 PM progress note documented that Resident #28 told staff that his/her teeth hurt when he/she tried to eat. A 6/30/2022 at 15:37 (3:37 PM) dietician note documented, per nursing, resident reports difficulty chewing PBJ snack related to dental issues. On 7/14/22 at 6:02 PM a dietician note documented that Resident #28 occasionally had chewing issues reported from nursing due to dental issues. On 8/4/22…

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

Based on observation, record review, and interview it was determined the facility failed to provide rehabilitation services following the recommendation from an orthopedic physician consult. This was evident for 1 (#55) of 2 residents reviewed for rehabilitation. The findings include: On 7/21/22 at 9:54 AM observation was made of Resident #55 lying in bed. Resident #55's left arm appeared contracted. On 8/1/22 at 1:37 PM Resident #55's medical record was reviewed. Resident #55 was admitted to the facility in May 2017 with diagnoses that included but were not limited to a cerebral infarction affecting the left dominant side and nontraumatic intracerebral hemorrhage. On 8/8/22 at 10:23 AM an interview was conducted with Staff #53, physical therapist (PT). Staff #53 stated that Resident #55 was currently not on a program due to him/her being at baseline. Continued review of Resident #55's medical record revealed a progress note dated 3/22/22 at 15:00 (3:00) PM which documented that the resident returned from an ortho (orthopedic) appointment with the recommendation to continue PT/OT…

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 staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Pneumococcal vaccines before requesting consent. This was evident for 1 (Resident #401) of 5 residents reviewed for Immunizations during the survey. The findings include: Pneumococcal vaccine helps to prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and…

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

Based on staff interviews and record review, it was determined that the facility failed to properly prevent the transmission of COVID-19 by failing to conduct staff testing twice a week during the time the facility was in a COVID-19 outbreak. This was evident for 1 (Staff #41) of 5 randomly selected staff reviewed for COVID-19 testing during the survey. The finding includes: During an interview with the Director of Nursing (DON) on 8/4/22 at 7:30 AM, she was asked about COVID-19 Staff testing. The DON stated since the facility was under outbreak that started on 7/20/22, all staff needed to be tested twice a week regardless of their vaccination status. The DON submitted the COVID-19 testing log from the week of 6/12/22 to the week of 7/24/22 on 8/4/22 at 9:00 AM. Review of the COVID-19 testing log revealed that Geriatric Nursing Assistant (GNA #41) did not do the COVID-19 test on 7/24/22. During an interview with the DON on 8/4/22 at 9:39 AM, she stated, for some reason, the twice-weekly COVID testing log was not updated timely. Staff did the test, filled out COVID-19 test results…

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

Based on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff. This was evident for 1 (Resident #401) of 5 residents and 2 (staff #10 and #20) of 4 facility staff members reviewed for COVID-19 vaccinations during the survey. The findings include: 1) On 8/1/22 at 09:00 AM, Resident #401's immunization medical record was reviewed. There was documentation found as [name-Responsible Party(RP)] refused vaccine in the electronic medical record (EMR) immunization under the COVID-19 vaccine tab. However, no documentation was found for evidence of education provided under the resident's paper chart or electronic medical record. During an interview with the Infection Control Preventionist (ICP) and the Director of Nursing (DON) on 8/1/22 at 3:10 PM, they stated the facility staff provided vaccination education to the resident or RP and documented it under EMR. The DON also said, sometimes education should be charted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined the facility failed to ensure that residents had access to alert staff for assistance through the facility's call bell system. This was evident in 1 (resident #61) of 32 resident call bells activated during this survey. The findings include: On 7/21/22 at 10:13 AM resident #61 was observed sitting on the edge of his/her bed asking for assistance. She was informed to utilize her call bell. She was observed to press her call button and there was not a light or sound. Resident #61's call light was not operational. The resident's roommate was not in the room at the time. The surveyor pressed the call button that was for the resident's roommate and a sound was heard and the light above the door lit up. From the hallway, the unit manager (staff #48) was observed going into resident #64's room and was heard informing the resident that she will get someone and turned off the call light. The Unit manager was interview at 10:17 AM on 7/21/22. She was asked about 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.

Based on medical record review and family and staff interview it was determined the facility failed to accommodate Resident #21 by leaving the television on a channel where Russian was the primary language spoken. This was evident for 1 resident investigated for language concerns during the survey. The findings include: On 12/19/18 at 11:09 AM, a family member voiced a concern that staff kept changing the TV (television) stations to English-speaking channels instead of leaving it on a Russian-speaking channel. According to the family, Resident #21 understands some English but speaks Russian. On 12/19/18 beginning at 12:53 PM, the medical record was reviewed. According to his/her care plan, Resident #21 is dependent on staff for socialization related to behaviors and language barrier. One planned intervention states: Offer music, pictures, games with the assistance of language line. On 12/20/18 at about 9:30 AM, the resident was observed with the Director of Nursing (DON) present. The TV was on an English-speaking channel. On 12/20/18 at 11:04 AM during an interview, the…

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

Based on observation, medical records review, and family and staff interview it was determined the facility failed to ensure that Resident #21 was shaved daily. This was evident for 1 resident reviewed for activities of daily living during the survey. The findings include: On 12/18/18 at 2:30 PM, Resident #21 was observed to be unshaven. On 12/19/18 at 10:09 AM, the resident was observed to still not have been shaved. On 12/19/18 at 11:11 AM during an interview with a family member, he/she stated family usually shaves the resident, but the spouse just had surgery and the family hasn't been able to come in to do it. Per the family member, the resident is unable to shave independently. Beginning on 12/18/18 at about 3:00 PM, the medical record was reviewed. Although there was a care plan that addressed activities of daily living such as personal hygiene which includes shaving, bathing, toileting, etc., no reason was documented as to why the resident was not being shaved daily. It is a minimum standard of nursing practice that male residents are to be shaved daily.

Based on observation and staff interviews it was determined that the facility staff failed to ensure that food was stored and prepared in sanitary manner. This practice has a potential of effecting all residents in facility. The findings include: During the initial tour of the kitchen on 12/18/18 at 9:15 AM, accompanied by the Certified Dietary Manager (CDM) staff member #10 who verified all surveyor observed finding. On 12/18/18 10:29 A.M. observed on clean kitchen pan storage shelve: 1). 1- 4-inch 1/2 pan, 2-1/3 pan, 1-1/2 pan with 1-full pan was observed with water resting at bottom of pan is called wet nesting. 2). 1-full pan, 1-2 inch, 4-inch, and 6-inchdirty with visible white reside dried food in the bottom of each pan. Infection Control issues: On same day staff member #1 was observed with no facial beard hair cover on while preparing chicken, with other food for lunch menu. On 12/18/18 at 10:15 A.M. staff member #1 replied during staff interview he/she it was my fault for not wearing the facial face net cover and was just busy working and forgot. On 12/18/18 at 11:15 A.M.…

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 ensure that equipment used for personal hygiene was stored appropriately in a room shared by Residents #44 and #55. This was evident for 2 of 32 residents reviewed during the survey. The findings include: On 12/19/18 at 1:53 PM, wash basins for roommates Residents #44 and #55 were found stored one inside the other. This was confirmed by staff nurse #4.