Hartley Nursing And Rehab

Based on observation, interview and record review, it was determined that the facility failed to use appropriate infection control practices such as 1) improper use and care of oxygen administration equipment, 2) improper storage of clean linens, and 3) inadequate infection surveillance. This was evident for 1) 1 (Resident #45) of 1 resident, 2) 1 of 1 laundry observation, and 3) 9 of 9 months of infection surveillance reviewed during the recertification survey.The findings include: 1) Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. On 1/14/2026 at 10:30 AM, during the initial rounds of the facility, Resident #45's O2 concentrator was found turned off with the nasal cannula resting on the floor under the bed. On 1/14/2026 at 10:39 AM, Unit Manager (UM #2) was informed of the finding and verified this observation. He/she confirmed that nasal cannulas not in use should be stored in a clean plastic bag. On 10/16/2025 at 10:45 AM, the…

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

Based on record review and interview, it was determined that the facility failed to collect all the information required for monitoring antibiotic stewardship. This was evident for 9 of 9 months of antibiotic logs reviewed during the recertification survey. This deficient practice has the potential to affect all residents in the facility.The findings include:Antibiotic stewardship requires a facility to develop and implement policies, procedures and/or protocols to ensure residents who need antibiotics are treated appropriately. This is to reduce the risk of residents having adverse reactions to antibiotics, receiving them unnecessarily and/or developing antibiotic-resistant organisms. A facility-wide process must be in place to monitor the use of antibiotics so the results/feedback can be reported to nursing staff and prescribing clinicians.On 1/20/2026 at 7:10 PM, a review of the antibiotic surveillance logs from May 2025 to January 2026 revealed significant inconsistencies. Logs lacked critical data, including onset dates, room numbers, antibiotic order, diagnosis, ordering…

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 screen, offer and educate the residents or the Responsible Parties (RP) of risks and benefits of pneumococcal vaccines and flu vaccines. This was evident for 4 (Resident #62, #57, #45 and #9) of 5 residents randomly reviewed for immunizations. The findings include: According to Centers for Disease Control (CDC), flu vaccine is an annual injection (or nasal spray) recommended for everyone 6 months and older to protect against influenza, while pneumococcal vaccines prevent serious bacterial infections causing pneumonia, meningitis and sepsis. On 1/21/2026 at 1:08 PM, a medical record review revealed the following:- Resident #62: admitted [DATE], the record lacked evidence that the pneumococcal vaccine was offered upon admission or thereafter.- Resident #57: Originally admitted [DATE] with a recent readmission on [DATE]; the record lacked evidence that pneumococcal and flu vaccines were offered. While the Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to offer and provide required education regarding the benefits, risks, and potential side effects of COVID-19 vaccine to residents and staff. This was evident for 3 (Registered Nurse RN #10, Geriatric Nurse Assistants GNA #10 and #11) staff members and 4 (Resident #57, #45 and #9) of 5 residents randomly reviewed for immunizations. The findings include: According to Centers for Disease Control (CDC), COVID-19 vaccines are recommended for individuals aged 6 months and older to protect against severe illness, hospitalization, and death. These vaccines work by training the immune system to recognize and fight the virus, with protection decreasing over time, making updated doses necessary especially for high risk groups.A) 01/20/2026 at 10:15, the surveyor requested 5 random employee health records, however, the Assistant Director of Nursing/Infection Preventionist Nurse (ADON/IP) stated, we don't require immunization for 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 record review and interview, it was determined that the facility failed to provide evidence that nursing staff have received required training on abuse prevention, neglect, and exploitation upon hire and annually. This was evident for 5 (Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed for annual training requirements during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed the following: 1. GNA #8 (hired 2/23/24): Completed a 7-item abuse quiz, however, the completion date was not recorded.2. GNA #11…

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

Based on record review and interview, it was determined that the facility failed to provide Quality Assessment and Performance Improvement (QAPI) training to staff. This was evident for 5 (Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: QAPI is a Centers for Medicare and Medicaid (CMS) program that merges proactive Performance Improvement (PI) with reactive Quality Assurance (QA). It requires nursing homes to use data-driven, systematic approaches to improve quality of care, resident safety, and overall quality of life. On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. 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 record review and interview, it was determined that the facility failed to provide mandatory infection prevention and control training to staff upon and hire and routinely thereafter. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include:On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator.Guideline #16 of the facility's Infection Prevention and Control Program Policy (reviewed/ revised 1/7/25) indicated the following: Staff Education a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility'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 record review and interview, it was determined that the facility failed to provide compliance and ethics training to staff. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed no evidence of compliance and ethics training for the following staff members. 1. GNA #8 (hired 2/23/24)2. GNA #11 (hired 11/1/22)3. GNA # 10 (hired 3/19/25)4. RN #9 (hired 10/10/23)5. LPN #12 (hired 1/29/24) On 1/21/2026 at 11:19 AM, the DON and the…

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

Based on record review and interview, it was determined that the facility failed to provide the required 12 hours of annual in-service training for nurse aides. This was evident for 3 Geriatric Nurse Assistants (GNA# 8, #11, and #10) of 3 randomly selected GNAs reviewed for trainings during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27, a review of the employee records revealed no evidence of training on file for the following GNAs: 1. GNA #8 (hired 2/23/24)2. GNA #11 (hired 11/1/22)3. GNA # 10 (hired 3/19/25) On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator…

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

Based on record review and interview, it was determined that the facility failed to provide the mandatory behavioral health training program for all staff members upon and hire and annually. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed: 1. GNA #8 (hired 2/23/24): No evidence of training on file.2. GNA #11 (hired 11/1/22): Completed a Dementia Overview on 10/21/25; however, there was no evidence of training upon hire or…

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 complaint review, medical record review and interviews, it was determined the facility staff failed to ensure home health services and community referrals were in place at discharge for a resident (Resident #2). This was evident for 1 of 4 residents reviewed for community discharge during a complaint survey.The findings include: Review of Resident #2's medical record on 10/27/25 for complaint 337322 related to the Resident's discharge on [DATE] revealed the Resident was admitted to the facility in March 2022 for rehabilitation following hospitalization. Further review of Resident #2's medical record revealed on 8/15/24 the facility received a Denial of Continued Nursing Facility Services based on patients' needs and documentation, patient has a BIMS (Brief Interview of Mental Status), needs no skilled nursing services, no daily subcutaneous medications, no behaviors and does not need hands on assistance with any ADLs (Activities of Daily Living) and does not meet criteria for NFLOC (Nursing Facility…

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 medical record review and interviews it was determined the facility failed to notify a resident that his/her Medicare services were ending with the right to appeal. This was evident for 1 out of 3 (Resident #1) residents reviewed during the survey. The findings include: Review of Resident #1's medical record on 07/09/2024 at 11:45 AM revealed a Notice of Medicare Non-Coverage form stating that Resident #1's Medicare covered services would end on 01/10/2024 with the right to appeal. Further review of this form revealed that there was no signature documented that Resident #1 had received this notice. During an interview on 07/09/2024 at 11:50 AM Staff #10 stated and verified that the Notice of Medicare Non-Coverage form was not signed by Resident #1. BIMS (Brief Interview for Mental Status) is a tool used to screen and identify the cognitive condition of a resident. The resident's BIMS score is calculated according to their correct answers. A score of 15 out of 15 reveals that the resident's cognitive functions are intact. Review of resident #1 medical record on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an initial tour of the facility, this surveyor made the following observations: On 7/8/24 at 10:30am in room [ROOM NUMBER], the upper part of the wall, above the headboard had ripped drywall with large holes in the wall. This damage could be seen immediately upon entering the room. Cracks were noted on several floor tiles. The floor was black in color thru-out the room and a broken and peeling baseboard was noted on the side of the sink. The shower on the back hall was noted with cracked and yellow stained-glass tiles. During an interview on 7/8/24 at 3:30pm the Administrator stated the Director of Maintenance was in the process of stripping floors and repairing rooms. As of exit on 7/11/24 at 1pm, the repairs or stripping of the floor had been completed. Based on observation and interview it was determined the facility failed to provide the residents with a clean, comfortable and homelike environment. This was evident for 3 residents' (#13, #17 and #11) rooms out of 8 residents rooms observed during…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#29) of 2 residents reviewed for hospitalization during the survey. The findings include: Review of Resident #29 's medical record on 7/9/24 at 1:52pm revealed on 3/19/24 the resident was transferred to the hospital for a change in his/her medical condition. Further review of the medical record failed to reveal that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. During an interview with the Director of Nursing and the Administrator on 7/9/24 at 3pm, it was revealed they was unable to locate any documents that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. They stated that the former Administration used The Maryland Notice of…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident #29) of 2 residents reviewed that were transferred to an acute care facility. The findings include: Review of the medical record for Resident #29 on 7/9/24 at 2pm revealed on 3/19/24 the resident was sent to an acute care facility for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the resident and /or the resident representative were given written notice of the bed hold policy. During an interview with the Social Worker (staff # 17) on 9/26/23 at 5:50pm she stated the resident was given the reason for the transfer; however, she was unable to produce written evidence that the resident /resident representative was given written notice of the bed hold policy. During an interview with the Social Worker staff # 10 on 7/9/24 at 3pm,…

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 develop a person-centered care plan for residents. This was evident for 2 residents (#11 and 21) out of 24 residents reviewed during the survey. The findings include the following: 1. On 7/9/24 at 3:57pm a review of Resident #11's electronic medical record (EMR) revealed the resident was prescribed Paxil an antidepressant medication for off label use of sexually inappropriate behavior. Further review of the EMR revealed Resident #11 did not have a care plan for Paxil and/or sexually inappropriate behavior. On 7/9/24 at 4:30 pm the Director of Nursing (DON) verified the findings. She stated the Unit manager should have completed a care plan for the use of Paxil. I am unsure why the care plan was not completed. 2. On 7/10/24 at 2pm a review of Resident #21's electronic medical record (EMR) revealed the following physician orders: A. Administer Tylenol (Acetaminophen) 2 tablets by mouth every 6 hours as needed for right knee pain. B. Administer Tramadol 50 MG 1 tablet by mouth every 6 hours as…

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, resident medical record review and interviews it was determined the facility failed to complete a smoking assessment for Resident #56. This was evident for 1 resident (#56) out of 2 residents reviewed for smoking during the survey. The findings include: During the facility entrance conference on 07/08/2024 at 11:00 AM the Administrator stated that there were no smoking residents in the building and the facility was a smoke free facility. During observation rounds on 07/10/2024 at 1:20 PM Resident #56 was found smoking outside unattended, on the facility property near a resident facility room window. The facility room window had a sign posted on it stating room [ROOM NUMBER]. Review of Resident #56's medical record on 07/10/2024 at 2:45 PM revealed that the resident was admitted on Hospice 04/18/2024. Continued review of the resident medical record revealed a care plan that was initiated on 03/20/24 documenting that the resident was a smoker. Further review of the resident medical record…

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

Based on medical record review and staff interview it was determined that what the Physician and the Nurse Practitioner documented in the resident's (#11) progress notes did not accurately reflect what was in the resident's medical record. This was evident for 1 of 24 residents reviewed during the survey. The findings include: Resident #11's medical record was reviewed on 7/10/24 at 5:04pm. The review revealed Resident #11 was admitted to the facility with diagnosis that included Anxiety disorder, Depressive disorder. Review of the medical record on 7/10/24 at 6pm revealed Resident #11 was seen by the physician (staff # 15) on 5/17/24 and by the Nurse Practitioner (Staff #14) on 6/12/24 and at that time staff (#15) and staff (#14) documented that the resident was receiving Lexapro for panic attacks; however, according to the Medication Administration Record and the Physician Order the resident Lexapro was discontinued on 5/24/23 by staff (#15). During an interview with the Assistant Director of Nursing (ADON) on 7/10/24 at 6:30pm he verified the findings.

Based on observations, interviews and review of facility documentation, the facility failed to properly store medications and biologicals under proper temperature controls. This was evident in 1 out of the 2 medication storage refrigerators and freezers observed during the survey. The findings include the following: During observation rounds of the North Hall medication storage room on 07/08/2024 at 05:50 PM with Maintenance Director staff #6 the refrigerator thermometer read 44 degrees Fahrenheit, and the freezer thermometer read 30 degrees Fahrenheit. Several medications and biologicals for facility residents were found in this refrigerator. During an interview on 07/08/2024 at 5:50 PM staff #6 stated that yes, the refrigerator and freezer temperatures were too high, and he would look into this. Review of the facility policy for Monitoring of Cooler/Freezer Temperature on 07/08/2024 at 6:00 PM revealed that all refrigerator storage must be maintained at or below 41 degrees F and that all freezer storage must be maintained at or -4 degrees F.

Based on observation and interview the facility failed to store food in accordance with professional standards for food safety. This was evident during the kitchen observation of the recertification survey. The findings include: On 07/8/24 10:55AM during an initial tour of the facility with Kitchen Supervisor #9 the following concerns were identified. Inside of the Reach In Refrigerator the following items did not have a date label: 1. Pudding x 9 containers 2. Sandwich x 1 There was no July 2024 temperature log present and the June 2024 temperature log were missing entry dates for 6/12/24 (AM/PM), 6/18/24 (AM and PM), 6/19/24 (AM), 6/20/24 (AM), 6/25/24 (AM), 6/26/24 (AM and PM), 6/27/24 (AM and PM). Inside the Refrigerator the following items did not have a date label: 1. Chunky Salsa-69 ounce container 2. Peaches-x 1 bucket (1/2 full) 3. Bar-b-que sauce x 1 bucket (1/2 full) 4. Vanilla Pudding x 1 bucket (1/4 full) 5. Chocolate Pudding x 1 bucket (1/4 full) 6. Pears x 1 bucket (1/2 full) Inside the Freezer the following items did not have a date label: 1. Large bag of hamburgers…

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 provide documentation supporting the use of an intramuscular (in the muscle) antipsychotic injection for 1 of 6 resident reviewed for unnecessary medications during the survey (Resident #36). The findings include: Beginning on 7/31/19 10:10 AM, the medical record for Resident #36 was reviewed. According to the diagnostic list on the Care Plan and the Physician Order Sheet, the resident had diagnoses which included dementia as well as other mental, mood, and behavioral disorders. On 8/2/19 at 9:13 AM, a facility reported incident from November 2018 was investigated. It involved Resident #36 and an injury of unknown origin. A nurse's note on 11/10/18 written at 2:40 AM by Nurse #10 stated the resident was ambulating (walking) on the unit and looking for his/her mother and father. The nurse stated she explained to the resident that he/she was at the nursing home and the resident became angry at staff, wanting to go home. She wrote that the resident sat down and drank a soda and 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, medical record review, and staff interview, it was determined the facility failed to ensure less restrictive alternatives were tried and documented prior to administering an antipsychotic for 1 of 6 residents reviewed during the survey for unnecessary medications (Resident #36). The findings include: Beginning on 7/31/19 10:10 AM, the medical record for Resident #36 was reviewed. According to the diagnostic list on the Care Plan and the Physician Order Sheet, the resident had diagnoses which included dementia as well as other mental, mood, and behavioral disorders. On 8/2/19 at 9:13 AM, a facility reported incident from November 2018 was investigated. It involved Resident #36 and an injury of unknown origin. A nurse's note on 11/10/18 written at 2:40 AM by staff Nurse #10 stated the resident was ambulating (walking) on the unit and looking for his/her mother and father. The nurse stated she explained to the resident that he/she was at the nursing home and the resident became angry at staff, wanting to go home. She wrote that the resident sat down and drank 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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents and their representatives received written notice of resident transfer. This was evident for of 1 resident reviewed for hospitalization 1 (Resident #26). The findings include: Resident #26's medical record was reviewed on 7/30/19 at 12:29 PM. During the review, it was noted that Resident #26 was hospitalized in April, 2019. A review of the facility's documentation surrounding that hospitalization failed to reveal that the resident or his/her representative had been notified of the transfer and the reasons for it in writing. The Director of Nursing (DON) was interviewed on 7/30/19 at 1:15 PM. During the interview, the DON stated that the requirement of written notification was new information to her. She confirmed with this surveyor that the facility had not been providing written notification of transfer to residents or their representatives at time of transfer.

Based on review of medical records and interviews with facility staff, it was determined that the facility staff failed to develop a care plan to address each residents medical condition. This was evident for 1 of 24 residents investigated during the survey process (Resident #14). The findings include: On 07/31/19 at 8:52 AM while observing Resident #14, it was noted that the Resident had edema (swelling) to both lower legs. While reviewing the Resident's medical record it was noted that there were no routine weights for this resident. Further review of the record revealed that the Resident was taking Lasix daily. Lasix (furosemide) is a diuretic medication that reduces extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease. A review of Resident #14's plan of care did not identify any interventions to address the edema or any possible problems the resident might face as a result of any fluid shifts. The Director of Nursing was informed on 8/2/19 prior to the exit interview.

Based on observation, medical record review and staff interview, it was determined the facility failed to revise the behavioral care plan to address approaches to agitation and/or aggressive behavior and when to use intramuscular (in the muscle) antipsychotic injections. This was evident for 1 of 6 residents reviewed for unnecessary medications and care plans during the survey (Resident #36). The findings include: On 7/31/19 10:10 AM, the medical record for Resident #36 was reviewed. According to the diagnostic list on the resident's care plan and the Physician Order Sheet, the resident had diagnoses which included dementia as well as other mental, mood and behavioral disorders. On 8/2/19 at 9:13 AM, a facility reported incident from November 2018 was investigated. It involved Resident #36 and an injury of unknown origin. A nurse's note on 11/10/18 written at 2:40 AM by Nurse #10 stated the resident was ambulating (walking) on the unit and looking for his/her mother and father. The nurse stated she explained to the resident that he/she was at the nursing home and the resident became…

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 the facility failed implement a system to prevent the spread of communicable diseases and to discreetly notify visitors and staff to take standard precaution for 1 of 1 resident reviewed for isolation precautions during the survey (Resident #55). The findings include: On 7/30/19 at 9:51 AM during a review of the medical record for Resident #55, a physician order was found that stated the resident was to be on contact precautions for Clostridioides difficile (C. diff). According to a C. diff fact sheet published by the CDC (Center for Disease Control) from https://www.cdc.gov/cdiff/pdf/Cdiff-Factsheet-508.pdf, Clostridioides difficile (formerly known as Clostridium difficile ) is a bacterium that causes diarrhea and colitis (an inflammation of the colon). C. diff infections can be deadly . C. diff spreads when people touch surfaces that are contaminated with poop from an infected person or when people don't wash their hands with soap and water.Healthcare professionals can help prevent the spread…

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.