Patapsco Healthcare

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 the care and services it delivers meet acceptable standards of quality, maintain documentation on how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, identifies improvement activities, implements corrective and preventative action, tracks performance, and conducts performance improvement projects. The was found to be evident by repeated citations from the previous annual survey and for QAPI review during the current annual survey.The findings include: According to the Centers of Medicare and Medicaid Services (CMS), QAPI stands for Quality Assurance and Performance Improvement, a systematic, data-driven, and proactive approach to maintaining and improving the safety and quality of care in nursing homes, as mandated by the Affordable Care Act. It combines Quality Assurance (QA), which sets and ensures standards for care, and Performance Improvement (PI),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews with staff, it was determined that the facility failed to provide the residents with respect and dignity by failing to 1.) knock/ask permission to enter prior to entering the residents' rooms, evident for 5 resident rooms (#222, #221, #223, #224, # 227) out of 15 resident rooms observed on the Liberty Hall Unit; 2.) ensure dependent residents were clothed and out of bed to chair, evident for 3 (Resident #23, Resident #124, and Resident #74); 3.) ensure residents clothing was timely laundered, evident for 5 (Resident #61, Resident #87, Resident #53, Resident #2, and Resident #125); and 4.) maintain privacy and appropriate covering during care and transfers, evident for 2 (Resident #13 and Resident #63) out of 57 residents reviewed during the survey. The findings include: 1. On 2/2/2026 at 8:55AM through 9:13AM, the Surveyor observed Geriatric Nursing Assistant (GNA) #29 as they passed out breakfast trays on the Liberty Hall Unit. The Surveyor observed GNA #29 enter rooms #222,…

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 facility staff it was determined the facility failed to accommodate residents by allowing residents to smoke at the designated facility times. This was found to be evident for all residents who smoked including 2 Residents (# 4 and # 121) of 25 residents reviewed for smoking during the facility's survey. The Findings include: A recertification survey was conducted at the facility between 2/2/2026 and 2/9/2026. During the survey resident interviews were conducted and resident observations were made as follows:1. Resident # 4 was interviewed on 2/2/26 at approximately 12:22 PM. The resident was asked the question regarding smoking, are you able to smoke when you want to and the resident replied, no. I have not been allowed to go outside to smoke for approximately two weeks. The resident went on to say that the facility has designated times in which they can go outside and smoke, but were being told that the temperature outside has been less than 32 degrees each day, which was a facility restriction, preventing residents from…

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 monitoring and oversight of food temperatures in accordance with professional standards for food service safety, failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, failed to ensure food and food equipment was stored in accordance with professional standards for food service safety, failed to ensure thorough environmental cleaning and a sanitary environment of the kitchen, failed to ensure monitoring and oversight of kitchen equipment and environment, and failed to ensure kitchen wall paint was in good repair to prevent potential for contamination of food and food contact surfaces. This was evident during surveyor review of the kitchen task during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility's kitchen on 2/2/26 at 8:13AM the surveyor conducted an interview with Certified Dietary Manager #11 who confirmed that the dishwasher was used and was used in hot…

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, interview and record review it was determined the facility failed to ensure: 1. & 2 .) medical record documentation from outside consult providers was present within the medical record. This was evident for: 1.) 1 out of 1 Resident (#55) reviewed for urinary catheter and 2.) 1 out of 1 Resident reviewed for Neglect (#134) and during the surveyor's review of Complaint #2694340 during the facility's recertification survey.The findings include: Based on observation, interview and record review and review of Complaint #2694340 it was determined the facility failed to: 1) maintain medical records in accordance with accepted professional standards and practices. This was evident for 7 (Resident #5, #23, #7, #99, #115, #61, and #125) out of 57 residents reviewed; 2) ensure that a hospital transfer form document contained current and accurate documentation. This was found to be evident for 1 (Resident # 11) of 3 residents reviewed for hospitalizations; 3) ensure medical record documentation from…

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 staff, it was determined that the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings had the required committee members in attendance and conducted meeting at least quarterly. This was found to be evident for 1 out of 2 quarterly committee attendance sheets reviewed during the survey and due to no documentation made available for 3 out of 4 quarterly meetings in 2025. The findings include: During a review of the QAPI attendance sheets conducted on 2/9/2026 at 4:30PM, the Surveyor discovered that the facility had documented QAPI meetings on 10/30/2025 (quarterly), 11/21/2025, 12/26/2025, and 1/29/2026 (quarterly). A review of the quarterly committee attendance sheet for January 29,2026 revealed that the Medical Director or his/her designee did not attend the meeting. Further review failed to reveal documentation of QAPI meetings held from January 2025 through September 2025. During an interview conducted with the Nursing Home Administrator (NHA) on 2/9/2026 at 4:40PM, the Surveyor was informed that the NHA…

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 with facility staff it was determined the facility failed to ensure the facility environment was kept safe, clean, comfortable, and homelike. This was found to be evident of 4 (Resident # 4, # 41, 31 and # 121) of 40 residents observed and 2 out of 2 ceiling vents observed during the facility's survey. The findings include: During observation rounds conducted during the survey, the following concerns were identified: 1. Resident # 4's room was observed on 2/2/26 at approximately 8:35 AM and a pile of clothes and personal belongings were piled in the corner and extending along the wall and walk space near the resident bed. 2. Resident #41's room was observed on 2/2/26 at approximately 8:40AM and there was an oversized TV on top of the dresser leaning back against the wall. There were no legs observed underneath the TV to stabilize the TV to keep it from falling. 3. Resident # 31's room was observed on 2/2/26 at approximately 8:45AM and inside of the bathroom there was an open…

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 record review, interview, it was determined the facility failed to ensure facility Residents were free from abuse. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.The findings include:On 2/4/26 at 9:30AM in response to the surveyor's request to the facility Administrator to provide the complete investigative file and all documentation relating to Facility Reported Incident #2728128, the surveyor was provided with the complete investigative file. At this time, the surveyor conducted an interview with the facility Administrator who confirmed with the survey team that the file being provided was the facility's complete investigative file. On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 in which the allegation type was documented as sexual and additionally documented under the…

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

Based on record review and interview it was determined the facility failed to ensure an allegation of abuse was timely reported and failed to ensure all applicable agencies were notified. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed during the facility's recertification survey.The findings include:On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 at 7:45PM in which the allegation type was documented as sexual and additionally documented under the suspected crime section: allegation of physical abuse. Further review of the initial self report revealed that Resident #86 was documented as an alleged victim and Resident #69 was documented as an alleged perpetrator. Continued review of the facility's initial self report form revealed the following documented allegation details: On 1/27/26 at approximately 5:15PM, the evening shift supervisor informed the…

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

Based on review of Facility Reported Incident #2728128, interview, and record review it was determined the facility failed to ensure a thorough investigation. This was evident for 1 out of 1 facility reported incident (#2728128) reviewed by the surveyor during the facility's recertification survey.The findings include:On 2/4/26 at 9:30AM in response to the surveyor's request to the facility Administrator to provide the complete investigative file and all documentation relating to Facility Reported Incident #2728128, the surveyor was provided with the complete investigative file. At this time, the surveyor conducted an interview with the facility Administrator who confirmed with the survey team that the file being provided was the facility's complete investigative file. On 2/4/26 at 9:42AM the surveyor reviewed the facility's complete investigative file for Facility Reported Incident #2728128 which revealed an initial self report made to the Office of Health Care Quality by the facility's Administrator dated 1/27/26 in which the allegation type was documented as sexual 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 record review and interview with staff, it was determined that the facility failed to provide the resident representative with written notification of transfers to the hospital and written notification of the facility's bed hold policy upon transfer to the hospital. This was found to be evident for 2 (Resident #11 and Resident #2) out of 3 residents reviewed for hospitalizations during the annual survey. The findings include: A Resident Representative is a person authorized to act on behalf of the resident. Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1. A medical record review was conducted on 2/4/26 at 1:21 PM for Resident # 11. The review revealed that on 12/18/25 the resident made a 911 call indicating that s/he wanted to go to the hospital. The resident went to the hospital. Further review revealed the resident was assessed on 1/31/26 for concerns of difficulty breathing. The resident was sent to the hospital for further evaluation. During a meeting with the DON and on 2/4/26…

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 with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 3 (Resident #2, #99, and #125) out of 25 residents reviewed for smoking during the annual survey.The findings include:The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A comprehensive MDS assessment is completed at admission, annually, quarterly, and with significant change.On 2/3/2026 at 2:00PM, a review of the facility's Smoker's List as of 2/2/2026 revealed that Resident #2, #99, and #125 were independent smokers.On 2/5/2026 at 8:10AM, a review of Resident #99's electronic medical record revealed the resident was admitted to the facility on [DATE] and was a smoker prior to admission. A Smoking Contract was completed upon…

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 interviews with staff, it was determined that the facility failed to ensure comprehensive person-centered care plans were developed and implemented for residents which reflect resident's goals, measurable objectives, and interventions to meet the specific goal for the resident. This was evident for 1 resident (Resident #84) out of 5 residents reviewed for choices, 2 residents (Resident #55 and Resident #53) out 25 residents reviewed for smoking, and 1 resident (Resident #5) reviewed for communication-sensory during the annual survey.The findings include: 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. 1.) 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 observations, record review, and interview with staff, it was determined that the facility failed to ensure the use of a functional communication system for a non-English speaking resident. This was evident for 1 resident (Resident #5) reviewed for communication-sensory during the annual survey. The findings include:On 2/2/2026 at 8:51AM, the Surveyor observed Resident #5 laying in bed sleeping. Geriatric Nursing Assistant (GNA) #29 entered the resident's room to bring his/her breakfast tray. The GNA called to the resident in English to inform him/her that breakfast was here. The resident remained asleep. GNA #29 did not use any language interpretation device while communicating with the resident.On 2/3/2026 at 12:20PM, during an interview with Resident #5, the Surveyor discovered that the resident did not speak English; however, spoke Spanish. No observations of nursing staff using a language interpretation device while communicating with the resident. On 2/4/2026 at 1:30PM, a review of Resident #5's electronic medical record revealed a quarterly Minimum Data Set…

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

Based on observation, record review, and interview, the facility failed to ensure adequate one-to-one supervision for Resident #69 as ordered by the physician. This occurred for 1 of 1 resident reviewed for supervision during the annual survey.The Findings include:During observation rounds on 02/06/26 at approximately 6:30 a.m., Resident #69 was observed on the unit without one-to-one supervision in place. At that time, staffing on the unit consisted of one Geriatric Nursing Assistant (GNA) staff #17 and one licensed nurse staff #12. No staff member was assigned to provide continuous one-to-one supervision for Resident #69.Review of the medical record on 02/06/26 at 6:45 a.m. revealed a physician's order for one-to-one supervision every shift (24 hours per day, 7 days per week) due to inappropriate sexual behavior toward staff and other residents.During an interview on 02/06/26 at 7:00 a.m., Nurse Staff #12 and GNA Staff #17 stated that a scheduled GNA had called out and there were no available staff to replace her.During an interview on 02/06/26 at 7:30 a.m., Staff Nurse #22 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 observation, interview, and record review it was determined the facility failed to ensure a Resident's environment was free from accident hazards. This was evident during 1 out of 1 initial observation made of Resident #105 during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility on 2/2/26 the surveyor observed Resident #105 at 9:03AM from the hallway sleeping in their bed with a fall mat which was situated flat on the floor against the wall located next to the doorway to the room and was situated several feet away from the Resident's bed with hard flooring tiles located in between the mat and the Resident's bed. On 2/2/26 at 9:05AM the surveyor conducted an interview and inquired to Licensed Practical Nurse (LPN) #12 as to if and why Resident #105 had a fall mat in place. LPN #12 stated to the surveyor during the interview: Yes s/he has a fall mat in place because sometimes s/he rolls out of bed. At this time, the surveyor requested and conducted a dual observation and shared the concern with Licensed Practical…

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

Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure oxygen therapy was administered as ordered by the physician. This was evident for 1 resident (Resident #5) out of 3 residents reviewed for respiratory care during the annual survey. The findings include:A nasal cannula is a device that delivers oxygen directly to a person's nares via a flexible plastic tube.On 2/2/2026 at 8:53AM, the Surveyor observed Resident #5 wearing a nasal cannula connected directly to the oxygen concentrator without a humidifier bottle. The resident was receiving oxygen via nasal cannula at a rate of 3 Liters per minute (L/min).On 2/3/2026 at 12:20PM, the Surveyor observed the resident wearing a nasal cannula connected to the oxygen concentrator with a humidifier bottle. The oxygen tubing and humidifier bottle was labeled 2/3/2026. The resident was receiving oxygen via nasal cannula at a rate of 3.5L/min.On 2/4/2026 at 9:41AM, during a review of Resident #5's electronic medical record, the Surveyor discovered that the resident had diagnoses 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 observations, record review, and interview with residents and staff, it was determined that the facility failed to ensure residents were properly assessed for the safe use of bedrails, obtain consent from the resident or resident representative prior to use of bedrails, and obtain a physician's order for the use of bedrails. This was evident for 4 (Resident #23, #74, #87, and #124) out of 7 residents reviewed for accidents during the annual survey.The findings include:Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails.On 2/2/2026 between 8:20AM and 9:30AM, during a tour 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 record review, observation, and interviews, the facility failed to ensure sufficient nursing staff to meet the needs of residents to provide one-to-one supervision for Resident #69 as ordered by the physician.The Findings include:On 2/6/26 at approximately 6:30 AM, observation revealed that Resident #69, who had a physician's order for 1:1 supervision due to behavioral problems, was not being supervised as ordered. At that time, one GNA (Staff #17) and one nurse (Staff #12) were assigned to the unit, and no staff provided continuous 1:1 supervision.Staff #12 and GNA #17 stated that the GNA called out and no replacement staff were assigned. The Director of Nursing (DON) confirmed that Resident #69 has a 24/7 1:1 supervision order and acknowledged that staffing shortages prevented adherence to the order.

Based on observation and interview with staff, it was determined that the facility failed to assure that medications were secure in a locked medication cart under the direct observation of authorized staff in an area where residents could not access it. This was evident for 1 treatment cart observed on the 2nd floor Liberty Hall nursing unit.The findings include:On 2/2/2026 at 8:13AM, during a tour conducted on the 2nd floor Liberty Hall nursing unit, the Surveyor observed an unattended, unlocked treatment cart labeled LIBERTY TX CART located across from the unattended nurses' station.During an interview conducted with Licensed Practical Nurse (LPN) #28 on 2/2/2026 at 8:16AM, the Surveyor was informed that they were one of the nurses on duty for Liberty Hall. LPN #28 confirmed that the treatment cart was unattended and unlocked and stated that the cart should've been locked when authorized staff finished using it. LPN #28 locked the treatment cart.On 2/2/2026 at 11:25AM, during an interview with Unit Manager (UM) #13, the Surveyor expressed the concern that the Liberty treatment…

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, record review, and interview with the resident and staff, it was determined that the facility failed to obtain routine dental care for the resident. This was evident for 1 resident (Resident #23) reviewed for dental services during the annual survey.The findings include:On 2/2/2026 at 8:30AM, during an interview conducted with Resident #23, the Surveyor observed poor dentition, missing teeth, poor oral care, and a tooth with internal black/grey discoloration. The Surveyor was informed that the resident had not been seen by a dentist since he/she was admitted to the facility and would like to see the dentist.On 2/3/2026 at 11:33AM, a review of Resident #23's electronic and paper medical record revealed that the resident was admitted to the facility on [DATE]. Further review failed to reveal documentation of any routine or emergent dental visits.On 2/6/2026 at 2:35PM, during an interview conducted with Licensed Practical Nurse (LPN) #28, the Surveyor was informed that they do not recall the…

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

Based on observation and interview it was determined the facility failed to ensure food provided was palatable and at safe and appetizing temperature. This was evident for 1 food test tray provided by the facility during the surveyor's review of the kitchen task during the facility's recertification survey.The findings include:On 2/3/26 the surveyor conducted an interview of a facility Resident who requested to remain anonymous with regard to their concern. During the interview the Resident stated: The food is disgusting, it's sometimes cold, most of it is not that good.On 2/6/26 at 1:44PM the surveyor performed palatability testing of a meal tray provided by the facility at which time the mixed vegetables was tasted and found to be difficult to chew with hard pieces present, at which time the food was not swallowed due to the consistency present. Breaded fish was tasted and found to be too cool in temperature. The bread roll was served cold and was not appetizing due to the temperature. On 2/6/26 at 2:02PM the surveyor conducted an interview and shared concerns with the facility's…

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

Based on observation and interview, the facility failed to ensure oxygen equipment was properly dated and labeled in accordance with infection control standards (Resident #136) failed to store clean linen appropriately in accordance with infection control and prevention guidelines to prevent cross contamination. This was evident during observations during the annual survey.The Findings include: 1. During observation rounds on 2/2/2026 at 9:33 AM, Resident # 136 was observed receiving oxygen at 2 liters per minute via nasal cannula. The oxygen humidifier bottle was observed without a date indicating when it was initiated or last changed. The oxygen tubing was also observed without labeling to identify initiation date or change date. On 2/3/2026 at 10:00 AM, during follow-up observation and interview, the humidifier bottle was observed dated 1/28/2026. At that time, the oxygen was not running. During interview on 2/3/26 at 10:15AM nurse staff #13 stated he did not know who labeled the bottle and was not aware of who was responsible for labeling the resident's oxygen humidifier bottle.…

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 maintenance of the facility's dishwasher plumbing. This was evident upon the surveyor's initial tour and during subsequent observation of the facility's kitchen during review of the kitchen task during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility's kitchen on 2/2/26 at 8:13AM the surveyor conducted an interview with Certified Dietary Manager #11 who confirmed that the dishwasher was used and was used in hot water mode. At this time the surveyor requested for CDM #11 to perform a dual observation of the kitchen. On 2/2/26 at 8:14AM the surveyor observed the dishwashing area with multiple areas of pooling water present on the floor.On 2/2/26 at 8:15AM the surveyor observed the plumbing connecting to the facility's commercial conveyer dishwasher to be in severely eroded condition with white and brown flaky areas and powdery appearing areas. A layer of white and brown debris was observed on the top surface of the facility's dishwasher…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and homelike environment in good repair. This deficient practice was observed on 2 of 2 units reviewed (Promenade and Liberty Units) and in the laundry room during the annual recertification survey.The Findings include:1. Promenade UnitDuring observation rounds on 2/2/26 at 8:30 a.m., the following was observed:room [ROOM NUMBER]: The floor contained dried food and debris. The trash can was overflowing with spilled contents noted on the floor. A resident clothing bin was full. The room had a noticeable urine odor.room [ROOM NUMBER]: The floor contained multiple dried food particles and appeared sticky with a dried substance.Large chips of paint and wood were missing from resident doors on Unit 1.Shower Room: Several wet used washcloths were observed lying on the floor.Staff #16 accompanied the surveyor during the observations on the Promenade Unit and stated he…

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 review of pertinent document and interviews it was determined the facility staff failed to notify the resident's representative when there was a significant change in the resident's treatment plan. This was evident for 1 (Resident #14) of 24 residents reviewed for a complaint during the complaint survey.The findings include:Peripheral artery disease (PAD) is a condition where the arteries in the legs and arms become narrowed or blocked due to plaque buildup, reducing blood flow to these extremities.Angiogram-atherectomy-angioplasty-stent procedure uses angiogram (medical imaging procedure) to visualize blockages in leg arteries, then an atherectomy (removes plaque from arteries), an angioplasty (procedure to open blocked or narrow arteries) with a balloon to widen the artery, and finally a stent (metal tube inserted into the artery) to keep it open. This minimally invasive technique improves blood flow to the legs to relieve pain, heal wounds, and prevent amputation in patients with peripheral artery disease. On 9/10/25 at 1:00 PM a review of…

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

Based on review of facility investigative material and interview with residents and facility staff, it was determined that the facility failed to thoroughly investigate an injury sustained by a resident. This was evident for 1 (Resident #9) of 11 residents reviewed for a facility reported incident during the complaint survey.The findings include:The Resident Assessment Instrument (RAI) -Minimum Data Set (MDS), a comprehensive, standardized process used in nursing homes to identify residents' needs, strengths, and preferences to create individualized care plans.On 9/10/25 at 9:10 AM, a review of facility reported incident #299724 alleged Resident #9 sustained an injury during care. The alleged incident occurred on 3/15/25 at 6:15 AM. The facility's initial self-report documented the RN (registered nurse) supervisor reported that Resident #9 had bruising to the left eye. When Staff #16, GNA (geriatric nursing assisted) who provided care to Resident #9 was questioned about the injury, the GNA stated that the resident poked herself in the eye during personal care and the resident lacked…

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, review of pertinent documents and staff interviews, it was determined that the facility failed to ensure the discharge information was sufficiently documented in the medical record. This was evident for 1 (Resident #30) of 24 residents reviewed for a complaint during the complaint survey. The findings include:The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need.On 9/8/25 at 12:00 PM, a review of complaint #299668 alleged on 10/26/24, the facility staff were asked to send Resident #30 to the emergency room because the resident's sacral wound had gotten worse. The complainant alleged that when s/he asked the nurse to send the Resident #30 to the hospital, the nurse said s/he had to call…

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 facility staff roster and staff interview, it was determined that the facility failed to employ a qualified activities director from 10/2024 to 12/2024. This deficient practice was found during a complaint survey. The findings include: The surveyor reviewed intake # 299716 on 9/6/25 at 11:30am. The intake alleged that the facility failed to employ an activities director. The complainant stated that the last activities director left the facility in 10/2024. Interview with Activities Director #13 on 9/8/25 at 10:30am revealed that Activities Director #13 was hired in 12/2024. Interview with Unit Manager # 9 confirmed that the facility did not have an Activities Director in the month of 11/2024. On 9/10/25 at 10:06 AM, the surveyor interviewed the Administrator regarding the staff in the activities department. The Administrator stated that the activities department has a activities director that will transfer to the social services department on 9/27/25. A new activities director is expected to start on the same day. The surveyor informed the Administrator that the activities…

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 facility staff roster and staff interview, it was determined that the facility has a bed capacity of 160 and did not employ a qualified social worker from 4/2025 - 5/2025 and then again from 7/2025 to the present on a full-time basis. This deficient practice was found during a complaint survey. The findings include: Interview with the Regional Behavioral Analyst #10 on 9/8/25 at 12:50pm revealed that the facility's social work department does not have a current full-time qualified social worker. The last full-time qualified social worker left the position in 6/2025. Currently, Activities Director #13 assists with the social services tasks. Also, Regional Social Worker #11 supervises the social work tasks and assists as needed until a qualified full-time social worker director is hired. On 9/10/25 at 10:06 AM, the surveyor interviewed the Administrator regarding the staff in the social services department. The Administrator confirmed that the facility has not had a full-time qualified social worker since former social worker director #12 left in 6/2025. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation staff and resident interviews, it was determined that the facility failed to provide residents with an environment that promotes a dignified existence. This deficient practice was evidenced in 10 (Resident #2, #42, #48, #71, #76, #26, #85, #281, #34, #15 ) 21 resident's reviewed for dignity during the survey. The findings include: 1. On 09/16/24 at during observation rounds the surveyor observed Resident #42 in bed wearing a hospital gown. The surveyor observed clothes in a white trash bag on top of the resident's armoire and clothes were inside of the armoire. On 09/17/24 at 9:15 am the surveyor observed Resident #42 in bed wearing a hospital gown. On 09/18/24 at 2:46 pm the surveyor observed Resident #42 in bed wearing a hospital gown. On 09/18/24 at 2:51pm during an interview with LPN #16, the surveyor asked what the protocol was for getting residents dressed and out of bed (OOB) daily. LPN #16 verbalized some of the residents have physical therapy and they wait for therapy to come to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and residents' interview, it was determined the facility failed to provide safe clean homelike environment. This deficient practice was discovered on 5 units of 5 units observed during the survey. The findings include: 1. During a facility tour on 9/18/24 at 11am the laundry room was noted to have three laundry dryers with bath linens. The Laundry Aide staff #27 stated he was waiting for the linens to dry. When questioned about surplus of linen he stated there was not enough linens to send to every unit to meet the PAR (Periodic Automatic Replenishment) level. A par level is the minimum number of linens a floor and/ or facility should have on hand at any given time. On 9/18/24 at 11:30am, observation of the second-floor linen closet revealed there were no towels, washcloths, gowns or pillowcases. During interview with Resident #73 on 9/18/24 at 12:50pm, s/he stated there was not enough linen in the facility, the linen is removed from the bed washed and replaced. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of a facility reported incidents, review of medical records, and family and staff interviews, it was determined that the facility failed to report and submit facility related incident reports (FRI) to OHCQ related to injury of unknown origin, serious bodily injury, elopement, misappropriation of resident property and potential employee related abuse towards a resident within the required two-hour framework and failed to submit a follow up investigation report within 5 days. This was evident 9 (Resident #131, #133, #117, #78, #104, #89, #144, #145, #139) out of 38 facility reported incidents reviewed during the 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, serious bodily injury, and misappropriation of resident property are to be reported to the OHCQ in a timely manner (within 2 hours for the initial report 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 review of medical records and interview with facility staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of residents' admission to the facility and provide the resident and their representative with the baseline care plan. This was evident for 7 (#27, #104, #12, #48, #49, #54, #281) ) of 12 residents reviewed for baseline care plans during the annual survey. The findings include: A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the minimum healthcare information necessary to properly care for each resident. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission. 1. On 9/17/24 at 9:34 AM review of the medical record 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 observations, record reviews and interviews it was determine the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for the residents' highest practicable being. This was evident for 4 of 82 residents (Resident #27, #104, #61) reviewed during the survey. The findings include: 1. On 9/17/24 at 3:00 PM, in an interview with Resident #27's Power of Attorney (POA) he/she stated that they had requested Resident #27 have an evaluation to see if they could go from a pureed diet to a mechanical soft diet. Review of Resident #27's medical record on 9/17/24 at 3:10 PM revealed the resident had a Brief Interview for Mental Status (BIMS) of 5 out of 15, which indicated the resident had severe cognitive impairment. Further review of the medical record revealed the resident was diagnosed with dementia. On 9/19/24 at 1:40 PM in an interview with the Director of Rehabilitation #11 she stated that Resident #27 was referred to therapy for a swallow evaluation, but when the Speech Language Pathologist (SLP #33) attempted to do…

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, the facility failed to provide supervision to prevent a resident-to-resident altercations and to ensure residents were free of accident hazard devices. This was evident for 3 (Resident #72, #140, #34 ) of 6 resident's reviewed for supervision. The findings include: 1. On 9/16/24 at 02:51 PM, facility reported incident MD00203897 was reviewed. The facility reported a resident-to-resident interaction that happened on 3/21/2024. The report incident stated that Resident #72 wandered into Resident #46's room. Based on the incident detail, Resident #46 struck Resident #72 on the right cheek leaving a quarter size skin tear. On 9/18/24 at 4:27 PM, a review of Resident #72's progress notes was conducted. Review of Change of Condition Assessment note on 3/21/24 stated, [Resident #72] in wheelchair wandered to [Resident #46]'s room [ROOM NUMBER]A. [Resident #46] started yelling get out of my room and punched [Resident #72] on right side of cheek and obtained a superficial skin…

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 nurse practitioner failed to ensure physicians documented resident conditions and treatments accurately, write complete orders, address, sign & date pharmacy recommendations, and failed to ensure that physician progress notes were entered into the medical record. This deficient practice was evidenced in 4 (#56, #67, & #129, #139) of 8 resident records reviewed for physician care during the survey. The findings include: 1. On 09/24/24 at 8:45 am the surveyor reviewed Resident #56's pharmacy recommendations. The pharmacy reviews for May 2024 were not signed, June 2024 had an unreadable signature without a date, and July 2024 had a date that was scratched out. The recommendation dated 05/06/24 Fluoxetine HCL 20 mg capsule give one tab by mouth one time day for mood was to change the order so the indication was for depression. Review of the medication administration record (MAR) for May 2024, revealed there was no change on the MAR in May or June 2024. The pharmacy recommendation 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 a review of facility investigative material and interview with facility staff, it was determined that the facility failed to ensure that residents remained free of abuse. This was evident for 1 (Resident #151) out of 2 residents reviewed for abuse during the survey. The findings include: The facility's investigation related to facility reported incident MD00198074 was reviewed on 09/24/24 at 12:10 PM. The review revealed that the facility incident report indicated that on 10/03/23, a nurse that was assigned to the floor had made an allegation to the Director of Nursing of staff-to-resident abuse. The incident also stated that Geriatric Nursing Assistant (GNA) #60 was in the hallway collecting all the trays, and Resident #151 had a plate full of food. He/she was taking it down the hallway and the GNA #60 asked the resident, Can I have the plate please, and h/she ignored the GNA. GNA #60 repeated herself and grabbed the plate. Then, the resident took a handful of food and put it down GNA #60's shirt. The GNA said that it was her instinct to get the resident off her, so she…

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

Based on medical record review and interview with facility staff and resident family members, it was determined that the facility failed to maintain accurate Controlled Drug Receipt/Record/Disposition and an environment that was free of misappropriation of property. This was evident during the review of 2 of 8 (Resident # 101, #104) residents reviewed during the survey. The findings include: A controlled drug log is delivered with the controlled medication. The log is completed as the medication is administered and once the medication is completed the form goes into the resident's medical record. Each form is designated to the packet of medications that it was delivered with. On a controlled drug log, the date the medication is delivered, the resident name, medication, amount that is delivered, dosage, and administration orders are all noted at the top of the form. As medication is administered, staff are to document date/time, dose, amount wasted if applicable, administered by, and amount remaining. Once a medication has been administered in its entirety, staff need to reorder 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 facility administrative and medical records review and interviews, it was determined that the facility staff failed to complete thorough investigations of an alleged resident to resident abuse incident, injuries of unknown origin and failed to maintain and provide investigation documentation of a facility reported incidents reported to the state agency. This deficient practice was evidenced in 4 of 38 facility reported incidents for residents (#67, #131, #72, #89) reviewed during the survey. The findings include: 1. On 09/18/24 at 1:31 pm the surveyor requested to review the facility report for MD00208358 associated with Resident #67. The surveyor provided the resident's name and date the alleged incident occurred to Administrator #1. On 09/23/24 at the surveyor requested to view the investigation for the self-report again. On 09/26/24 1:32 pm Administrator #1verbalized not being able to find the investigation associated with the self-report. On 09/27/24 at 3:28 pm Administrator #1verbalized they had been filing the self- reports. An investigation would start immediately…

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 Minimum Data Set (MDS) Assessment documentation and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #124) of 61 residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. Each assessment must be encoded within seven days and transmitted within fourteen days of the assessment being performed. On 9/26/24 at 11:21 AM review of the medical record revealed Resident #124 was admitted to the facility on [DATE]. On 9/26/24 at 1:54 PM review of the Final Validation Report revealed Resident #124's MDS assessment was not transmitted until 5/3/24. Transmission occurred 37 days after completion of the resident's MDS assessment. On 9/26/24 at 2:11 PM in an interview with MDS…

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, interview with facility staff, and the resident RP (Responsible Party) it was revealed the facility staff failed to notify the physician in a timely manner of a resident (#135) change in condition. This occurred in 1 of 1 resident reviewed during the survey. The findings include: Review of the investigation of Facility Reported Incident MD00198432, on 9/16/24 at 10:00 AM revealed the following: On 10/7/23 at approximately 3AM Resident #135 complained of heartburn. The resident was assessed by the nurse #59 at least twice during the night shift (11pm-7am) to include review of pain. An antacid medication and pain medication was administered to Resident #135. Review of the medical record on 9/17/24 at 9am revealed at Approximately 5:30am nurse #59 received a call from Resident #135's daughter stating the resident called her complaining of abdominal pain, and if the facility intervention was not effective the resident should be transferred to the hospital. According to the medical record the physician was not contacted regarding the resident complaint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to complete a care plan for a resident who was receiving hospice care and a resident who was receiving oxygen therapy. This deficient practice was evident in 2 (#67 & #129) out of 7 medical records reviewed for care plan during the survey. The findings include: 1. On [DATE] at 9:26 am a review of Resident #67's electronic medical record (EMR) revealed the resident was receiving hospice care. Further review of the EMR revealed the resident did not have a care plan for hospice. Review of Resident #67's care plans revealed a care plan was initiated on [DATE] that indicated the resident was a Full Code. Review of Resident #67's MOLST form revealed the resident's code status was No CPR Option B Palliative & Supportive Care. On [DATE] at 11:48 am during an interview with Director of Nursing #2 the surveyor asked if Resident #67 should have a care plan for hospice care. DON #2 verbalized the resident should have a care plan for hospice…

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 have quarterly care plan meetings for a resident. This deficient practice was evident in 1(#42) of 3 records reviewed for care plan meetings during the survey. The finding include: On 09/18/24 2:10 pm a review of Resident #42 electronic medical record revealed there were no care plan meeting notes. On 09/19/24 at 9:08 am during an interview with Social Work Assistant #8, the surveyor asked when were care plan meetings held. SW Assistant #8 verbalized they receive a list the end of the month. They call the family and resident to let them know they have an upcoming meeting. The residents are made aware in person a week before the meeting or the morning of the meeting. Care plan meetings are held quarterly; new admissions within 48 hours, then quarterly however SW Assistant #8 revealed they had not been working at the facility for the past three quarters to schedule the quarterly meetings. On 09/19/24 at 2:03 pm during an interview with Social Work Director #9 who verbalized all department heads…

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 it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by not signing the narcotic form to verify the was completed during change of shift, failed to give resident report to the oncoming nurse, failed to report narcotics were taped in the blister packs, and administering oxygen therapy without a complete order. This was evident for 1 of 1 (Resident #67) reviewed for oxygen and 4 of 6 change-of-shift narcotic counts that were reviewed during the survey. The findings are: 1. On 09/23/24 at 9:45 am review of Resident #67's electronic medical record (EMR) revealed on 09/20/24 at 10:08 pm Nurse Practitioner ordered oxygen (02) nasal cannula (NC) as needed for shortness of breath (SOB). The order did not indicate how many liters of oxygen that should be administered. On 09/23/24 at 9:55 am the surveyor observed Resident #67 in bed with 2 liters (L) of 02 being administered by NC. On 09/23/24 at 10:09 am the surveyor asked LPN #26 to show the surveyor Resident #67's 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 observations, interviews, and record reviews, it was determined that facility staff fail to arrange medical transportation for a resident's follow up appointment. This deficient practice was evident for 1 (#281) of 1 resident reviewed for incontinence during the survey. The findings include: On 9/16/24 at 9:36 AM, during the surveyors initial screening of Resident #281, both the resident and a family member reported that the resident had a scheduled follow up appointment on 09/16/24 at 8:30 AM to have their urinary catheter removed. According to Resident #281, transportation was not arranged, and the resident missed the appointment. On 9/16/24 at 3:28 PM, review of Resident #281 treatment administration records failed to reveal urinary catheter treatments or care plan. On 09/19/24 at 2:57 PM, during an interview with the DON #2 regarding Resident #281's care plan for their indwelling catheter, the DON #2 admitted that she failed to create a baseline care plan because the resident was admitted to the facility without a qualifying urinary diagnosis. When asked 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 and interviews with facility staff it was determined the facility failed to ensure that the posted staffing schedule was updated and accurate. This was found to be evident when tours of the facility were conducted during the facility's survey. Findings include: The survey team conducted a tour of the facility on 9/23/24 at 2:15 AM, and observations were made of the Memory Unit located on the second floor. The assignment board which listed the staff assignments was dated 9/22/24 7:00 AM, and had staff #48 as the assigned nurse for the unit and staff #46 and #47 as the assigned GNA's. The nurse who was present and working on the unit was staff #31, and not staff #48. The GNA's who were present and working on the unit were staff #42 and staff # 46. GNA # 47 was not working. An interview was conducted with the nurse #31 on the same date at 2:18 AM and she was asked who was responsible for ensuring that the assignment board was accurate, and her immediate response was, I don't usually work here, I am an agency nurse. The nurse further acknowledged that she received…

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

Based on medical record review and interviews it was determined that the pharmacist failed to communicate timely the need to discontinue two unnecessary intranasal medications after the pharmacy review was completed in August and September 2024. This deficient practice was evidenced in 1 (#9) of 2 resident records reviewed for unnecessary medications during the survey. The findings include: On 09/19/24 at 11:28 am a review of Resident #9's medication administration record revealed on 06/16/24 at 12:54 AM an order was written for Flonase 1 spray each Nare one time a day for allergy and on 08/11/24 at 10:38 am an order for Flonase Allergy Relief Nasal Suspension 50 mcg/act 2 sprays in both nostrils one time a day for allergy was ordered which was a duplicate medication order. Further review of the electronic medical record (EMR) revealed both medications were being signed off as given by the nurses. On 09/19/24 at 2:56 pm the surveyor reviewed Resident #9's Electronic Medical Record (EMR) with Pharmacist #23, the surveyor asked why the resident had two different orders for Flonase.…

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 medical record reviews it was determined that facility staff failed to follow physician orders and fail to schedule dental appointments. This deficient practice was evident for 1 (#120) of 1 residents reviewed for pain during the survey. The finds include: On 09/17/2024 at 09:53 AM, during an interview with Resident #120, the surveyor asked if they have any pain concerns. Resident #120 reported tooth pain in their left upper and lower molars due to cracked teeth. The surveyor asked Resident #120 if they had gone to the dentist to address the cracked teeth, Resident #120 replied No. When ask why, Resident #120 stated they did not know the reason. During an interview with the Director of Nursing (DON) #2 on 09/17/24 at 10:01 AM, the surveyor inquired about Resident#120's cracked teeth and any scheduled dental appointments. The DON #2 responded that they would need to review the resident's chart to provide information. Following the surveyor's inquiry about Resident #120's cracked teeth and dental appointment, a new dental appointment order was placed 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 observations of the facility's kitchen and food services, it was determined that the facility failed to store food items to maintain the integrity of the specific item and accurately maintain dishwasher temperature logs. This was evident during the initial tour of the kitchen. The findings include: 1. On 9/16/24 at 7:57 AM initial observations were made in the facility's kitchen. Dietary [NAME] (DC #75) stated she was the staff in charge as the cook until the Dietary Manager (DM) comes in. After surveyor observations in the kitchen, freezer and refrigerator, observations with DC #75 revealed the following: At 8:12 AM, the walk-in refrigerator had ham covered very loosely with saran wrap open to air and undated. When asked about the expectations for food storage, she stated it was supposed to be in a Ziplock bag and dated. There were 2 logs of ground beef without an expiration date. When the surveyor asked DC #75 what the expiration date of the ground beef was, she stated, there is not one. The surveyor asked how staff would know if it were safe to serve to residents and she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility staff did not update the facility assessment to reflect how the facility with address all the needs of the residents. This deficient practice was discovered during the survey. The findings include: On 09/30/24 at 1:15 pm the surveyor reviewed the facility assessment and noticed the facility manager was not updated to reflect the current facility manager. The diagnoses that the facility staff can manage did not reflect the residents who were currently residing within the facility. The facility currently housed residents who receive wound care, and had compromised musculoskeletal system. There was no mention of the residents' acuity levels the facility was able to manage. The assessment did not mention how the ethnic, cultural, or religious factors of the current residents or potential residents are addressed or will be addressed. The staffing plan did not indicate how many nurses and geriatric nursing assistants are needed to care 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.

Based on a review of the facility investigation, medical record, interviews with facility staff and other pertinent documentation it was determined that the facility nursing staff failed to document the administration of medication and failed to have updated and accurate records of the residents' belongings in the medical record. This was true for 3 of 4 residents (Resident #135, #42, #111) reviewed during the survey. The findings include: 1. Review of the investigation of Facility Reported Incident MD00198432, on 9/16/24 at 10:00 AM revealed the following that on 10/7/23 at approximately 3am Resident #135 complained of heartburn. The resident was assessed by the nurse (staff #59) at least twice during the night shift (11pm-7am) to include review of pain. An antacid medication and pain medication was administered to Resident #135. Review of the medical record on 9/17/24 at 9am revealed at Approximately 5:30am staff #59 received a call from Resident #135's daughter stating the resident called her complaining of abdominal pain, and if the facility intervention was not effective 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 observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines linen management and for resident's residing in the facility. This was found to be evident for 1 (Resident # 15, #2) of 77 residents observed during observations made during the survey. The findings include: 1. During a random observation of the facility on 9/23/24 at 2:15AM the following observations were made while on the second floor. Room # 213 had two cover pads on the floor with a medium size dark brown substance protruding through the top of the cover pads. Flies were observed in the room [ROOM NUMBER] and landing onto the Resident (#15). Staff at the nursing station were made aware of the observations. The NHA was made aware of the findings on the same date at 5:30AM. All concerns were discussed with the Administration team at the time of exit on 9/30/24 at 4:30PM. 2. On 09/16/24 at 10:35 am the surveyor entered the elevator on the first floor and observed…

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 staff failed to keep the facility in good operating condition. This deficient practice discovered on the [NAME] Cove unit during the survey. The findings include: On 09/16/24 at 8:19 during observation rounds the surveyor checked the shared bathroom in room [ROOM NUMBER] and observed urine and excrement in the commode. The surveyor attempted to flush the commode, and the commode contents almost overflowed onto the floor. At 10:56 am the surveyor observed the trim below the window on the floor in the Dayroom located on [NAME] Cove unit. At 11:25 am the surveyor observed Resident #2 in bed exposed. Agency LPN #3 attempted to pull the privacy curtain over to cover the resident, but the curtain was unable to be fully extended. Afterwards the surveyor made Agency LPN #3 aware the commode in room [ROOM NUMBER] was clogged and unable to be flushed. On 09/16/24 at 12:12 pm the surveyor observed Regional Director of Operations #5 pushing the trim…

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 provide care which promoted the highest practicable well-being for residents, failed to obtain finger sticks as ordered by the physician for Resident (7) and failed to initiate aspiration precautions for Resident (#7) per recommendations, and failed to follow a resident's care plan and apply a splint (Resident #7, #26 and #106). This was evident for 3 of 57 residents selected for review during the annual survey process. The findings include: 1. During review of Resident #106's medical record on 10/18/19 revealed the Resident's chart contained a scrap piece of paper stating Family request colonscopy history of rectal cancer and because resident complains of rectal pain. The paper did not contain a staff name who wrote request, date or evidence the request had been reviewed by the physician. Review of the physician orders revealed no order for a colonscopy. Review of the nurses' notes for September and October 2019 revealed no notification to the physician of the family's concern. 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 medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Residents (#7) This was evident for 1 of 6 residents selected for unnecessary medication review during the annual survey process and 1 out of 57 residents selected for review during the annual survey. The findings include: Medical record review for Resident #7 revealed the Consultant pharmacist was in the facility on 5/7/19. At that time the pharmacist reviewed the medical record for Resident [NAME] and made the following recommendation: resident has a diagnosis of high blood pressure and receives a product containing pseudoephedrine (Alavert allergy and sinus) which may elevate the blood pressure. Alavert is a combination medicine used to treat sneezing, runny or stuffy nose, sinus pain, itchy or watery eyes or nose, and other symptoms of allergies and the common cold. Loratadine Pseudoephedrine is a combination of an antihistamine and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to provide dental services for a resident(Resident #55). This was evident for 1 out of 57 residents selected for review during the annual survey process. The findings include: Observation of the Resident #55 on 10/17/19 at 10:10 AM, revealed the Resident has multiple missing front upper and lower teeth. During interview with the Resident at that time, the Resident stated he/she has two broken back teeth and would like to be seen by a dentist. Review of the medical record revealed the Resident was admitted to the facility on [DATE]. On 5/9/19 the facility staff completed an Oral Health Evaluation of the Resident and documented abnormalities found and 1-3 decayed or broken teeth. Review of the Resident's care plans revealed a care plan initiated on 9/11/19 for Resident exhibits or is at risk for oral health or dental problems as evidenced by broken, loose and carious teeth. Further review of the Resident's medical record on 10/18/19…

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 staff failed to 1) maintain confidential information-HIPPA located in a medication cart computer, and 2) follow the Maryland State regulation regarding the facility providing a copy of a resident's MOLST to the guardian within 48 hours. The HIPPA violation was observed one time and the MOLST violation was evident for (Residents #43, #69) of 57 residents selected for review during the annual survey. The findings include: 1) The Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule is the first comprehensive Federal protection for the privacy of personal health. The HIPPA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health…

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 upon record review and staff interview it was determined that facility staff failed to ensure that the resident's medical record was accurate and complete (Resident #37, #40, #55, #61, #69 and #87). This was evident for 6 of 57 residents selected for review during the annual survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #37's medical record on 10/18/19 revealed the last documentation of a physician visit and progress note in the medical record was 8/28/19. After surveyor intervention, documentation of the physician visit and progress note for 9/18/19 and 10/13/19 was obtained and placed in the medical record for the Resident. Interview with the Director of Nursing on 10/18/19 at 10:40 AM confirmed the facility staff failed to maintain the medical record in the most complete…

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 a resident's health related information was protected (#159). This was true for 1 out of the 57 residents that make up the survey sample. The findings include: This surveyor was at the ground floor nursing station on 10/18/19 at 9:35 AM when a phone call was broadcast from the phone speaker. It was loud and clearly announced that it was regarding a medical appointment for Resident #159. Other residents' doors were open and could have overheard the message. The Administrator was interviewed on 10/22/19 at 8:35 AM and he said this would be addressed.

Based on reviews of a medical record review and staff interview, it was determined the facility staff failed to notify a resident's physician and family member of a significant weight loss. This was evident for 2 (Residents #89 and #101) of 2 residents reviewed for notification of changes during an annual recertification survey. The findings include: 1) Reviews of Resident #89's medical record on 10/18/19 revealed the following monthly weights: 07/05/19 - 153.4 pounds 06/03/19 - 178.1 pounds Between 06/03/2019 and 07/05/2019, Resident #89 lost 24.7 pounds (13.8%). Further review of Resident #89's nursing documentation failed to reveal Resident #89's physician and family member were immediately notified of the 13.8% weight loss. In an interview with the facility nutritionist, staff member #6 on 10/22/19 at 9:15 AM, staff member #6 stated that s/he became aware of Resident #89's, 07/05/19 weight loss on 07/11/19 and notified Resident #89's physician and family member at that time. 2) Reviews of Resident #101's medical record on 10/18/19 revealed the following monthly weights: 03/01/19…

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 thoroughly investigate the allegation of abuse for Residents (#262 and #263). This was evident for 2 of 3 residents selected for review of facility reported incidents of alleged abuse and 2 of 57 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse or misappropriation of property of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence will be investigated by the facility. This investigation includes interviews with all direct care giver staff for a least 1-2 days prior to the reported allegation. 1. The facility staff failed to thoroughly investigate an allegation of abuse for Resident #262. Surveyor investigation of facility reported incident: MD00128663 revealed Resident #262 made an allegation of abuse in June 2018. The resident alleged the incident took place in 2017; however, failed to report the allegation to the facility until 2018.…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #82) of 57 residents reviewed during an annual recertification survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Observations of Resident #82 seated in the dining area at 9:00 am on 10/16/18 did not reveal that the nursing staff had applied any type of restraint to prevent Resident #82 from rising out of his/her chair. Review of the medical record for Resident #82 on 10/16/19 revealed Resident #82 was coded for having a restraint being applied to prevent Resident #82 from…

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 initiate a care plan to address insomnia for Resident (#7). This was evident for 1 of 57 residents selected for review of care plans during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. The Long-Term Care Minimum Data Set (MDS) is a health status screening and assessment tool used for all residents of long-term care nursing facilities certified to participate in Medicare or Medicaid. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. Once 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.

Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #106). This is evident for 1 out of 57 residents selected for review during the annual survey process. The findings include: Review of Resident #106's medical record revealed on 7/12/19 the Resident was seen by the eye doctor. The physician's plan stated Please schedule an appointment for this patient to see an opthalmologist for further evaluation of glaucoma with elevated IOP (intraocular pressure). Left untreated, high eye pressure can cause glaucoma and permanent vision loss in some individuals. Further review of the Resident's medical record on 10/17/19 revealed the Resident had not been seen by an opthalmogist specialist. After surveyor intervention, an follow up appointment for an opthalmogist was scheduled. Interview with the Director of Nursing on 10/18/19 at 10:25 AM confirmed the surveyor's findings.

Based on medical record review and staff interviews, it was determined that the facility staff failed to initiate an AIMS test for a resident as recommended by the facility pharmacist and ordered by the resident's physician. This was evident for 1 (Resident #88) of 6 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: An AIMS (Abnormal Involuntary Movement Scale) test records the occurrence of tardive dyskinesia (TD) in residents receiving neuroleptic medications. The AIMS test is used to detect TD and to follow the severity of a resident's TD over time. Review of Resident #88's medical record revealed a monthly pharmacist consultation report, dated 04/03/19, that recommended the staff monitor Resident #88 for involuntary movements and requested the staff conduct an AIMS test every 6 months. The pharmacist rationale for the recommendation was because Resident #88 receives the medication Metoclopramide that carries a Boxed warning for tardive dyskinesia that residents may develop symptoms of tardive dyskinesia. Early detection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility failed to keep a resident free from unnecessary psychotropic medications (Resident #57). This was evident for 1 of 57 residents selected for review during the annual survey process. The findings include: Review of Resident #57's medical record revealed the Resident was admitted to the facility on [DATE]. Review of the Resident's diagnoses included: Dementia without Behavioral Disturbance, Altered Mental Status and Major Depression Disorder. Review of the physician's orders revealed an order on 10/7/19 for Risperdal 0.25mg at bedtime for psychosis. Risperdal is an atypical anti-psychotic used to treat symptoms of schizophrenia or Bipolar Disorder. Further review of the medical record revealed on 10/14/19 the Resident was seen by the Psychiatric Nurse Practitioner with a recommendation to discontinue the Risperdal. Review of the Resident's Medication Administration Record for October 2019 revealed the Resident received Risperdal 0.25mg 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 review, observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% for (Residents #84 and #259). This was evident for 2 out of 5 residents observed for medication pass and 4 errors out of 31 opportunities for error and a medication error rate of 5.71%. The findings include: The Five Rights of Medication Administration. One of the recommendations to reduce medication errors and harm is to use the five rights: the right patient, the right drug, the right dose, the right route, and the right time. 1. The facility staff failed to administer a medication to Resident #84 as ordered by the physician. Medical record review for Resident #84 revealed on 9/21/19 the physician ordered: Iron, 325 milligrams by mouth 3 times a day as a supplement. Ferrous sulfate is used to treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body). Observation of medication pass on 10/17/19 at 8:35 AM revealed facility staff #22 failed to administer the Iron to Resident #84 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 observation, it was determined the facility staff failed to properly store medications. This was observed once during an annual recertification survey. The findings include: 1. An observation was made on 10/17/19 at 10:38 AM on the second floor Liberty nursing unit. The surveyor observed an unattended and unlocked medication cart. The computerized pharmacy medication administration screen, used by the nursing staff to sign off medication administration, was also available for reviewing by residents and visitors. The medication cart holds medications for the resident's residing on the second floor Liberty nursing unit. No nursing staff members were attending the medication cart at the time of the observation. The facility assistant director of nursing (ADON) (staff member #15) came out of a resident's room and immediately locked the medication cart and minimized the pharmacy computer screen. The ADON acknowledged that staff nurse #17 should have locked the medication cart and minimized the pharmacy administration computer screen before leaving the medication cart. Cross…

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.