Chapel Hill Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure a person-centered care plan was updated and revised. This was evident: for 2 (#50, #63) out of 3 residents reviewed for care plan revisions during the annual recertification survey and investigation of complaint #320972.A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Do Not Resuscitate (DNR)…

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 interviews with a resident and staff, it was determined that the facility failed to ensure a resident attended a scheduled medical appointment and the missed appointment was rescheduled timely. This was evident for 1(Resident #45) out of 2 residents investigated for communication/sensory during the annual recertification survey.The findings include:On 3/23/2026 at 12:24PM, during an interview with Resident #45, the Surveyor was informed that the resident missed a scheduled follow-up eye appointment on 2/27/2026 because the facility did not schedule transportation. The resident stated that the Appointment Scheduler (AS) #31stated that she would ensure that his/her appointment is rescheduled immediately, but he/she had not received any information regarding the rescheduled appointment.On 3/24/2026 at 1:00PM, a review of Resident #45 electronic medical record failed to reveal an order for a follow-up eye appointment.On 3/24/2026 at 1:54PM, during an interview with AS #31, the Surveyor was informed that she was unaware of Resident #45's follow-up eye…

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 personnel files and interviews with staff, it was determined that the facility failed to ensure required Geriatric Nursing Assistant (GNA) performance reviews were completed every 12 months. This was evident for 2 (GNA #15 and GNA #37) out of 5 employees reviewed for sufficient staffing during the annual recertification survey.The findings include:On 3/30/2026 at 12:15PM, a review of GNA #15's personnel file failed to reveal that the facility conducted a yearly performance review at least every 12 months.On 3/30/2026 at 12:30PM, a review of GNA #37's personnel file failed to reveal that the facility conducted a yearly performance review at least every 12 months.During an interview with the Director of Nursing (DON) on 3/30/2026 at 2:20PM, the Surveyor the Surveyor expressed the concern that the facility failed to complete yearly performance reviews for GNA #15 and GNA#37. During a review of GNA #15's and GNA #37's personnel files, the DON confirmed that no yearly performance review was conducted at least every 12 months. The DON did not conduct any…

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 it was determined the facility failed to ensure:1. Medications were securely stored, this was evident in 1 out of 2 medication carts observed on the Unit 1 hallway during the facilities recertification survey.2. Nutritional supplements were not expired. This was evident in 2 of 2 storage areas for Nepro nutritional supplements observed during the facility's recertification survey. The findings include:1. During the surveyor's initial tour of the facility on [DATE] at 7:43AM the surveyor observed an unattended and unlocked medication cart on the Unit 1 hallway in which all drawers were found to be accessible containing various Resident medication pill packs, bottled medications and medical supplies.On [DATE] at 7:47AM the surveyor requested and conducted a dual observation of the concern with Nurse #26 who after surveyor intervention, was observed locking the medication cart. The surveyor conducted an interview at this time with Nurse #26 and inquired as to what staff was…

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

Based on observation, interview and record review it was determined the facility failed to ensure the menu was followed. This was evident for 1 out of 1 lunch meal tray pass observation conducted by the surveyor during the facility's recertification survey. The findings include: On 3/30/26 at 12:13PM Food Protection Manager (FPM, Staff #5) informed the surveyor that a new tray will be made from scratch for Resident #33 whose food was left exposed in the hallway. FPM #5 reported that because there was no more lasagna, Resident #33 would receive something different.On 3/30/26 at 12:14PM the surveyor conducted an interview of FPM #5 and inquired as to why the menu of lasagna being served for the lunch meal did not follow the facility's posted menu reviewed by the surveyor. During the interview FPM #5 reported that the prime rib posted on the menu was not served because it was not available for order when they went to order the food on Thursday. FPM #5 confirmed that Residents were not notified of the menu substitutions prior to the meal being served.On 3/30/26 at 12:43PM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of an employee file, online sources, and interview with staff, it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) staff had an active, current certification. This was evident for 1 (GNA #15) out of 5 GNAs reviewed for staff qualifications during the annual recertification survey.The findings include: On [DATE] at 11:30AM, a review of staffing sheets from [DATE] through [DATE] revealed that GNA #15 worked on a resident care assignment on the following days:[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM [DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]:…

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 interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (Resident #18) out of 2 residents reviewed for communication/sensory during the annual recertification survey.The findings include:On 3/26/2026 at 2:15PM, a review of Resident #18's electronic medical record failed to reveal a personal inventory sheet.On 3/26/2026 at 2:20PM, a review of Resident #18's paper chart failed to reveal a personal inventory sheet.On 3/26/2026 at 2:23PM, during an interview with Registered Nurse #34, the Surveyor was informed that if a resident has personal belongings, they should be logged on a personal inventory sheet located in the resident's paper chart.A review of the facility's Personal Property policy on 3/27/2026 at 2:50PM, #10, revealed that The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. A copy of the personal inventory sheet should be maintained in the residents'…

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

Based on observation and interview with staff, it was determined that the facility failed to ensure clean linen was handled, transported, and stored in a safe and sanitary manner. This was evident for 2 of 2 clean linen transports, and 1 of 1 main supply room observed during the annual recertification survey.The findings include: 1. On 3/25/2026 at approximately 9:30 AM, the Surveyor observed Laundry Staff #33 carrying clean, uncovered resident garments on hangers while walking up the facility steps. The garments draped over the laundry staff member's arm. On 3/27/2026 at approximately 8:30AM, the Surveyor observed Laundry Staff #20 transporting an uncovered, yellow clean linen cart with folded facility linen on Unit 1 and then down the freight elevator. On 3/27/2026 at 12:55PM, during an interview conducted with Environmental Services/ Laundry Manager #19, the Surveyor expressed the concern that a laundry staff member was observed carrying clean, uncovered Resident garments on hangers and in their arms as they walked up the facility steps and another laundry staff member was…

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

Based on observation and interview it was determined the facility failed to ensure maintenance of essential kitchen equipment. This was evident during the surveyors review of the kitchen task during the facility's recertification survey. The findings include: On 3/23/26 at 7:58AM the surveyor conducted an initial tour of the facility's kitchen.On 3/23/26 at 7:59AM the surveyor observed the digital exterior thermometer on Freezer #3 to be reading: 110. On 3/23/26 at 8:00AM the surveyor observed the warming plate base in the warmer was observed to have food debris present on the surface.On 3/23/26 at 8:01AM the surveyor observed food cooking equipment located on the clean cooking utensil rack with a layer of food debris and clear liquid present on it. On 3/23/26 at 8:02AM the surveyor observed a rectangular bucket of cloudy liquid sitting beneath the dishwasher's filter container and drain. The drain stopper used for containing water used for washing of dishes was observed to be disconnected from the machine. On 3/23/26 at 8:04AM the surveyor observed the three compartment sink…

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 with residents and staff, it was determined that the facility failed to ensure effective pest control to ensure the environment was free from gnats. This was evident in 1 of 2 units, and 1 of 1 kitchen reviewed for effective pest control during the annual recertification survey.The findings include: 1. On 3/23/2026 at 8:17AM, during an initial tour of Unit 2, the Surveyor observed the shared bathroom of Resident #19 and Resident #45. The bathroom had a musty odor and there were flying gnats observed in the shower area. On 3/24/2026 at 8:30AM during a tour of Unit 2, the Surveyor observed flying gnats at the nurses' station and in the hallway. On 3/25/2026 at 9:30AM, during an interview conducted with Resident #28, the Surveyor observed flying gnats in the room. The resident mentioned the facility had an issue with gnats. On 3/26/2026 at 1:34PM, during an interview conducted with the Director of Maintenance (DOM) #22, the Surveyor was informed that the facility utilizes [Pest Control Company] and an employee was in the building on 3/23/2026 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 review of employee files and interview with staff, it was determined that the facility failed to maintain an in-service training program to consistently evaluate each Geriatric Nursing Assistant (GNA) based on individual performance of mandatory education and clinical skills competencies of no less than 12 hours per year. This was evident for 4 (GNA #15, GNA #35, GNA #36, and GNA #37) out of 5 employee files reviewed for sufficient staffing during the annual recertification survey.The findings include:On 3/30/2026 at 12:15PM, a review of employee personnel files for GNA #15, GNA #35, GNA #36, and GNA #37 failed to reveal annual mandatory in-service and clinical competency of no less than 12 hours completed in the last 12 months. The Surveyor expressed the concerns to Nursing Home Administrator (NHA) and requested documentation to verify the individual performance of mandatory education and clinical skills competencies for GNA #15, GNA #35, GNA #36, and GNA #37.On 3/30/2026 at 1:30PM, the NHA provided the Surveyor with copies of GNA #15's, GNA #35's, and GNA #37's 2025…

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 with the facility staff, it was determined that the dietary staff 1) Failed to maintain the temperature logs on the refrigerator and freezer, 2) failed to date and label foods stored in the refrigerator and freezer with expiration dates and, 3) failed to put on beard covers while handling the resident's food. These were identified during 2 out of 4 observations of kitchen food service operations during the recertification survey and has the potential to affect all residents. The findings include: 1) On 01/08/25 at 08:28 AM, during the initial tour of the kitchen, the surveyor observed that the temperature logs on the doors of the refrigerator (1 and 2) and freezers (1 and 2) were not charted from 01/04/2025 - 01/06/2025. The Dietary Manager Staff #12 stated that the temperature logs were not completed because they were short staff during those days. The copies of the temperature logs were requested for and provided to the surveyor. On 01/09/2024 at 07:58 AM, during a follow-up visit to the kitchen, surveyor observed that the temperature logs on…

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

Based on record review and staff interview, it was determined the facility failed to provide evidence that all nursing staff had received education on abuse, neglect, and exploitation training annually. This was evident for 6 (nurse #11, #28, #38, and Nurse Aides #35, #39, and #40) of 6 nursing staff training records reviewed during the recertification/complaint survey. The findings include: On 1/15/25 at 11:29 AM, the surveyor reviewed randomly selected six nursing staff ( nurse #11, #28, #38, and Nurse Aides #35, #39, and #40) employee files for their training records from 2022 to current. The review revealed that a Registered Nurse ( RN #11) was hired in June 2019, a Licensed Practical Nurse (LPN #28) was hired in January 2023, and LPN #38 was hired in May 2022. There was no abuse, neglect, and exploitation training for all of them. Also, the Geriatric Nurse Aide #40 (hired in September 2017), #39 (hired in March 2019), and #35 (hired in January 2023) did not have any training records for abuse, neglect and exploitation annually. During an interview with the Director of Nursing…

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

Based on observation and an interview with facility staff, it was determined that the facility failed to ensure the environment of resident care was kept clean, comfortable and safe for resident use. This was evidenced by the floor radiator heater in the bathrooms observed with significant damage, rust build up along the floor radiator heaters, end caps were not in place which exposed sharp edges. This was evident for 2 of 5 bathrooms observed during the recertification survey. The findings include: On 01/08/25 at 01:45 PM it was observed that the bathroom floor radiator heater in rooms 36/38 (they are adjoining rooms and share a bathroom) had no cap at the end of it. Two sharp rusted edges were exposed and sticking out. A resident using the bathroom could potentially cut their leg on the rusted sharp edges. Two long flat metal pieces were also observed leaning on the wall in the bathroom for rooms 36/38. The two long pieces of metal were leaning on the wall from floor to ceiling opposite the toilet and sink. These two long metal pieces were not secured to the wall. The paper towel…

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 a facility reported incident, record review and staff interview, it was determined that the facility administration failed to ensure that a background check was done to protect residents from abuse, neglect, and theft. This was evident for 4 (Staff #26, # 46,# 47, and #48) of 9 employees reviewed for abuse during the re-certification survey. The findings include: 1) On 1/10/2025 at 2:05 PM the Director of Human Resources, Staff #25, was interviewed and asked if GNA #26 had a background check in their employee file. On 1/10/2024 at 2:40 PM Staff #25 was not able to provide a background check for GNA #26 after they reviewed the paper employee records and the electronic employee records. On 1/13/2025 at 8:00 AM Staff #25, the Director of Human Resources was asked again if GNA #26 had a background check in their employee file. Staff #25 replied no, I do not have any paperwork or documentation that showed GNA #26 had a background check during her employment here. 2) On 1/13/2024 at 8:15 AM the Administrator provided their facility reported incident (FRI) 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 review of facility records, Medical records, and interview with staff it was determined that the facility staff failed to immediately report an allegation of suspected resident abuse. This was evident for 1 (#37) of 15 residents reviewed for self-reported incidents during this recertification survey. The findings include: A facility self-reported incident involving Resident #37 was reviewed on 1/9/2025 at 11:01 AM. It was indicated that an allegation of abuse was reported on 12/19/2024 by the ombudsman during a care plan meeting. The family of Resident #37 reported to the ombudsman that a GNA (Geriatric Nursing Assistant), GNA #29, threw a positioning wedge pillow at him. Further review of the facility's investigation packet revealed that it had the following timelines documented: -The alleged incident occurred on 12/15/2024 at 8:45 PM -Nursing Home Administrator (NHA) was notified of the incident on 12/16/2024 -NHA interviewed Resident #37 on 12/17/2024 -NHA interviewed GNA #29 on 12/17/2024 -Ombudsman reported the incident at the Care Plan Meeting on 12/19/2024 -The…

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

Based on medical record review, facility investigation review, and staff interview, it was determined that the facility failed to 1) thoroughly investigate a resident's allegation of unknown origin of injury, 2) educate all staff to prevent similar elopement episodes in the future, and 3) thoroughly investigate an allegation of abuse, and provide documentation for the incident of an allegation of abuse. This was evident for 3 (Resident #30, #23, #19) of 36 residents reviewed during this recertification/complaint survey. The findings include: 1) A review of the facility's self-reported incident, MD00187097, on 1/09/25 around 10 AM revealed that Resident #30 was found with a bruise on his/her left flank and coccyx on 12/28/22. The facility investigated this incident as an unknown origin of injury through staff interviews, hospital follow-ups, and ADL (Activities of Daily Living) evaluations. However, there was no documentation for other residents' interviews. On 1/09/25 at 1:05 PM, the surveyor interviewed the Nursing Home Administrator (NHA). The NHA stated that the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative in writing about the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident #51) of 2 residents reviewed who were transferred to an acute care facility during the recertification survey. The findings include: Review of the medical record for resident #51 on 01/14/25 at 11:25 AM revealed that resident #51 was admitted to the facility on [DATE] and was sent to an acute care facility on 11/05/24 for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the resident and /or the resident representative were given written notice of the bed hold policy. The facility's documentation on eINTERACT transfer form reveals Bed hold policy was not sent. The bed hold policy was provided during an interview with the Director of Nursing (DON) 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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for one (Resident #257) of three residents reviewed for smoking during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Residents' strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. A portion of the investigation into a facility-reported incident, MD00185418, on 1/13/25 at 10:00 AM revealed that Resident #257 was found smoking in the room on 11/09/2022. The facility staff confiscated the Resident's smoking materials, and an evaluation and audit were conducted. The surveyor reviewed Resident #257's medical records on 1/13/25 around 1 PM. The review revealed that 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 the medical record review and staff interview, it was determined the facility staff failed to revise the interdisciplinary care plans to meet the resident's needs. This was evident for 2 ( Resident #30, #13) of 9 residents reviewed for abuse and 36 residents reviewed for for care plan timing and revision during the survey process. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The interdisciplinary team meets and develops care plans once the facility staff completes a comprehensive resident assessment. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assuring the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time…

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, staff interviews, and record review, it was determined that the facility failed to maintain a functional communication system for a non-English speaking resident (Resident # 51). This was evident for 1 of 1 resident reviewed for communication, including language and other functional communication systems, during the recertification survey. The findings include: On 01/08/25 at 10:15 AM, the surveyor attempted to interview resident # 51 in his/her room. The resident was not able to answer questions, except for occasional response of yes .yes. On 01/08/25 at 9:15 AM, during an interview with Licensed Practical Nurse (LPN) Staff # 42, when asked what language resident #51 speaks and how he/she communicates, Staff #42 stated, Resident # 51 doesn't speak English, and he/she speaks only Russian, but he/she can express what he/she wants with basic sign language. During business hours, an employee from another department helps when needed, but off hours and weekends, we have to call the resident'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 resident and staff interviews it was determined the facility staff failed to ensure that the dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident #37) of 2 residents reviewed for Activities of Daily Living (ADL) during this recertification/complaint survey. The findings include: During an interview with Resident #37 on 01/09/25 at 11:43 AM, when the surveyor asked the Resident if he got showers, the Resident stated Heck no. when asked if he would like a shower, he said Yes. On 1/13/2025 at 11:50 AM, an interview was conducted with a Geriatric Nurse Aide (GNA #35) who stated that when residents refused a shower, the GNAs would let the nurse know and document the refusal in the Electronic Health Record. GNA #35 stated that Resident #37 refused showers in the past, and had been getting bed baths. A record Review was conducted on 1/13/2025 at 1:16 PM revealed: -Order for shower and Skin Check 7-3 Shift Tuesday and Friday, written on 12/20/2024 at 07:00 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 record review and interview with facility staff, it was determined that facility staff failed to communicate and document a concern about a resident with a contracted dentist prior to tooth extraction which resulted in a resident having gum bleeding after the tooth extraction. This was evident for 1(Resident #264) out of 4 complaint investigations reviewed during the Medicare/Medicaid recertification survey. The findings include: On 01/13/2025 at 9:09 AM, review of intake MD00200513 showed that a complainant had stated that on July 29, 2024 their loved one, who was a resident at the facility, had a dental procedure (tooth pull) and his/ her blood-thinner medication was not held prior to the procedure which caused a trip to the emergency department due to excessive bleeding. On the same day at 9:14, the surveyor reviewed the electronic health record of the resident and it revealed the following: 1. Health Status Note on 7/27/2024 at 13:17 Note Text: Alert and verbal, no distress noted. was seen by a Dentist today. SBAR progress note on 7/27/2024 at 21:38 Note Text: 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 a review of the medical record and interview with staff it was determined that the facility failed to monitor a resident's significant weight changes. This was evident for 1 (#37) of 2 residents reviewed for nutrition during the recertification/complaint survey. The findings include: On 1/08/2025 at 1:44 PM, a review of Resident #37's medical record revealed, in a weight tracking system report, Resident #37's weight was documented as 187.2 Lbs. (pounds) on 04/08/2024 and 6/18/2024 Resident #37's weight was documented as 166.5 lbs., which was a 20 lbs weight loss. Further review of Resident #37's medical record revealed a note from the dietician, staff #50 on 5/16/2024 that the resident refused weight, noted with failure to thrive in adult, swallowing difficulty, speech more remote/ slurred, and needs 100% support with meals. However, there was no documentation from a physician that he/she was aware of Resident #37's weight loss, nutritional status, or weight management. The weight log was as follows:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the medical record review and staff interview the facility failed to ensure that the use of high-risk psychotropic medication was necessary and justified when staff failed to complete behavior monitoring documentation and utilization of nonpharmacological interventions before administering Anxiolytic medication for the resident (#13). This concern was evident for 1 (Resident #13) of 2 residents reviewed for utilization of unnecessary medication during the recertification survey. The findings include: Resident #13's medical record was reviewed on 01/10/25 at 11:06 AM and revealed that the resident was admitted on [DATE]. Resident #13 was receiving an anxiolytic medication (Ativan) for the diagnosis of Anxiety. On 01/10/25 at 11 AM, a medical record review revealed that an initial order from 12/15/23 for Ativan Tablet 0.5 MG every 12 hours as needed for anxiety was placed for 14 days. The order was renewed to manage resident behaviors on 01/02/24 for 14 days, 01/22/24 for 14 days, and 02/19/24 for 14…

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 the staff interviews, it was determined that the facility failed to properly store medications, as evidenced by failing to ensure that medication was properly labeled and dated. This was evident in two of the two medication rooms and one of the two refrigerators observed during the recertification survey. The findings include: On [DATE] at 12:48 PM, the surveyor checked the refrigerator in Units 1 A and B and noted two opened resident-specific insulin vials. Vial one was opened on [DATE], and vial two was opened on [DATE]. Per the facility's medication labeling and storage policy, Multi vials that have been opened or accessed are dated and discarded within 28 days. On [DATE] at 12:50 PM, the Surveyor checked the supplies along with the Licensed Practical Nurse(LPN) # 45 at Unit 2 A and B medication storage room and noted an expired spill kit (Econo kit). The kit expired on [DATE] and contained a scoop, a red bag, and gloves. The surveyor also noted three Condom catheter packs (Ref…

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, review of resident's immunizations records, and interviews with residents and facility staff, it was determined that the facility failed to 1) prevent infection in a resident with an indwelling catheter and failed to protect the resident's dignity, 2) perform Tuberculosis screening on all admissions, and 3)ensure that medication administration methods were free from contamination in a manner that minimized the potential spread of infection. This was evidenced by 2 residents (Residents #57 and #207) of 36 residents reviewed during the recertification/complaint survey, and a Registered Nurse (RN) (Staff#43), not sanitizing hands between residents during medication administration during this recertification/complaint survey. 1) On 01/08/25 at 12:21 PM during an initial tour of the facility, the surveyor observed that Resident #207's Foley bag was seen on the floor in a pillowcase. LPN staff#6's attention was called to see resident Foley's bag. When she was asked what was used to cover the Foley bag, she stated that it was a pillowcase and stated that she was not…

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

Based on record review and interview with facility staff it was determined that the facility failed to have a system in place to ensure that Geriatric Nursing Assistant (GNA) received education about residents' safety and residents' care after an alleged abuse incident. This was found to be evident for two Geriatric Nursing Assistants (GNA #10 and #37) out of 7 GNAs' reviewed for training records reviewed during this recertification/complaint survey. The findings include: 1)On 01/09/25 at 12:48 PM, a review of GNA #10's employee file revealed that she was hired in July 2023. However, there were no training records for residents' safety and transfer mobility seen for the employee upon hire date and afterward. On 01/09/25 at 12:54 PM, in an interview with the Director of Nursing DON, when she was asked about the training process upon hire, she explained to the surveyor that the education/skills packets are given to the employees, and they take the packets to the employee who is orienting them, and the signed/completed skills packets are put in the new employee file. When she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation during an initial tour of the facility and an interview with the resident, it was determined that the facility failed to maintain and enhance the dignity of the resident (Resident #37). This occurred in 1 of 6 sampled residents. The findings include: During observations rounds on 2/11/20 at 9:39 AM Resident #37 was noted with a dried yellow sticky substance on the floor next to his/her chair near the bathroom door. While this surveyor was walking in the resident's room a sticking sound could be heard. The resident stated, that is dried urine on the floor, sometimes I don't make it to the bathroom. On 2/13/20 at 1:24 PM during a follow-up interview with the Resident #37, the resident's room floor again was noted with a dried yellow sticky substance throughout the floor. The resident was also noted with a bandage to the right knee. When asked what happened? The resident stated, I fell while coming out of the bathroom [ROOM NUMBER] days ago. I sometimes don't make it to the bathroom…

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 interviews with the resident and the facility staff, the facility failed to ensure that Resident #90 had an alternative method to wash his/her hands secondary to a resident wheelchair not being able to fit through the bathroom door. This is evident for 1 of 6 residents reviewed during the annual survey. The findings include: During an interview with Resident #90 on 2/12/20 at 10 AM, s/he stated, I would like to wash my hands in the bathroom, but my wheelchair will not fit through the door. Review of Resident #90's medical record on 2/13/20 revealed the resident was admitted to the facility 02/2020, with a diagnoses that included Paraplegia, depression and Bipolar Disorder. During interview with the Acting Director of Nursing (ADON) and the Administrator on 2/14/20 at 11 AM, the ADON stated, the residents' wheelchair is longer than the average wheelchair and wipes can be supplied to the resident for handwashing. During a follow-up interview with Resident #90 s/he stated, the wipes were given to him/her by Nurse #6.

Based on interview with facility staff and the resident it was determined the facility failed to ensure a resident receives his/her packages unopened. This was evident for 1 of 7 residents (Resident #7) reviewed during the annual survey. The findings include: During an interview with Resident #7 on 2/11/20 at 12:24 PM s/he stated, the social worker opens my packages before me receiving them. On 2/12/20 at 2 PM during an interview with the Social Worker she stated, she has opened the resident packages to ensure that the resident can have what is being delivered. She was informed by this surveyor that the resident was concerned about this. The Social Worker stated, it would not happen again.

Based on medical record review and interview with the facility staff, it was determined that the facility failed to provide notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment. This was evident in 3 of 3 residents (Resident #33, #243 and #24) reviewed during beneficiary protection notification. The findings include: Advance Beneficiary Notice (ABN) is a written notice from Medicare, given to residents before receiving certain items or services notifying beneficiaries that Medicare may deny payment for that specific procedure or treatment. An ABN gives residents the opportunity to accept or refuse the items or services and protects them from unexpected financial liability in cases where Medicare denies payment. 1. On 2/19/2020 at 11:58 AM Resident #33's Beneficiary Protection and Notification task was conducted. This review revealed that the last covered day for skilled nursing facility services for the resident was 1/17/2020, further review revealed that the facility failed…

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 maintain a safe, functional, and comfortable environment for residents. This was evident for 2 of 7 residents (Resident #7 and #37) reviewed during the annual survey. The findings include: 1. During a tour of the facility on 2/11/20 at 9:39 AM, upon entering Resident #37's room, occupied by one resident, there was a very strong odor of urine that lingered. The room was noted with a dried yellow sticky substance on the floor next to his/her chair near the bathroom door. While this surveyor was walking in the resident's room a sticking sound could be heard. The resident stated, that is dried urine on the floor. 2. During a tour and interview with Resident #7, on 2/11/20 at 12:24 PM, the surveyor observed that the resident had several boxes in his/her room near the window, behind the boxes were mice droppings. The resident stated, I hear the mice every night rambling through my stuff. The Administrator was made aware of the resident concern and this surveyor's observation. The Administrator…

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, medical record review and interviews with facility staff it was determined the facility failed to report an injury of unknown origin to the state regulatory office. This was found to be evident for 1 (Resident # 15) that was reviewed for general skin condition during the facility's annual Medicare/Medicaid survey. Findings include: An observation was made on 2/11/10 at 8:40 AM of Resident #15 who was in his/her bedroom in the bed. The resident was noted to have an abrasion to the left arm. Review of the Resident #15's medical record on 2/14/20 revealed the resident was admitted with the following but not limited diagnosis; Stiffness of Right and Left Shoulder, Age-related Osteoporosis. Review of a care plan initiated on 9/19/19 revealed that the resident had a history of wandering and listed as an intervention: Staff will continue to monitor and re-direct the resident. An interview was conducted with the Nurse# 13 assigned to unit one on 2/18/20 at 1:55 PM and she was asked about resident's bruise and she stated that the resident wanders at times and that the…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to complete a thorough investigation for a resident injury with an injury of unknown origin. This was found to be evident for 1 resident (Resident #15) reviewed for abuse during the facility's annual survey. Findings include: During the facility's annual survey on 2/11/20 at 8:40 AM, Resident #15 was observed in his/her bedroom with an abrasion to the left arm. Review of the resident's medical record on 2/14/20 revealed the resident was admitted with the following but not limited diagnosis: Stiffness of Right and Left Shoulder, Age-related Osteoporosis. Further review of a care plan initiated on 9/19/19 revealed the resident had a history of wandering and listed as an intervention: Staff will continue to monitor and re-direct the resident. Further review of the medical record revealed the resident was observed by the nurse on 1/11/20 at 10:50 AM with his/her shoulder bent moderately to the right side while walking. X-Ray results indicated Resident #15 had an Anterior Inferior…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure residents or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information. This was found to be evident for 3 out of 3 residents (Residents #20, # 240 and #22) reviewed for hospitalization during the investigative stage of the survey. The findings include: 1. On 2/14/2020 at 9:39 AM review of Resident #20's medical records revealed the resident had been discharged to the hospital on 1/5/2020. Review of the medical records revealed a Nursing Home to Hospital Transfer form revealing that the Responsible Party (RP) was called and made aware of the transfer. Further review of the form failed to reveal documentation that the transfer/discharge information was mailed to the RP nor did it have information about the resident's appeal rights or Ombudsman contact. During an interview with the Director of Nursing (DON) and the Corporate Nurse on 2/14/2020 at 12:30 PM, they both…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or residents' responsible party (RP) were given written notification of the facility bed-hold policy when they were being transferred out of the facility to a hospital. This was found to be evident for 2 out of 3 residents (Residents #20 and #240) reviewed for hospitalization during the survey investigation. The finding includes: 1. Resident #20's medical records were reviewed on 2/14/2020 at 9:39 AM and revealed that the resident had been discharged to the hospital on 1/5/2020. Further review of the medical records revealed a Nursing Home to Hospital Transfer form revealing that the RP was called and made aware of the transfer. Further review of the form failed to reveal documentation that a copy of the facility bed-hold policy was sent with the resident or mailed to the RP. Review of the facility Nursing Policy and Procedure on Discharge/Transfer documentation that is sent with the resident to the hospital includes the following:…

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, interviews with family and staff it was determined the facility failed to: 1.) review and update the care plan in relation to the resident's Activities of Daily Living (ADL) care plan based on the resident's current status and needs or include family preferences for dining and getting out of bed or follow the interventions for bladder incontinence and 2.) revise a care plan to specify how frequent staff is to monitor a resident who is at risk for falls. This was evident for 2 of 21 residents (Resident #32 and #21) reviewed for care plan updates during the survey investigation. The findings include: ADLs (Activities of Daily Living) refer to daily self-care activities such as eating, toileting, grooming and dressing. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. During an interview with Resident #32's family member on 02/11/2020 at 2:26 PM he/she stated he/she and my sisters attend care plan meetings and they do a lot of talking about 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 observations, tour of the facility, medical record review as well as review of other pertinent documentation and interview of facility staff it was determined the facility failed to: 1.) provide a safe and hazard-free environment for 1 of 1 resident (Resident #37) reviewed for accidents and 2.) ensure a resident at risk for falls received increased monitoring by staff according to the care plan interventions (Resident #21). This was found to be evident for 1 of 1 resident reviewed for falls during the facility's annual survey. The findings include: 1. During observations rounds on 2/11/20 at 9:45 AM Resident #37's room was observed with a fall mat near the window with white board strips 3 feet by 8 feet L shaped nailed to the floor around it. During an interview with the Administrator on 2/13/20 at 10 AM he stated,the prior Maintenance Director was asked to remove the wood strips, however, he quit before removing them. During an interview with the interim Maintenance Director on 2/13/20 at 10:30 AM, he stated, the facility is in the process of removing the wood strips. 2.…

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

Based on medical record review and interview with facility staff it was determined that a facility physician failed to sign monthly orders timely and when the physician first visited the resident when the orders were written. This was evident during the medical record review of Resident #2. The findings include: Review of the medical record for Resident #2 on 2/13/2020 at 10:30 AM revealed that after the resident's December 2019 hospitalization and monthly record turnover was completed the January 2020 orders were printed out from the pharmacy dated 1/2/2020. The turnover and order process was confirmed with Staff #6 on 2/13/2020 at 11:47 AM. The Physician #30 signed the orders on 1/28/2020 although the orders were acted on and implemented all through January 2020. A review of the physician notes and visits with Resident #2 revealed that Physician #30 saw Resident #2 on multiple occasions prior to 1/28/2020, including on 1/7/2020, however, did not sign the orders until 1/28/2020. This concern was reviewed with the Director of Nursing on 2/13/2020 at 4:39 PM.

Based on medical record review and interview with facility staff, it was determined that the facility failed to have a completed psychiatric consult on the chart and further provide additional psychiatric services to a resident due to a resident's payor source. This was evident during the review of 1 of 5 residents (Resident #13) for unnecessary medications. The findings include: Review of the medical record for Resident #13 on 2/18/2020 5:18 PM revealed the resident was just re-admitted to the facility after an incident of noted aggression towards other residents and staff. The medical record documented that the resident had a diagnoses including unspecified dementia with behavioral disturbances, mood disorder due to known physiological conditions with manic features and altered mental status. Resident #13's attending physician noted on the resident's history and physical that Patient currently on 2 antipsychotics and not likely benefiting from both with potential for more side effects. Per the history and physical after an initial consultation with behavioral services, the Haldol…

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

Based on medical record review and interview with facility staff, it was determined that the facility pharmacist failed to identify and act on a medication irregularity. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage. The findings include: Review of the medical record for Resident #14 on 2/12/20 at 5:16 PM revealed diagnosis of insulin dependent diabetes. The resident was also ordered Lantus a long acting insulin at different doses twice a day. Resident #14, according to the physician notes and medication administration records (MAR) reviewed on 2/12/2020 was monitored by glucose checks daily. According to the weekly results of the glucose checks the resident's insulin would be adjusted. On 11/21/2019, the Nurse Practitioner #8, saw Resident #14 and recommended decreasing his/her nightly Lantus dose from 10 units to 7 units. According to the MAR however, the resident's daytime dose of Lantus that was at 30 units was discontinued and 7 units was added to the nighttime regime for a total of 17 units given via 2 injections. NP #8 was…

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

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to follow physician orders by discontinuing the wrong diabetic medication on a resident that was dependent on insulin. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage. The findings include: Review of the medical record for Resident #14 on 2/12/20 at 5:16 PM revealed diagnosis of insulin dependent diabetes. The resident was also ordered Lantus, a long acting insulin at different doses twice a day. Resident #14, according to the physician notes and medication administration records (MAR) reviewed on 2/12/2020 was monitored by glucose checks daily. According to the weekly results of the glucose checks the resident's insulin would be adjusted. On 11/21/2019, the Nurse Practitioner #8 saw Resident #14 and recommended decreasing the nightly Lantus dose from 10 units to 7 units. According to the MAR however, the resident's daytime dose of Lantus ordered for 30 units, was discontinued and 7 units was added to the nighttime…

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

Based on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass completed by 1 licensed nurse during the administration of 26 medications, in addition to administration of 5 medications that were observed for a total of 31 medication opportunities that resulted in 10 errors for an error rate of (32%) for Resident #11 and Resident #13. The findings include: Surveyor completed an observation of a medication pass on 2/12/2020 at 7:48 am with LPN #4. During the observation of the medication pass, LPN #4 pulled the medications from the medication cart for Resident #11 and reviewed the medications with the surveyor. According to the physician orders a medication that was ordered, Divalproex was ordered as Delayed Release (for depression). LPN #4 stated that she was crushing all the resident's medication and that a certain Geriatric Nursing Assistant (GNA) would give the medication as the resident would not…

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

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to follow physician orders and promptly identify a medication error involving diabetic medication for a resident that was dependent on insulin for daily functioning. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage. The findings include: Review of the medical record for Resident #14 on 2/12/20 at 5:16 PM revealed diagnosis of insulin dependent diabetes. The resident was also ordered Lantus, a long acting insulin at different doses twice a day. Resident #14, according to the physician notes and medication administration records (MAR) reviewed on 2/12/2020 was monitored by glucose checks daily. According to the weekly results of the glucose checks the resident's insulin would be adjusted. On 11/21/2019, the Nurse Practitioner #8 saw Resident #14 and recommended decreasing the nightly Lantus dose from 10 units to 7 units. According to the MAR however, the resident's daytime dose of Lantus ordered for 30 units, was…

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

Based on observations and interviews with the facility staff it was determined the facility staff failed to store foods properly in the dry storage area. This was found to be evident during an initial tour of the facility conducted during the facility's annual survey. The Findings include: An initial tour of the main kitchen was conducted on 2/11/20 at 7:25 AM with the Food Service Director present. The main kitchen was noted with water pouring from the ceiling with a gray trash can under the leak to catch the water. The wall in the dry storage room across from the kitchen was observed with water stains and peeling drywall and paint. Additional observation revealed there were multiple food items stored on the shelf that were outdated and identified as follows: Seven expired thickened cranberry thickeners dated 12/25/18 One apple thickener dated 7/18/19 One orange juice honey consistency dated 7/19/19 One pomegranate Berry flavor thickener dated 12/10/19 On 2/14/20 at 7 AM during observation of the breakfast tray line the cart that contained the lids for the plate trays for 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 medical record review and interviews with facility staff it was determined the facility failed to: 1.) maintain accurate documents related to the care of resident (Resident #37) and 2.) provide documentation that a resident was monitored for aggressive behaviors and was sent for an evaluation for those behaviors according to the resident care plan (Resident #13). This was found to be evident for 2 of 24 residents (Resident #37 and #13) reviewed during the facility's annual survey. The findings include: 1. Review of Resident #37's medical record on 2/13/20 at 11 AM revealed a Medication Management assessment dated [DATE] by CRNP (Certified Registered Nurse Practitioner) for Med Option Psych services which indicated the resident was receiving Klonopin 0.5 mg every morning for anxiety and Trileptal 300 mg two times a day for seizures. Klonopin is a sedative used to treat seizures, panic disorder, and anxiety. Trileptal is an Anticonvulsant that can be used for seizures. Continued review of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to: 1.) ensure that each resident or responsible party (RP) received education regarding benefits and risk and document that the residents or the responsible party were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization prior to administration. This was evident for 4 residents (Resident #23, #25, #21 and #28) reviewed for immunization. The findings include: On 2/18/2020 the facility influenza and pneumococcal immunization policy and procedure was reviewed and revealed the following: The resident or RP will sign the consent/declination for after receiving education regarding the immunization. Review of Resident #23, #25, #21 and #28's medical records revealed all residents listed had orders for influenza vaccination and for the Pneumococcal 13-[NAME] Conj Vacc Suspension inject 0.5 milliliter intramuscularly one time. Further record review revealed 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 during the initial tour it was determined that facility staff failed to maintain an effective pest control program so that the facility was free of pests. The findings include: During an observation tour and interview with Resident #7 on 2/11/20 at 12:24 PM, the surveyor observed that the resident had several boxes in his/her room near the window and behind the boxes were mice droppings. The resident stated, I hear the mice every night rambling through my stuff. The Administrator was made aware of the resident concern and surveyor observation. The Administrator placed sticky traps in the resident's room and contacted Ecolab the pest control company used by the facility. On 2/12/20 during an interview with Resident #90 at 10 AM, s/he stated state, a mouse comes to visit my room every night. Several mice dropping were noted under the resident's bed. During an interview with the Administrator on 2/13/20 at 1 PM, he stated, Ecolab pest control comes in monthly. I will notify them. On 2/14/20 at 10 AM, the Administrator reported to this surveyor that mice were caught…

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 reported incidents and further review of employee records, including interview with facility staff, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given annual abuse training. This was evident during the review of 3 of 4 employee records reviewed (Staff # 16, #17 and #18). The findings include: Interview with the Human Resources Director (HR) #15 on 2/18/2020 at 11:30 AM to review the employee files provided to the survey team, revealed that for Employee #16, #17 and #18 there was no trainer reviewed and dated proof that the training documentation in the files related to annual training of abuse, neglect and exploitation. Within the employee's files was paperwork that the HR Director #15 stated was proof of training. It was a type of post-test that was not reviewed by anyone that the employees would receive after they were given an in-service related to abuse. HR Director #15 stated that after the in-service they discuss what was in the in-service and give the employees a paper to sign…

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 reported incidents and further review of employee records, including interview with facility staff, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given in-service training related to abuse and dementia care upon hire. This was evident during the review of 1 of 2 new employee records reviewed (Staff #16). The findings include: Interview with the Human Resources Director (HR) #15 on 2/18/2020 at 11:30 AM to review the employee files provided to the survey team, revealed that for Staff #16 there was no training provided to the employee for 2019 related to required abuse, neglect and dementia care when the employee was hired. Within the employee's file was paperwork that the HR director stated was proof of training. It was a type of post-test that was not reviewed by anyone that the employees would receive after they were given an in-service related to abuse. HR Director #15 stated that after the in-service they discuss what was in the in-service and give the employees a paper to sign 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.