Manokin Nursing And Rehab

Based on interviews with facility staff and review of pertinent documentation, it was determined that the facility failed to employ a qualified social worker on a full time basis in a facility licensed with more than 120 beds. The facility is licensed for 135 beds. This deficient practice was found to be evident during the facility's recertification/complaint survey and has the potential to affect all residents. The findings include:On 9/23/25 at 9:41 AM in an interview with Social Worker Designee (SWD #6) she stated she was not licensed or certified. During the interview she stated she had worked at the facility for 1 year, been in the Social Services position for 5 months, and that prior to this position she was a certified medicine aide.On 9/23/25 at 12:35 PM the surveyor requested SWD #6's degree and credentials qualifying her for the Social Worker position; however, by the exit of the survey team on this day, no documents were provided. On 9/23/25 at 5:25 PM review of SWD #6's employee file revealed an application for the Social Work Designee position. In the Record 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 interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 5 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19) out of 5 direct care staff employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.The findings include:On 9/23/25 at 5:19 PM in an interview with the Human Resources Director (HRD #20), when asked about the training and education provided to facility staff, she stated the facility did not use an online learning platform like Relias. She stated that all new hires (clinical and non-clinical) completed tasks online for their onboarding and showed the surveyor a printed copy from a binder in her office. When asked for clarification of what it meant to complete a task, she stated the staff read the tasks and then signed off when they finished showing they read through all of them. She verified and confirmed…

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

Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to provide mandatory Quality Assessment and Performance Improvement training to staff. This was evident for 7 (GNA #3, GNA #18, GNA #22, LPN #33, RN #19, DA #41, HA #42) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.The findings include:Quality Assurance and Performance Improvement (QAPI) helps long-term care facilities improve the quality of life and care for residents by using a structured, data-driven process to identify issues, address the root causes of problems, and implement solutions. It involves ongoing monitoring, teamwork from all staff levels, and continuous review and revision of plans to ensure a safe, resident-focused environment, and adherence to regulations. As a facility's QAPI program involves input and collaboration from all staff, the term staff includes all new and existing 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 observation, interview, and record review, it was determined that facility staff failed to treat residents with dignity. This was evident for 2 (#214, #97) of 27 residents that resided on the memory care unit and for 13 residents on the memory care unit that were in the dining/activity area on 1 of 3 days observed during a revisit survey. The findings include:On 12/1/25 from 1:30 PM to 2:20 PM observation was made on the Chase memory care unit of 13 residents sitting in the dining/activity area of the unit. There were no activities at the time. There was no music on, the television screen was on with a still photo of channels and there was no sound. One resident was crying, and one resident was complaining. None of the residents had any type of activity such as books, coloring books, music, videos, or any type of interaction with the staff on the unit. The residents were sitting and staring at each other. There were 5 nursing staff members standing and sitting around the nurse's station. Resident #213 said to the surveyor, they won't turn the tv on and that bothers me.After…

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 maintain a homelike environment for the residents, this was evident for 2 of 3 units observed during the recertification/complaint survey.The findings include,On 9/22/2025 at 9:39 AM during the initial tour of the facility, observations were made of the following rooms/bathrooms:RM 200: The bedroom door was scraped up all the way to the handle and needed replacement covers.room [ROOM NUMBER]B: the wall trim at the head of the bed was missing from bed A to bed B. Also observed behind the head of the bed on the B-side were lots of paint scrapings on the wall.room [ROOM NUMBER]: The bathroom door had holes about 6 x 5 inches long; there were paint scraps on the wall opposite the toilet measuring about 12 x 5 inches. The wood on the bathroom door was scraped off towards the bottom section in two areas measuring about 3 x 2 and 7x 5 inches long.room [ROOM NUMBER]A: The wall paint by the bed was peeled off about 10 x 9 inches, 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 medical record reviews and interviews, it was determined that the facility staff failed to provide appropriate care to residents when they had abnormally elevated blood pressure (BP). This was evident in 1 (Resident #6) out of the 45 residents reviewed for their care during this recertification/complaint survey.The findings include:On 9/22/25 at 2:38 PM, the review of Resident #6's medical record revealed that the resident had transferred to the hospital on 8/13/25 due to elevated blood pressure; the systolic blood pressure went over 200 mm Hg.Further review of Resident #6's vital signs from 8/14/25 to 9/23/25 revealed that the resident had elevated blood pressure, with systolic BP measured over 190 mm Hg, 14 times during the period. The highest record was 215/88 mm Hg on 9/12/25. However, there was no documentation to support that Resident #6's medical conditions were notified to the physician or that specific care was provided to the resident related to managing the symptoms.During an interview with Staff #13 (Licensed Practical Nurse) on 9/23/25 at 11:35 AM, she stated…

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 interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 2 (GNA #3, GNA #18 ) out of 2 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 9/24/25 at 9:38 AM GNA #3's employee file was reviewed. The review revealed she was hired on 1/19/24; however, failed to reveal a performance review was conducted in 2025. On 9/24/2025 at 9:48AM GNA #18's employee file was reviewed. The review revealed she was hired on 11/7/05; however, failed to reveal a performance review was conducted in 2023 or 2024. On 9/24/25 at 1:44 PM an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON)…

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 records and interview with facility staff, it was determined that the facility failed to 1) ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication, and 2) complete controlled medication counts with two nurses. This was evident for four (Resident #44, #79, #96, #35) out of the six residents reviewed for administration of narcotic medication during this recertification/complaint survey.The findings include:A Controlled Medication Utilization Record (count sheet) is a form used to record controlled medication dispense. It documents the details for each use of any controlled substance amount removed from its original container, including the date, time, the dose given, the signature of the nurse administering the medication, the amount remaining, the amount wasted, and the signature of the individual who checked.A shift count sheet in a nursing home is a form used at the end of a nursing shift to document the inventory of controlled substances, particularly narcotics, ensuring accuracy 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 observation and staff interviews, it was determined that the facility failed to date and label drugs when opened with an open date. This was evident for 3 of 6 medication carts reviewed on the nursing units during the recertification/complaint survey.The findings include:On 9/24/2025 at 8:36 AM, the medicine (Med) cart on the short hall was reviewed with staff #12 a License practical Nurse (LPN) and staff #11 a unit manager and revealed medications opened with no dates on them to indicate when they were opened. These medications include:1-Fluticasone Propionate (Flonase) nasal spray 50mg-2-Clopatadine drops-Pataday 0.1%According to the manufacturer's instruction, open bottles of Flonase nasal spray which is used to treat seasonal allergies should be discarded after 2 months or when the number of sprays indicated on the bottle has been used or whichever comes first. This is due to reduced effectiveness and contamination risks. Also, the Clopatadine (olopatadine)eye dops use to treat allergic reactions should be discarded after 4 weeks (28 days) per manufacturer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to 1) ensure food items were stored under sanitary conditions by labeling and dating food items and 2) maintain proper freezer temperature for food items on the units. This deficient practice had the potential to affect all residents who consume food in the facility and was evident during the recertification/complaint survey.The findings include:1) On 09/21/2025 at 8:29 AM during the kitchen tour with the food service director (Staff #25), the surveyor observed the following items in the freezer that were not labeled: a bag of fish, sliced cheese in a container, 1-gallon open jars of ranch dressing, golden Italian dressing, creamy [NAME] dressing, and BBQ sauce.During an interview with Staff #25 on 9/21/2025 at 8:31 AM, when asked about labeling of food items, he/she stated that items are labeled with a receive date and a use by date. Staff #25 stated that the items observed should have been labeled. Surveyor…

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 the facility failed to implement an effective infection control program and the staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to complete tuberculosis (TB) screening for newly admitted residents. This was evident for 4 (Resident #17, #8, #3, and #77) of five residents for TB screening during this recertification/complaint survey.The findings include:Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. Each resident must have a health assessment upon admission, including significant past or present infectious diseases and signs and symptoms of tuberculosis (TB).Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure (administering 2nd skin test within 1-3 weeks) is advisable for the initial testing of residents and employees. Each…

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 record review and staff interview, it was determined that the facility staff failed to assess and document residents' vaccination status for influenza and pneumococcal vaccines and failed to provide education regarding the benefits and risks of the vaccines. This was evident for two (Resident #17 and #3) of the five residents reviewed for immunizations during the recertification/complaint survey. The findings include:The pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by Streptococcus pneumoniae bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for adults 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)Influenza (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…

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 maintain residents' and staff's COVID-19 vaccination status in their medical records. This was evident for five (Resident #3, #8, #17, #27, and #77) of 5 residents and one (Staff #19) out of five facility staff members reviewed for COVID-19 vaccinations status during this recertification/complaint survey.The findings include:1) Resident RecordsOn 9/24/25, at 3:27 PM, the surveyor randomly selected five residents to review their immunization status. The review revealed Resident #3, #8, #17, #27, and #77 did not have their COVID-19 vaccination status in their medical records.During an interview with Staff #23 (Infection Preventionist) on 9/24/25 at 4:05 PM, she stated that the facility staff should maintain residents' COVID-19 vaccination status and update them in the medical records.In an interview with the Director of Nursing (DON) on 9/24/25 at 4:53 PM, the surveyor reviewed residents' immunization records with her. The DON verified that there was no information for COVID-19 vaccination…

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 ensure the kitchen's freezer was in working order. This was evident during a revisit survey.The findings include:On 12/1/25 at 10:43 AM a tour of the kitchen was conducted. In the freezer, which was accessed through the refrigerator, observation was made as the door was opened of plastic curtain sleeves that had significant ice and frost build-up and ice build-up on the door. There were chunks of ice approximately 6 inches by 2 inches on the floor and 8 inches by 2 inches going up the poles of the storage carts. There were small mounds of ice built up on the ceiling above the compressor fans. There was ice on top of boxes that were stored in the freezer. The surveyor had the Dietary Manager, Staff #38 come into the freezer to confirm the findings. Staff #38 stated that they had the freezer worked on a month or two ago. He said he would call the company to come look at it. On 12/2/25 at 11:45 AM an interview was conducted with Staff #6, the maintenance director who stated, I was made aware of the freezer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, interviews with residents and facility staff, and review of pertinent documentation, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification survey.The findings include:During the survey several observations were made of flies and gnats in the building. On the first day of the survey on 9/22/25 at 8:35 AM, surveyors were placed in the facility's conference room with multiple gnats and flies observed in the room. Throughout the survey conducted from 9/22/25 through 9/25/25, there were observations made each day of gnats and flies in the conference room and hallways of the facility. On 9/22/25 at 8:39 AM the surveyor observed flies flying around in the dining room.On 9/23/25 at 2:35 PM the surveyor observed several flies flying around room [ROOM NUMBER] and landing on Resident #72. When asked if flies were an issue s/he stated, Yes, that white thing [pointed to the wall behind…

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

Based on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received compliance and ethics training. This was evident for 5 (GNA #18, GNA #22, RN #19, DA #41, HA #42) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey. This deficient practice had the potential to impact all residents.The findings include:On 9/23/25 at 5:19 PM in an interview with the Human Resources Director (HRD #20), when asked about the training and education provided to facility staff, she stated the facility does not use an online learning platform like Relias. She stated that all new hires (clinical and non-clinical) completed tasks online for their onboarding and showed the surveyor a printed copy from a binder in her office. When asked for clarification of what it meant to complete a task, she stated the staff read the tasks and then signed off when they finished showing they read through all of them. She verified and confirmed there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and interviews it was determined that facility staff failed to honor the wishes of the guardian of Resident #21. This finding was evident for 1 out of 3 residents reviewed for behaviors during the recertification/complaint survey.The findings include:Review of the clinical record for Resident #21 revealed an order of court -consent that ordered [NAME] County Department of social Services as guardian of person for Resident #21. Review of the clinical record for Resident #21 revealed a discharge form dated 9/26/25. The form documented for the signature of the patient/representative verbal consent.Further review of the clinical record for Resident #21 revealed a discharge planning instruction sheet completed on 9-26-25, that documented under the person receiving instructions verbal consent with the initials of a staff member. Under Relationship to the Resident, it was documented facility staff member.Review of the clinical record revealed no evidence that a 30 day…

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 medical records and interview with facility staff, it was determined that the facility failed to inform the responsible party on three separate dates when a new medication was ordered for a resident. This was evident for 1 (Resident #72) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include:The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at S483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior (CMS, 2023). These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. These medications can have serious potential risks, including side effects, drug interactions, and the possibility of neuroleptic malignant syndrome (a rare but potentially life-threatening condition) or tardive dyskinesia (a movement disorder that can develop if you take 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 interviews with facility staff, it was determined the facility staff failed to notify the physician and the responsible party in a timely manner of a resident's significant change in condition. This was evident for Resident #113, one of the three closed records reviewed during this recertification/complaint survey.The findings include:Agonal breathing is an abnormal, involuntary reflex that signals a severe medical emergency, such as cardiac arrest. It is not effective breathing and cannot sustain life. Though the person is still alive, this reflex indicates that the brain is not receiving enough oxygen and that death is imminent without immediate intervention.On 9/23/25 at 8:10 AM, the surveyor reviewed the three system-selected residents for the closed records review. The review revealed the following:7/16/25 at 11:03 AM: A nurse wrote a progress note stating, Resident has agonal breathing, RR (respiration rate) is 4, does not appear to be in any pain or discomfort, care continues. 7/19/25 at 2:55 AM: A progress note was written by the ADON…

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

Based on interview with residents and interviews with facility staff, it was determined that the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency, the Office of Health Care Quality (OHCQ), in a timely manner. This was evident for 1 (Resident # 72) of 4 residents reviewed for abuse during the facility's recertification survey. The findings include:The OHCQ is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse are to be reported to the OHCQ in a timely manner (within 2 hours for the initial report and within 5 working days for the final report).On 9/22/25 at 9:16 AM in an interview with Resident #72 s/he stated s/he felt abused whenever the aides (Geriatric Nursing Assistants, GNAs) yell at her, which happens at least once a week. During the interview s/he stated, They just push and push when trying to clean me up or give me a bath in my bed. Instead of saying would you please do this, they just grab me and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and interviews it was determined that facility staff failed to appropriately discharge Resident #21. This finding was evident for 1 out of 3 residents reviewed for behaviors during the recertification/complaint survey.The findings include:Review of the clinical record for Resident #21 revealed an order of court -consent that ordered [NAME] County Department of social Services as guardian of person for Resident #21. Review of the clinical record for Resident #21 revealed a discharge form dated 9/26/25. The form documented for the signature of the patient/representative verbal consent.Further review of the clinical record for Resident #21 revealed a discharge planning instruction sheet completed on 9-26-25, that documented under the person receiving instructions verbal consent with the initials of a staff member. Under Relationship to the Resident, it was documented facility staff memberReview of the clinical record forResident #21 revealed no evidence that a 30 day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and interviews it was determined that facility staff failed to provide the guardian of Resident #21 with a notice of transfer or discharge 30 days prior to the transfer or discharge. This finding was evident for 1 out of 3 residents reviewed for behavior during the recertification/complaint survey.The findings include:Review of the clinical record for Resident #21 revealed an order of court -consent that ordered [NAME] County Department of social Services as guardian of person for Resident #21. Review of the clinical record for Resident #21 revealed a discharge form dated 9/26/25. The form documented for the signature of the patient/representative verbal consent.Further review of the clinical record for Resident #21 revealed a discharge planning instruction sheet completed on 9-26-25, that documented under the person receiving instructions verbal consent with the initials of a staff member. Under Relationship to the Resident, it was documented facility 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 medical record review and staff interview it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 2 (Residents #3 and #4) out of 6 residents reviewed for care plans during this recertification/complaint survey.The findings include:1) On 09/22/2025 at 11:20 AM, Resident #4 stated that he/she was getting antibiotics but did not know for how long. Medical record review on 09/24/2025 at 11:08 AM noted an order written on 6/20/2025 to give Cephalexin 500 mg capsule, one capsule by mouth twice daily for UTI for 6 days. Additional orders found for Ketoconazole 2 % Cream, apply topically to facial rash twice a day for seborrheic dermatitis, and Triamcinolone Acetonide 0.1 % Cream apply topically to right leg rash twice daily for stasis dermatitis written on 6/22/2025. There was no care plan documented for the focus, goal, or intervention for the use of these medications.An interview was conducted on 09/24/2025 at 11:49 AM with the Infection Preventionist (IP) Staff #23 who stated that part of the…

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

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to hold interdisciplinary team care plan meetings for residents concurrent with their quarterly care plan revisions. This deficiency was observed in 2 (Resident #88 and #10) of 2 residents reviewed for care plan meetings during this recertification/complaint survey. The findings include: Care plans are essential guides for the care residents receive within the facility. They must be developed within seven days of a resident's comprehensive admission Minimum Data Set (MDS) assessment and revised at least quarterly (or more frequently as needed). The facility is required to have these care plans developed and revised by an interdisciplinary team, which includes the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative, as practicable. 1) On 9/23/25 at 11:01 AM, the surveyor reviewed Resident #88's medical records. The review revealed that the resident was re-admitted 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, interview with staff, and medical record review, it was determined the facility failed to provide the level of assistance needed with feeding for dependent residents. This was evident for 3 (Resident #50, #55, and #97) of 7 residents reviewed for Nutrition during the recertification/complaint survey.The findings include:Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility.1)On 09/22/2025 at 12:22 PM, during a phone interview with the complainant for Resident #50, concerns were expressed regarding Resident #50 eating with his/her fingers.On 09/23/2025 at 8:16 AM during a dining observation, Resident #50 was observed eating breakfast at a table in the dining area. The meal consisted of oatmeal and ground meat, which Resident #50 was eating with his/her fingers. Only a fork and knife were present on the meal tray, and no staff member was present assisting Resident #50 with the meal.On 09/23/2025 at 9:55 AM, in a review of Resident # 50'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, staff interview, and medical record review it was determined that the facility staff failed to provide 1 to 1 resident-centered activities to improve or maintain the resident's mental and psychosocial well-being. This was evident for 1 (Resident # 3) of 6 residents reviewed for activities during the recertification/complaint survey. The findings include:During the screening phase of the survey on 9/22/2025 at 10:15 AM when surveyor asked Resident #3 if he/she participated in activities, resident stated, you tell me. The surveyor asked if activities are done in the room, resident stated, no.On 9/22/2025 at 1:12 PM, Resident #3 was observed in bed with the television off. When surveyor asked if he/she were engaged in any bedside activity, the resident stated no.A record review of the care plan on 9/23/2025 at 11:46 AM, noted that the resident is dependent on staff for activities, meeting emotional, physical, social needs related to (if dependent) Immobility, Physical Limitations, and that the resident needed 1:1 bedside/in-room visits and activities if 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 observation, clinical record review, and staff interview it was determined that the facility staff failed to ensure medications were not left unattended on the locked unit. This was evident for 1 (#10) out of 45 residents that were part of the survey sample during the recertification/complaint survey.The findings include:On 9/22/25 at 9:00 AM, the surveyor observed the room of Resident #10 which was located on the locked unit which houses residents with some form of dementia and/or a psychiatric diagnosis. On the bedside table was an open bottle of Greer's goo (a compound medication to treat skin irritation and to act as a moisture barrier), a near empty container of Greer's goo on nightstand with a do not use past 9/4/25 date, and another container of Greer's goo on the nightstand as well. This surveyor told Staff #3 (a geriatric nursing assistant - GNA) on 9/22/25 at 9:08 AM about the findings and showed her what was observed. She said the nurse must have done a treatment earlier. She then said she would move the creams. This surveyor interviewed Staff #14 (the nurse on…

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

Based on observation, medical record review and interviews. It was determined that the facility failed to label and date oxygen tubing to indicate when it was last changed. This was evident for 2 (Residents #66 and #41) of 2 residents reviewed for respiratory care during the recertification/complaint survey.The findings include:On 9/22/25 at 8:30 AM and 8:42AM during the initial round on the unit, Residents #66 and #41 were observed in their respective rooms, both residents were receiving oxygen (O2) via a nasal cannula (NC) which is a tubing used to deliver oxygen to the nares. The NC was connected to an O2 humidifier, a medical device that provides supplemental O2 at the bedside. Continuous observation revealed that both O2 tubing were not labelled with a date to indicate when they were last changed.A second observation was made on 9/23/2025 at 1:19 PM. Resident #66 was sitting in the A/B day room with two family members with a portable O2 tank, the O2 tubing was not labelled with a change dated. Review of the physician's orders on 9/24/25 at 13:00 PM revealed an order for…

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 the physician failed to enter progress notes and order medications in a timely manner for a resident (Resident #6). This was evident for 1 of 3 residents reviewed during a revisit survey.The findings include:Review of Resident #6's medical record on 12/2/25 revealed the Resident was admitted to the facility in 2021 with diagnosis to include hypertension. Hypertension, or high blood pressure, is a condition where the force of blood against artery walls is consistently too high, which can lead to serious health problems like heart attack and stroke.Further review of Resident #6's medical record revealed the last physician/nurse practitioner note was on 10/20/25.During interview with the Director of Nursing (DON) on 12/3/25 at 8:15 AM, the DON confirmed there are no physician/nurse practitioner notes for Resident #6 since 10/20/25. The DON stated she contacted the Physician (Staff #31) and the Physician stated he had seen the Resident in November but had not put in the progress note in the medical record yet.After Surveyor…

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 medical record review and interview, it was determined that the facility staff failed to monitor and document residents' behavior for those who had mental disorders. This was evident for one (Resident #11) of the three residents reviewed for behavioral issues during this recertification/complaint survey.The findings include:On 9/24/25 at 10:12 AM, the surveyor reviewed Resident #11's medical records. The review revealed that the resident was admitted in April 2025 with diagnoses of schizoaffective disorder, major depressive disorder, and anxiety disorder. The resident had been administered several medications for the mental disorder, including those addressing symptoms of verbal or physical aggression. However, there was no order for behavior monitoring.During an interview with the Director of Nursing (DON) on 9/24/25 at 1:53 PM, she confirmed that Resident #11 had several mental disorders, including aggressive behavior. The surveyor asked the DON about the care for residents who had behavior issues. She stated the facility nursing staff should monitor their behaviors 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 review of the medical record, interview with facility staff and review of facility policy, it was determined that the facility failed to ensure the physician reviewed and documented on the monthly pharmacy reviews and responded to the recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #72) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include:The Medication Regimen Review (MRR) is a thorough review of the medication regimen (plan) of a resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence,…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident received medication as ordered. This was evident for 1 (Resident #10) out of the 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include:A review of Resident #10's clinical record was conducted on 09/23/2025 at 1:35 PM. It was revealed that the resident's primary physician ordered on 5/22/25 Acetaminophen 325 mg to be administered with two tablets every six hours as needed for mild pain (1-3). The resident told staff that they had pain that was rated as 6 on 9/4/25, as 8 on 9/7/25, and as 10 on 9/22/25. There was no evidence that the physician was contacted with instructions on how to address pain levels higher than the 1-3 reflected in the orders for the first two incidents of pain rated greater than 3. The physician wrote an order on 9/10/25 for Tramadol 50 mg to be administered by mouth every 8 hours as needed for severe pain (7-10) for 14 days. This medication was not administered at all even 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 Based on resident interview, review of the medical record, and interviews with facility staff, it was determined the facility failed to screen/evaluate a resident for rehabilitative services. This was evident for 1 (Resident #72) of 2 reviewed for Rehab and Restorative services during the facility's recertification survey. The findings include:On 9/22/25 at 9:31 AM in an interview with Resident #72 s/he stated, I am supposed to get therapy, and they do not give it to me. Review of Resident #72's medical record on 9/22/25 at 1:35 PM revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, muscle weakness (generalized), abnormal posture, and muscle wasting and atrophy.On 9/22/25 at 9:18 PM review of Resident #72's medical record revealed, Care Plan Conference Summary dated 7/3/25. In the Summarize Discussion of Care Plan Conference section it had documented, Family would like some type of therapy ordered for her. Goal is for [Resident #72'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 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 1 (Resident #100) of 6 residents reviewed for medical record accuracy during the recertification/complaint survey.The findings include:During a record review on 09/23/2025 at 09:20 AM of a Facility Reported Incident, it was noted that Resident #100 had an Emergency Petition (EP) transfer to the hospital for suicidal ideation on 9/9/2025. Upon further review of the record, the surveyor found a progress note dated 9/17/2025 documented as This visit was conducted with the use of an interactive audio and video telecommunication system with real-time communication between the patient and the provider. On 09/23/2025 at 9:23 AM, an interview with the unit manager, Staff #11 revealed that the resident was not in the facility on 9/17/2025 and could not explain why that progress note was written in the resident's medical record.An interview was conducted on 09/23/2025 at 10:17 AM with the medical record director, Staff # 7. 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 reviews and staff interviews, it was determined that the facility failed to have key essential personnel present during their monthly quality assurance (QA) meetings. This was evident during a review of the facilities quality assurance program activities during the recertification/complaint survey.The findings include:On 9/26/2025 at 11:02 AM the surveyors requested for the January to August of 2025 quality assurance (QA) monthly meeting sign in sheet from the facility.Review of the QA agenda/meeting sign in sheet from January to August 2025 on 9/26/25 at 11:10 AM revealed that in the months of July and August, certain key personnel did not attend the monthly meetings. For instance, in the month of July, the medical director, the social worker and the Infection preventionist were absent during the meeting and in the month of August the social worker, dietitian and the infection preventionist did not attend the meeting.On 9/26/2025 at 11:20 AM in an interview with the nursing home administrator who oversees QA. He was asked if he was aware that certain key…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews and staff interviews, the facility failed to protect resident property and provide a safe environment by not maintaining an inventory of resident belongings and not investigating a lost item for one Resident (R28) of three sampled residents. The findings included: Record review of the resident and family grievances policy facility's dated 02/06/2024, showed the following: It is the policy of the facility to support each resident's and family members' right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy documented the facility social worker has been designated as the Grievance Official and backup is the Administrator. The Grievance Official is responsible for overseeing the grievance process receiving and tracking grievance through to their conclusion; leading any necessary investigation by the facility, maintaining the confidentiality of all information associated with grievance; issuing written guidance decisions to the resident; and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of R35's face sheet showed an admission was dated 07/20/2022; diagnoses included Generalized anxiety disorder, Alzheimer's disease, and Major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03/15 indicating cognition was severely cognitively impaired. R35 care plan initiated 07/20/20/2022 documented the resident had Activities of daily Living (ADL) self- care deficit due to Alzheimer's. The care plan directed the staff to assist the resident with bathing and grooming. Record review of R35 nurse's notes dated 10/20/2023, revealed Licensed Practical Nurse (LPN)36 documented it was reported to her that R35 smacked GNA37 in the face and then GNA37 hit R35 back. LPN36 reported this information to the former administrator. The Medical Doctor (MD) stated he was going to see R35 the next day for assessment and readjust medications. The responsible party was contacted and notified of the R35 incident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to provide adequate supervision and implement intervention to prevent multiple falls for one Resident (R31) of 3 sampled residents who was at high risk for falls. Findings included: Record review of R31's face sheet showed an original admission was dated 12/13/2018; diagnoses included severe intellectual disabilities, major depressive disorder, restlessness, and agitation. R31's Minimum Data Set (MDS) dated [DATE] indicated that the resident had severely impaired cognitive skills for daily decision-making. R31's functional limitation in range of motion was impaired on both sides of upper extremity and lower extremity. The resident was dependent on staff with toileting hygiene and personal hygiene. R31 care plan initiated 04/04/2019 documented the resident was at risk and had potential for falls due to limited mobility, cognition decline due to severe Intellectual Disability (ID). The care plan directed the staff to place a bed against wall-per…

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, reviews of the facility policies, review of medical record, as well as staff interviews, it was determined that the facility staff failed to notify a resident's physician when a resident had fallen and received an injury to the head. This was evident for 1 (Resident #1) reviewed during a complaint survey. The findings include: A review of facility reported incident MD00195570 on 08/17/23 revealed an allegation Resident #1 had been observed with a hematoma to the forehead and a black eye on 08/12/23. A review of Resident #1's medical record on 08/17/23 at 9 AM revealed that Resident #1 was admitted to the facility on [DATE] for a Hospice, 5-day respite stay. Resident #1 was admitted with diagnoses that include: a history of falls, dementia, bone density and structure disorders, and hypertension. Further review of Resident #1's medical record revealed nursing progress notes indicating that on 08/11/23 at 2:20 AM, LPN #1 observed Resident #1 fall out of his/her wheelchair onto the floor hitting…

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, reviews of the facility policies and a medical record, as well as staff interviews, it was determined that the facility staff failed to initiate a neurological assessment when a resident fell and was observed with a head injury. This was evident for 1 (Resident #1) reviewed during a complaint survey. The findings include: A review of facility reported incident MD00195570 on 08/17/23 revealed an allegation Resident #1 had been observed with a hematoma to the forehead and a black eye on 08/12/23. A review of Resident #1's medical record on 08/17/23 at 9 AM revealed that Resident #1 was admitted to the facility on [DATE] for a Hospice, 5-day respite stay. Resident #1 was admitted with diagnoses that include: a history of falls, dementia, bone density and structure disorders, and hypertension. Further review of Resident #1's medical record revealed nursing progress notes indicating that on 08/11/23 at 2:20 AM, LPN #1 observed Resident #1 fall out of his/her wheelchair onto the floor hitting…

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 ensure that the infection line lists were updated and proper hand hygiene was performed during a medication administration. This was evident for 3 of 3 monthly line lists reviewed and 2 (#13, #12) out of 2 staff observed for hand hygiene during medication administration. The findings include: A Line List is a detailed list used by a team of clinicians to identify, track, and monitor suspected infections to ensure appropriate treatments. Information that can be gathered from the line list include, but are not limited to, residents, their locations, types of infections, dates of onsets, organisms, antibiotic resistance, antibiotics prescribed, classification, and dates resolved. It is an integral part of the infection surveillance process. 1) On 08/03/2023 at 9:30 AM the facility line lists, also called monthly infection control logs, were obtained from the Infection Control Preventionist (IP). There were 3 pages for the month of May, 3 pages for the month of June, and 2 pages for the month of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to ensure resident rooms were maintained in a homelike environment. This was found to be evident for 2 out of 10 rooms (# 100 and # 102) observed during the tour of the Antioch Nursing Unit. The findings include: During the initial tour of the Antioch Nursing Unit conducted on 07/24/23 at 9:45 AM, the surveyors observed water stained ceiling tiles in resident rooms # 100 and #102. The residents who resided in those rooms confirmed that when it rained, the ceiling leaked, and the ceiling tiles would become wet and stained. During an interview conducted on 07/24/2023 at 11:00 AM, the Maintenance Director stated that the roof leaked and needed repair. However, until the repairs are made the procedure is to replace the ceiling tiles that were water stained. The surveyor advised the Maintenance Director of the findings in resident rooms #100 and #102. On 07/26/23 at 9:33 AM, a tour was conducted on the Antioch Nursing Unit. The tour…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility staff failed to provide pharmaceutical services that met the needs of the residents. This was evident for 1 (#162) out of 68 residents in the survey sample. The findings are: An investigation of intake #MD00189012 was initiated on 8/3/23. A review of Resident #162's clinical record revealed the resident was admitted on [DATE]. A review of the resident's Medication Administration Record (MAR) revealed the resident was ordered several medications that were ordered to be administered starting on 1/15/23 but were not administered until 1/16/23. Some of these medications were available in the pharmacy interim box meaning the nursing staff could have taken the medications from this box and administered them to the resident but nursing staff instead chose otherwise. Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23 even though they were in the interim box: Lasix 40 mg (diuretic), Eliquis 5 mg…

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 recorded review and interviews it was determined that the facility failed to have monthly medication regimen reviews by a licensed pharmacist and failed to have a process in place to ensure the medication irregularity reports were part of the resident's medical record. This was found evident of 2 of 5 (Resident # 74 & #62) residents reviewed for medication regimen review during a Medicare/Medicaid recertification and complaint survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative. 1a) On 7/31/23 at 12:23 PM, the surveyor…

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 of medication administration it was determined that the facility staff failed to ensure medications were administered in a safe, appropriate, and timely manner. This was evident for 5 medications out of 31 administered. The findings include: Medication is to be administered according to the five rights of medication administration: right person, right medication, right route, right dosage, and right time. This surveyor observed Staff #12, Staff #10, and Staff #13 administer medications. The observations took place on 7/28/23, and 8/1/23. On 7/28/23 at 10:16 AM Staff #10 was observed administering medication to Resident #12. The resident was to be administered aspirin 81 mg (pain reliever), critical care supplement 30 cc, Omeprazole 20 mg (reduces stomach acid), Potassium Chloride 20 milliequivalents (supplement to treat low potassium levels), and Senna 8.6 mg (laxative) at 8:00 AM. Medication is to be administered within one hour of the medication time. The Administrator, Acting Administrator, and the Director of Nursing were interviewed on 8/4/23 at 12:45 PM.…

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 and review of the facility's policies it was determined that the facility failed to have a qualified, full-time social worker employed to oversee the social service duties. This was found evident of 4 months in 2022 and 2 months in 2023. The findings include: On 8/1/23 at 10:16 AM, the surveyor interviewed Social Worker Assistant Staff #4. During that interview, Staff #4 explained that the social service department sets up care plan meetings after the resident has a Minimum Data Set (MDS) assessment and stated the needs of the residents are addressed at those meetings. The surveyor asked Staff #4 to explain the process for addressing an identified dental need of a resident. Staff #4 explained, if a resident was assessed to have a dental need the Social Worker would follow up with the resident. If the resident did not have an established Dentist, then the facility would offer the resident to register with a provider that services dental needs within the facility. Staff #4 stated, currently the facility uses an contracter/consultant, who offers dental, as well 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.

Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure clarity regarding whether Advance Directives had been formulated by a resident. This was evident for 1 (#25) of 6 residents reviewed for Advance Directives during the annual survey. The findings include: Advance Directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. On 07/24/2023 at 1:05 PM, a clinical record review revealed that there were no Advance Directives in Resident #25's chart (clinical record). Contained within the chart was a document entitled Advance Directive Acknowledgement. The document had been signed on 06/11/2020. At the bottom of this document was a prompt which read: PLEASE CHECK ONE OF THE FOLLOWING STATEMENTS:. Provided were two options to check; I HAVE executed an Advance Directive or I HAVE NOT executed an Advance Directive. On Resident #25's document not only was the first option checked, but handwritten in was a third, ad-hoc option, pending, which was also…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident for 1 (#162) out of 68 residents in the survey sample. The findings are: 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 given to the resident 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. An investigation into intake #MD00189012 was initiated by the survey team on 8/3/23. The clinical record review revealed an absence of baseline care plans. The resident had Chronic Obstructive Pulmonary Disease, macular degeneration (affects eye site), was on 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 observations, interviews, and record reviews, it was determined that the facility staff failed to ensure that activities were provided that met a resident's needs. This was evident for 1 (#32) of 5 residents reviewed for activities during the annual survey. The findings include: On 07/24/2023 at 1:18 PM, 07/25/2023 at 10:00 AM, 07/25/2023 at 1:00 PM, and 07/27/2023 at 10:03 AM, Resident #32 was observed lying in his/her bed. The resident was not engaged in any individual activities nor were any facility staff engaging him/her in a 1:1 activity. On 07/27/2023 at 9:27 AM, Staff #8, the Activities Director (AD), was interviewed regarding activities for Resident #32. The AD stated, the Activities Aids will do 1:1s with [him/her], devotionals, short stories, anything that meets [his/her] interest. When asked to see the logbook where the 1:1 visits were recorded, the AD picked up a binder. It was discovered that there were no 1:1 visits logged for the resident. The AD commented they should be recording 1:1 visits. On 07/28/2023 at 10:32, an interview was conducted with Resident…

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

Based on resident and staff interviews, observations, and medical record review, it was determined that the facility staff failed to provide a resident with a multi podus boot, as ordered. This was evident for 1 (#92) of 2 residents reviewed for positioning and mobility. The findings include: A Multi Podus Boot is a protective brace that corrects foot misalignments and minimizes the chance of skin breakdown. On 07/24/2023 at 11:55 AM, Resident #92 was interviewed regarding issues with positioning and mobility. The resident stated that he/she needs a brace for the right leg. It was observed that the resident was not wearing a brace on either foot at the time. A subsequent record review revealed that there was a physician's order for Resident #92 to wear multi podus boot at all times while in bed except for during care for positioning and pain management. The order had been active since 9/22/2022. On 07/31/2023 at 9:15 AM, it was observed that Resident #92 was not wearing a multi podus boot. The resident stated, the doctor and nurses have mentioned it, nobody does anything. Before…

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 that the facility staff failed to ensure that medication carts were locked and secured. This was evident for 1 of 3 nursing units. The findings are: 1. This surveyor observed on 7/24/23 at 1:40 PM the medication cart parked across from the Antioch conference room was left unlocked. Two staff members walked past the cart and did not lock the medication cart. No residents were observed in the area. A third staff member, Staff #1, walked by at 1:44 PM and put her right hand behind her back and locked it. Staff #1 was interviewed on 7/24/23 at 1:48 PM. She was informed of the observation. She confirmed that she locked the cart and verbally informed the nurse responsible. 2. This surveyor observed on 7/31/23 at 11:45 AM the medication cart parked across from the Antioch conference room was left unlocked. Staff #1 was walking up the hallway and observed the unlocked and unattended medication cart. She locked the cart and spoke with Staff #10 at 11:47 AM.

Based on observation, record review, and interviews it was determined that the facility failed to provide routine dental services identified as need for a resident. This was found evident of 1 of 5 (Resident #91) residents reviewed for dental concern during an annual and complaint survey. The findings include: On 7/24/23 at 1:08 PM, the surveyor observed Resident# 91 eating at his/her bedside. Resident # 91 had both front teeth missing. On 7/31/23 at 1:29 PM, the surveyor reviewed Resident # 91's medical record. The record revealed Resident # 91 had been admitted in May of 2022 and had a past medical history that included, paranoid schizophrenia and dementia. Further review of the medial record revealed a care plan created on 5/10/2022 stating resident has potential for oral discomfort due to broken or carious teeth. The interventions included; Coordinate arrangement for dental care. On 7/31/23 at 1:50 PM, the surveyor reviewed Minimum Data Set (MDS) assessments. The MDS assessment, with a date of May 16th 2022, had box D checked on the Oral/Dental Status. The description of box D…

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 keep complete and accurate medical records. This was found evident of 2 of 68 (Resident #106 and #66) residents reviewed during a recertification and complaint survey. The findings include: 1) On 7/31/23 at 12:39 AM, the surveyor reviewed Resident #106's medical record. There review revealed that the resident was admitted to the facility on [DATE]. On 8/1/23 at 10:40 AM, the surveyor reviewed Resident #106's physician's assessment note dated 4/25/23. This note was located in the miscellaneous section in the medical record. Further review of this section revealed a physician's assessment note dated 3/27/23 for a person with the same first name but different last name. On 8/1/23 at 10:54 AM, the surveyor asked the Acting Nursing Home Administrator (NHA) for clarification of the two assessment notes with different names in Resident #106's medical record. The NHA stated she would look into the issue and follow up. On 8/2/23 at 7:50…

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, the facility failed to designate a qualified Infection Control Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control and Prevention program. This was evident for 1 of 1 staff member reviewed for IP credentials. The findings include: On 08/02/2023 at 9:55 AM, an interview was conducted with Staff #11, the facility designated IP. Per the IP, she had been working as the IP for the past 90 days and had received her certification within 2 weeks of starting the position. A copy of her certificate was requested at the time of the interview. On 08/03/2023 at 9:40 AM, the IP submitted records for review. A review of the records revealed that the IP had provided a copy of her transcripts for the IP course, however, there was no certificate of completion. This was brought to the attention of the Interim Nursing Home Administrator, who indicated she was already aware. On 08/04/3023 at 9:20 AM the IP provided a copy of her certificate with a completion…

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 and record review, it was determined that the facility staff failed to ensure that a resident had a functioning call system. This was evident for 1 (#6) of 68 residents reviewed during the annual survey. The findings include: Resident #6 had diagnoses which included, but was not limited to, dementia, anxiety, legal blindness, and syncope (fainting) and collapse. On 07/30/2023 at 7:23 PM, an observation conducted on the [NAME] Unit revealed that Resident #6's call system was continuously signaling the nurses station that assistance was required. A subsequent interview with Staff #9, a Registered Nurse, revealed that Resident #6's call system was malfunctioning. Staff #9 stated, I put in a maintenance request, but I guess nothing was done. Staff #9 pointed to where the call light indicator for Resident #6's room had been stuck on since 07/29/2023 at 11:59 PM. When asked how she would know if Resident #6 needed help, Staff #9 replied; [he/she] yells. On 07/31/2023 at 8:30 AM,…

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

Based on the record reviews and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) received the required 12 hours of in-service training. This was found to be evident for 1 (GNA #34) out of 5 training records reviewed during the recertification survey. The findings include: A record review on 08/09/23 at 10:00 AM, revealed that GNA #34 had not received the required 12 hours of annual in-service training since 7/13/2018. During an interview on 08/09/23 at 10:45 AM, the Staff Development, Staff #15, stated that she tried but could not locate additional training for GNA # 34. The Staff Development staff stated that she had not met GNA # 34 because she only worked once a month. During an interview on 08/09/23 at 11:30 AM, the Director of Nursing (DON) was notified of the missing required 12 hours of annual in-service training for GNA # 34 and stated she would look for more training records. On 08/09/23 at 2:33 PM, the DON confirmed that no other required training records were located for GNA # 34.

Based on staff interview and observation it was determined the facility failed to ensure that the facility kitchen was managed by fully certified and competent staff, when since October 1, 2023, the facility had no Certified Dietary Manager (CDM) managing the kitchen. The failure to ensure fully certified and competent kitchen management provided effective oversight of practices in the kitchen increased the risk for infection and food borne illness. This had the potential to affect all residents. The findings include: On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes. On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate…

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, observations, and documentation review, facility administration failed to effectively allocate resources to meet resident needs and to ensure their highest practicable well-being when (1) the facility administration failed to ensure effective management of dietary services with no Certified Dietary Manager (CDM) employed since October 1, 2023, (2) the facility administration failed to ensure and provide a safe and sanitary environment in the facility kitchen when the facility dishwasher and hot water heater had both failed and no hot water was available in the kitchen beginning intermittently on 11/6/23 and finally on 11/27/23; and (3) facility administration for at least three days allowed unsafe practices regarding food preparation, food service, and infection prevention and control requirements by utilizing the facility kitchen with no hot water (a) for hand washing and (b) for sanitization of dishes, utensils, pots, pans, trays and food prep surfaces; and (4) while continuing to operate the kitchen in unsafe and unsanitary conditions for at least 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 observation, interviews, and documentation review, it was determined the facility failed to ensure that essential equipment was operational and safe (1) when the facility hot water heater that supplied hot water to the kitchen began to fail intermittently on or around 11/9/23, and permanently on 11/27/23, and was not fixed or replaced, and (2) when the dishwasher failed to register the chemical cleaning agent as of 11/29/23, and it too was not fixed or replaced. With no hot water in the kitchen, all residents were at increased risk for food borne illness. The findings include: 1) The facility hot water heater that supplied hot water to the kitchen started to fail around 11/9/23 and was not fixed or replaced. On 11/27/23 the hot water heater totally failed to produce hot water to the kitchen on 11/27/23 and the facility was still waiting on contractor quotes as of 11/30/23 at 2:15 PM. On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area 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 observation and staff interview, it was determined that facility staff failed to treat each resident in a dignified manner by 1) standing over a resident while feeding the resident, and 2) pulling a resident down the hallway backwards. This was evident for 4 (#11, #43, #22, #14) of 30 residents observed during the serving of lunch on 1 of 3 nursing units during a revisit survey. The findings include: 1. On 11/29/23 at 12:22 PM observation was made of Resident #11 sitting in a wheelchair in the dining area adjacent to the nurse's station in the Chase unit. The food delivery cart was next to where Resident #11 was sitting. Staff #25 was standing to feed Resident #11 while talking to 2 other staff members about something unrelated to residents or the facility. Staff #25 continued to stand and feed Resident #11 during the entire observation. 2. On 11/29/23 at 12:30 PM Resident #43 was sitting in the common area on the Chase unit during lunch in a semi-reclining geriatric chair. Staff #12 was reaching over to touch the resident's food that was sitting next to him/her. Resident…

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

Based on medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments were evident for 5 (#15, #54, #27, #45, #38) of 12 residents reviewed for completed quarterly assessments during a revisit 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 11/30/23 at 10:30 AM a review of Resident #15 and Resident #54's quarterly MDS with an assessment reference date (ARD) of 11/1/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood. A review of Resident #27 quarterly MDS with an ARD of 11/6/23 revealed…

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 and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the medical needs of a resident. This was found evident for 2 out of 11 (Residents #24 and #28) residents reviewed for care planning during an annual and complaint survey. The findings include: 1) On 7/25/23 at 1:25 PM, the surveyor reviewed Resident #24's medical record. The review revealed that Resident #24 was admitted to the facility in early March of 2023 and had a past medical history of malignant neoplasm of the bladder (bladder cancer) and artificial opening of urinary tract. Further review of the medical record revealed Resident #24 was admitted to the facility with a urostomy. A urostomy is created in a surgical procedure and re-directs urine to an opening in the abdominal wall. The urine is collected in a bag secured to the outer abdomen. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 7/25/23 at 2:15 PM, the surveyor…

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 and record review, it was determined the facility failed to ensure residents attended care plan meetings. This was found to be evident for 2 (Resident #24, # 90) out of 11 residents reviewed for care plan meetings. The findings include: 1) On 7/25/23 at 1:25 PM, the surveyor reviewed Resident # 24's medical record. The review revealed that Resident #24 was admitted to the facility in early March of 2023 and was his/her own representative, responsible for making his/her own decisions. On 7/26/23 at 8:16 AM, the surveyor conducted an interview with Social Service Assistant, Staff #4. During the interview Staff #4 stated she remembers Resident #24 had a care plan meeting in June but Resident #24 refused to attend. Staff #4 continued to state that if a Resident refuses it should be documented in the medical record. Staff #4 stated she would provide the attendance log. On 7/26/23 at 9:32 AM, the surveyor conducted an interview with Resident #24. During this interview Resident #24 stated he/she was not asked to participate in the any of the care plan meetings. 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 Based on clinical record review, staff interview, and observation it was determined that the facility staff failed to ensure quality of care was provided to residents. This was evident for 4 (#161, #162, #60, #94, and #462) out of 68 residents reviewed for Quality of Care. The findings are: 1. Nursing failed to call physician for orders and to clarify treatment. An investigation of intake #MD00191247 revealed the resident was admitted on [DATE]. Resident #161 was admitted on [DATE] from the hospital with an Aspen neck collar (device used to support and protect neck). The hospital discharge summary did not include orders on how to care for the collar nor were orders on collar care obtained from the primary physician. The paperwork from the hospital did include a summary of a hospital consultation with the surgeon that included a note indicating the collar was to stay on but not how to care for the skin underneath. Further review of the medical record revealed that the nursing did not seek and/or clarify orders…

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 (#41, #17, #14, #25, #52) of 54 residents reviewed during a revisit survey. The findings include: On 11/30/23 at 3:00 PM Resident #41's medical record was reviewed and revealed on 11/30/23 the physician progress notes were uploaded in the medical record for dates of service (DOS) 10/23/23, 11/1/23, and (2) notes from 11/17/23. Continued review of medical records revealed Resident #17's physician progress notes dated 11/8/23 and 11/17/23 were not uploaded into the medical record until 11/30/23. Resident #14's physician progress note of 11/3/23 was not uploaded in the medical record until 11/30/23. Resident #25's physician progress note of 11/3/23 was not uploaded in the medical record until 11/30/23. Resident #52's physician progress notes dated 10/23/23 and 10/24/23 were not uploaded in the medical record until 11/30/23. On 11/30/23 at 3:45 PM Physician #3 was interviewed and stated, both the…

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

Based on the review of facility administrative records and interviews, it was determined that the facility failed to ensure a sufficient number of staff to meet the needs of the residents. This deficient practice has the potential to affect all residents. The findings include: During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the resident was left soiled for long periods of time, staff turnover was high and staff complained they don't have enough staff. On 8/7/23 at 11:51 AM, the surveyor reviewed the Activities of Daily Living (ADL) care documentation for August 2022 through December 2022 for Resident # 90. For the month of August there was no toilet use documented for 31 out of 87 shifts and urinary continence care was documented for 30 of 87 shifts. In September, toilet use was not documented 46 out of 90 shifts and urinary continence was not documented 47 out of 90 shifts. In October 2022 there was no toilet use documented for 38 out of 93 shifts and no urinary continence documented for 31 out of 90. For November 2022, 31 out of 90 shifts had…

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

Based on observations and facility staff interviews, the facility failed to ensure that all corridors had firmly installed handrails on each side. The findings include: On 07/25/2023 at 11 AM, surveyors observed there were no handrails available on either side of the two connected corridors in the facility. The first of the connected corridors began from the outside of a unit and at the furthest end, connected to the other corridor that led to the main entrance of the facility. On 07/31/2023 at 8:50 AM the interim Nursing Home Administrator (NHA) confirmed the absence of handrails. On 07/31/2023 at 09:21 AM an interview with the Maintenance Director who stated that he worked at the facility for 12 years and the two connected corridors never had handrails on either side. On 08/01/2023 at 9:10 AM the Maintenance Director confirmed that handrails were to be installed and the total distance of the connected corridors equaled two hundred thirty-six feet and six inches.

Based on staff interview and record review, it was determined that the facility failed to ensure that the dementia training provided to staff included managing challenging behaviors. This was evident for 1 of 2 staff training PowerPoint slide show presentations reviewed for content. The findings include: On 08/02/2023 at 10:04 AM, an interview was conducted with Staff #11, the IP/Staff Development Nurse, regarding the dementia training provided to staff. Per Staff #11, the training consisted of a PowerPoint presentation upon hire and annually thereafter. If a staff member needed additional training, Staff #11 would review a typed version of the same PowerPoint presentation with that staff member. Per Staff #11, the PowerPoint information was the only dementia training provided. On 08/02/2023 at 10:15 AM, the dementia PowerPoint presentation that the facility utilized to train staff was reviewed. The presentation did not address managing challenging behaviors. Examples of challenging behaviors include, but are not limited to, aggressiveness, wandering, elopement, agitation, yelling…

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

Based on record review and staff interview it was determined that the facility staff failed to ensure that a resident's right to make decisions was honored. This was evident for 1 (#164) out of 68 residents in the survey sample. The findings are: An investigation into a complaint (#MD00173260) on 8/4/23 revealed that on 8/16/22 Resident #164's family member observed that the resident did not awaken when nudged and appeared unresponsive. The family member told the nursing staff who responded that the resident was normally slow to awaken and that this was normal. The family member called the daughter who was the responsible party. The daughter called the nursing station and demanded that the nurse check the resident. Vital signs were taken and were within normal limits. The resident was put on the phone to speak with the daughter. Resident #164 said he/she was fine. Daughter insisted the resident be sent out to the hospital via 911. The resident was alert and oriented x 2. The nurse informed the daughter that the resident had the right to decide whether or not to go to the hospital.…

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

Based on observations and interviews it was determined the facility failed to ensure that the resident's call light was within reach to allow access to assistance when needed. This was evident for 3 (#16, #21, #15) of 3 residents observed on the Chase nursing unit during the initial tour of the facility. The findings include: On 11/29/23 at 8:53 AM a tour of the facility was conducted. Observation was made in Resident #16's room of the resident lying in bed. The bed was on the left side of the room against the wall. Observation was made of the call bell hanging off the wall on the other side of the nightstand and out of reach of the resident. Observation was made of Resident #16's roommate, Resident #21, who was lying in bed. There was a soft gray call bell lying on the floor next to the bed. The surveyor watched staff go in and out of the rooms without placing the call bell within reach. On 11/30/23 at 9:07 AM a second observation was made of Resident #16's call bell cord hanging on the wall. At that time the surveyor asked Certified Medicine Aide (CMA), Staff #26 to come in the…

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

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 ensure that nursing home staff fully informed a resident and their family of how to receive final disbursement of all monies sent to the facility in the resident's name. This was evident for 1 (#163) out of 68 residents in the survey sample. The findings are: An investigation into Intake #MD00192746 included a review of Resident #163's account which revealed the resident had $1,720 on [DATE]. The resident expired on [DATE]. The resident was charged $1407 on [DATE] for the cost of services for March. On [DATE] $1720 was returned to the Social Security Administration. The family, as of [DATE], had not received the money left in the resident's account. The Administrator was interviewed on [DATE] at 2:00 PM. He said that once the resident died the Power of Attorney (PoA) status disappeared. He said the former PoA has to write a letter to the Board of Administrators to request a check for the remaining balance. I asked if…

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 clinical record review and staff interview it was determined that the facility nursing staff failed to ensure a resident's family was notified of a hospitalization and to ensure only an authorized contact was notified. This was evident for 2 (#164 and #82) out of 68 residents in the survey sample. The findings are: 1. An investigation of intake #MD00182928 revealed Resident #164 was having respiratory issues on 7/26/22 at 5:30 AM. Nursing called the primary physician and an order to send to the hospital was received. The Power of Attorney (PoA) was not notified and did not know the resident was sent to the hospital until the resident returned to the facility. 2. An investigation of intake #MD00191339 revealed Resident #82 had a fall without injury on 1/20/23. Nursing staff called the daughter instead of the daughter in law. The daughter is not the responsible party or an approved contact person. The Acting Administrator was interviewed on 7/31/23 at 11:04 AM. She was informed the daughter is not an approved contact person and asked why she was called and not the daughter in…

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

Based on observation, interviews, and review of facility documentation, it was determined the facility failed to report a critical unusual occurrence that affected the health and safety of all residents in the facility to the Office of Health Care Quality (OHCQ). This was evident for 3 days when the kitchen failed to have hot water to provide to the kitchen dishwasher, handwashing sinks, and the 3 compartment sink to wash pots and pans. The findings include: On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes. On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate sanitation. Staff #8 was in the dishwashing area at that time 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 review of faciity records and interview, it was determined that the facility failed to conduct a thorough investigation. This was found to be evident for 2 (# 25, # 32) out of 20 facility reported incidents. The findings include: On 07/27/23 at 8:45 AM, a record review revealed that a facility reported incident (FRI) regarding Resident #25 was received by the Office of Healthcare Quality on 04/26/2022 at 1:06 PM. In the FRI, the facility reported that per Resident #25, on 03/18/2022 Staff #46 threw a remote at him/her. The facility's investigation was reviewed and was deemed to be missing several key components: 1. The self-report is missing. 2. The facility failed to obtain an interview with the alleged perpetrator, Staff #46. 3. No other residents, including the roommate, were interviewed. 4. There was no evidence that measures were put into place to protect the resident from further abuse while the investigation was being completed. On 07/27/23 at 11:04 AM, a record review revealed that a FRI regarding Resident #32 was received by the Office of Health Care Quality 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 medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments were evident for 1 (#44) of 5 residents reviewed for an annual/admission assessment during a revisit 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. On 11/30/23 at 10:30 AM a review of Resident #44's annual MDS with an assessment reference date (ARD) of 11/4/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood. On 11/30/23 at 11:37 AM an interview was conducted with the MDS Coordinator who stated, our social worker does those…

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 interview and record review, it was determined that the facility failed to provide incontinence care. This was evident for 1 (# 90) out of 8 residents reviewed for Activities of Daily Living (ADL) Care. The findings include: The Activities of Daily Living (ADL) care is a term used to collectively describe fundamental skills required to care for oneself, such as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence. During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the resident was left soiled for long periods of time. On 8/7/23 at 11:51 AM, the surveyor reviewed the ADL care documentation for August 2022 through December 2022 for Resident # 90. For the month of August there was no toilet use documented for 31 out of 87 shifts and urinary continence care was documented for 30 of 87 shifts. In September, toilet use was not documented 46 out of 90 shifts and urinary continence was not documented 47 out of 90 shifts. In…

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

Based on record review and staff interview, it was determined that the facility staff failed to ensure that consent was obtained prior to utilizing bed rails. This was evident for 1 (#212) of 68 residents reviewed during the annual survey. The findings include: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. On 08/08/2023, at 2:50 PM, a record review was conducted which revealed that Resident #212 had diagnoses which included, but were not limited to, left femur fracture, stroke and hemiplegia affecting his/her left non-dominant side. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body. A review of the MDS (Minimum Data set, or MDS, is a screening tool), with an assessment reference date of 01/17/2023, identified that the resident was cognitively intact. A nurses note dated 03/10/2023 at 12:27 PM, described how Resident #212 fell from bed while receiving care from staff. The corresponding…

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 and record reviews, it was determined that the facility failed to ensure the physician provided supervision for a resident with significant weight loss. This was found to be evident for 1 (Resident #90) out of 1 resident's reviewed for weight loss. The findings include: According to the Centers of Medicare and Medicaid (CMS) a significant weight loss is a weight loss of: 5% in one month; 7.5% in 3 months; or 10% in 6 months. During a phone interview conducted on 07/27/23 at 11:32 AM, the complainant stated the resident lost significant weight and the facility had not addressed it. During a review of the Resident # 90 weights on 07/28/23 at 06:54 AM, the surveyor discovered that on 09/21/22 Resident # 90's weight was 185.6 pounds and on 10/07/22 it was 163 pounds which was a 12.18 % weight loss. The physician progress notes from 11/4/22, 12/30/22, 1/27/23 and 3/3/23 report no weight changes and the Certified Registered Nurse Practitioner (CRNP) notes written on 10/24/22, 12/3/22, 1/2/23 and 2/18/23 did not address the weight loss. During an interview on 7/28/23 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 record reviews and interviews, it was determined that the facility failed to consistently monitor the behavior of a resident. This was found to be evident for 1 (#28) out of 1 resident reviewed for behavioral monitoring. The findings include: A complaint investigated on 8/21/2023 at 8:00 AM confirmed Resident #28 had been sexually inappropriate (masturbating) in a common area (dining room) on 04/04/2023. On 8/21/23 at 08:30 AM, the surveyors reviewed medical records for Resident #28. A review of the Monitor Behavior Symptoms tool from March 23 through the end of July 23 for sexually inappropriate revealed documentation for inappropriate sexual behavior only on 4/10/2023. Further review of the resident's progress note dated 4/4/23 at 2:28 PM, revealed a note from Social Worker (SW) # 4 that stated, I spoke with resident about the incident that happened today, and [resident] does understand [resident] shouldn't have done that, and [resident] was sorry, and [resident] will go to [resident] room for now on. I told [resident] that I talked to [resident] guardian, and [resident]…

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

Based on observations and interview of facility staff. it was determined that the facility staff failed to promote and enhance a resident's dignity while assisting the resident with their breakfast and lunch. This was evident for 1 of 2 residents reviewed during the annual survey process. The findings include: An observation was made on 2/12/19 at 1:30 PM of resident # 310 as s/he was being fed by GNA #5. GNA # 5 was standing above the resident feeding her/his lunch to the resident. The resident was leaning towards the right side of the bed and the GNA was standing on the left side of the bed leaning over the resident. An observation was made on 02/13/19 08:41 AM of resident # 310 as s/he was being fed by GNA # 6. GNA # 6 was standing above the resident feeding her/his breakfast to the resident. Interview with the Chief Nurse on 2/13/19 at 2:00 PM confirmed the facility staff failed to provide Resident # 310 with the most dignified existence while providing meals.

Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 8 residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident # 310 was conducted on 02/14/19. Review of the physician order written on 1/30/19 revealed that Resident # 310 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 2. A medical record review for Resident # 112 was conducted on 02/14/19. Review of the physician order written on 11/15/2018 revealed that Resident # 112 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of 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.

2. Review of the medical record for Resident #108 on 2/13/19 revealed Resident #108 had physician orders to obtain pre and post-dialysis vitals and weights. Monitoring a dialysis patient's weight helps the healthcare professional decide how much fluid needs to be removed from the body during dialysis. Maintaining a regular record of a patient's weight is necessary to avoid removing too much or too little fluid from the body. Review of Resident #108's Treatment Administration Record (TAR) revealed that post dialysis weights had not been obtained on 1/17/19 and 1/31/19. Review of Resident #108's Weight History showed no recorded weights on 1/17/19 and 1/31/19. Review of Resident #108's Dialysis Communication Forms from 1/17/19 and 1/31/19 showed no recorded weights by the facility. A Dialysis Communication Form is completed by both facility nurses and dialysis center nurses. It records vitals such as weight and temperature for the dialysis patient. Resident #108's Licensed Practical Nurse (LPN) (Staff #3) was asked on 2/14/19 at 8:42 AM about the missing weights and was 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 the facility staff failed to administer oxygen to Resident #6 in accordance with the standard of practice. This was evident for 1 of 2 residents selected for review during the survey process. The findings include: Review of the medical record for Resident # 6 revealed diagnosis including but limited to Chronic Obstructive Pulmonary Disease (COPD). COPD is a lung disease characterized by chronic obstruction of the lung airflow that interferes with normal breathing and is not fully reversible. Surveyor observation of Resident #6 on 02/12/19 at 09:46 AM revealed the resident in bed with the use of oxygen via nasal cannula. Further observation revealed the oxygen was being delivered using a concentrator which are medical devices that deliver medical grade oxygen (greater than 88% pure oxygen) to a patient via either a nasal cannula or mask. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils. Oxygen flows from these…

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 the facility staff failed to conduct AIMs testing on Residents (# 65). This was evident for 1 of 1 resident selected for review during the survey process. The findings include: The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970's to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. Tardive dyskinesia is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs, which affects 20%-30% of patients who have been treated for months or years with neuroleptic medications. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance. The facility staff failed to conduct an AIMS on Resident # 65. 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.