Future Care Cherrywood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to maintain accurate and complete records for residents. This deficient practice was evident for 2 (Residents #139 and #161) of 3 residents reviewed during the facility's recertification survey. The findings include: 1.) Medical record review on 9/29/25 at 10:10AM revealed Resident # 139 was admitted to the facility with the following but not limited to diagnosis: Dementia and had a fall on 7/10/25. Review of the fall investigation provided by the facility revealed the resident was found on the floor by GNA (#8) on 7/10/25 at approximately 8:30AM. Further review of the resident care plan for actual falls did not have documentation of the fall or interventions. The last update to the resident care plan was dated 10/7/21. During an interview with the DON on the same date at 10:40 AM, she was asked if the resident care plan was updated after the resident was found on the floor by the GNA (#8) on 7/10/25. The DON stated that when a…

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

Based on observation, interview, and record review, it was determined that the facility failed to implement infection prevention and control practices by not ensuring oxygen equipment was dated when placed into use and by not ensuring staff donned appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). This deficient practice was evident for 2 (Residents #70 and #17) of 30 residents reviewed for infection control practices during the facility's recertification survey.The findings include: 1.) On 9/24/25 at 8:33 AM, Resident #70 was observed with an oxygen setup. The humidifier bottle and oxygen tubing attached to the resident's oxygen concentrator were noted to be in use but were not dated. At that time, Surveyor located Staff #3, who was identified as responsible for the care of Resident #70. Staff #3 confirmed the humidifier bottle and tubing were in use and acknowledged that they were not dated as required. Staff #3 then obtained a new humidifier bottle and oxygen tubing, placed them on the resident's concentrator,…

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

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold/document care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan, and 2) revise residents' care plan based on their health status. This was evident for 8 (#18, #29, #40, #44, #49, #67, #111, and #115) of 10 residents reviewed for care plan meetings during the annual survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1a) During a review of Resident…

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

Based on observation, interview, and record review, it was determined that the facility failed to adhere to professional standards for food service safety. This was evidenced by the facility's failure to: 1) seal, label, and properly store food, 2) maintain proper function of the walk-in freezer, 3) monitor refrigerator temperatures, 4) monitor food temperatures, and 5) ensure the removal of expired food supplements. This was evident in the facility kitchen and 2 of 3 unit nourishment rooms observed during the survey. This had the potential to affect all residents. The findings include: 1) On 5/18/23 at 08:15 AM a tour of the facility's walk in refrigerator in the kitchen was conducted. There were 2 drink cups on the refrigerator shelf with amber liquid, one covered with a lid, one uncovered. There was no identification of the contents or date for either of the cups. On another shelf there was a 5 pound bag of part skim shredded mozzarella cheese that was approximately 25% full, that was gaping open. There were 2 cardboard boxes on the floor containing food. One was labeled and…

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

Based on observation, record review and interview, it was determined that the facility failed to develop and implement appropriate, comprehensive, person centered care plans. The care plan was not developed for 3 (Residents #18, #53, and #356), or implemented for 2 (Resident #18 and #67) of 11 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A contracture is a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. 1a) Investigation of self-reported incident MD00189698 was conducted on 5/30/23 at 10:00 AM. The incident was regarding Resident #53 who was noted to have two areas of purple discoloration on the right forearm dated 03/03/23. Further review of Resident #53's medical record revealed a diagnosis of vascular dementia, schizoaffective disorder, and deep vein thrombosis. Also, it showed that Resident #53 had taken anticoagulants 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a clinical record and a facility reported incident (FRI), review of the facility investigation, and interviews with the resident and staff, it was determined that the facility staff failed to treat residents with dignity and respect by not assisting a resident with toileting when requested. This was evident for 1 (Resident #50) of 24 residents reviewed for abuse during the survey. The findings include: Review of facility reported incident MD00190945 on 05/23/23 revealed an allegation that GNA #29 told Resident #50 that S/he could not use the bedpan immediately on 04/05/23. A review of the facility Resident Right's and Services policy on 06/05/23 at 10 AM, revealed section C -2 which indicated the resident has the right to receive treatment, care and services that are in an environment that promotes maintenance or enhancement of each resident's quality of life. Section C - 3 indicates a resident has the right to have a dignified existence, self-determination, and communication with access 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 and interviews with the facility staff and resident, it was determined the facility failed to ensure that a resident who chooses to go to the 1st floor to eat lunch in the main dining room and attend activities like bingo and music is aided to get prepared and transferred out of bed to a wheelchair for escort assistance. This was evident for 1 (#127) of 4 residents investigated for activities during a Medicare/Medicaid survey. The findings include: An interview was conducted with resident #127 on 5/18/23 at 10:37 AM. The resident was asked if he/she attends activities. Resident #127 pointed to a sign posted on the wall Please take downstairs for lunch, music and bingo. Review of resident #127's medical record on 5/23/23 revealed the resident was admitted to the facility on [DATE]. Review of the admission activity assessment dated [DATE] indicated that resident #127 presented with the activity potential to plan his/her own day but requires invitation, motivation, and encouragement needing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to 1) ensure the resident/responsible party was provided information in a manner easily understood by the resident or resident representative to formulate an advanced directive and offered the opportunity to develop an advanced directive, and 2) document/file the resident's advanced directive on their medical record. This was evident for 2 (Resident #40 and #111) of 10 sampled residents for advanced directives, and one resident ( #44) of 10 residents' advanced directive reviewed during the annual survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they can no longer make decisions for themselves because of illness…

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

Based on observation, interviews, and reviews of the facility administrative records, it was determined that facility staff failed to promote care for a resident in an environment that maintains or enhances each resident's dignity and privacy. This was evident for 2 (Resident #6, #259) of 2 residents observed during the annual recertification survey. The findings include: 1) The observation was made on 5/18/23 at 3:00 PM of Resident #6 lying in bed in his/her room with three beds and staying with one other resident. Resident #6's bed faced the window, so the resident's foot showed at the room door side. At 3:04 PM on 5/18/23, an X-ray technician (Staff #41) entered the room and prepared an X-ray for Resident #6. The surveyor came out of the room and observed staff #41's care from the hallway. The surveyor observed Resident #6 was shouting help, help without any procedure being performed. At 3:07 PM on 5/18/23, a Licensed Practical Nurse (LPN #42) entered the room to help the resident. The surveyor observed Resident #6's room was widely opened, and a privacy curtain was not applied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to ensure that resident care areas were in good repair. This was evident for 3 of 33 resident rooms located on the first floor, and 1 of 3 unit nourishment rooms. The findings include: On 05/18/23 at 11:08 AM, an observation of Resident #67's room was conducted. The privacy curtain had a hole at the top of the curtain in the netted area, which was approximately 4-5 inches in diameter. There was also a loose, displaced floor tile in the resident's bathroom next to the toilet. On 05/22/23 at 09:23 AM, an interview with Resident #18 was conducted. The resident stated that cleanliness in the room and bathroom has been an issue, but only recently. On 05/22/23 at 11:11 AM, an observation of Resident #18's bathroom was conducted. There was damaged drywall with deep scrapes on the wall next to the toilet. The drywall was puckered, and there was a hole in the drywall at the level of the cove molding, an area of approximately 8-10 inches long, 4 inches wide. On the back wall, behind the toilet, the flange where 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, review of a medical record, and staff interview, it was determined the facility staff failed to obtain a physician's order to use a restraint on a resident. This was evident for 1 (Resident #117) of 2 residents reviewed for physical restraints during an annual recertification survey. The findings include: During an observation of the unit 3 on 05/19/23 at 11:09 AM, Resident #117 was observed in her room, seated in a wheelchair, with a lap seat belt across his/her lower abdomen. In an brief interview with Resident #117, Resident #117 was unable to answer any questions or unlock/remove the seatbelt when asked. In an interview with Staff Member #34 on 05/19/23 at 11:10 AM, Staff Member #34 stated that Resident #117 is unable to remove a connected seatbelt. Staff Member #34 stated that Resident #117 is currently using a rental wheelchair and that Resident #117 does not need a seatbelt while seated in the wheelchair. Staff #117 stated that a staff member must have hooked the seatbelt. In an interview with GNA #37 on 05/19/23 at 2:23 PM, GNA #37 stated that S/he was…

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

Based on reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that 2 GNA staff members failed to immediately notify administrative staff when they observed bruising to a resident's left hand. This was evident for 2 (GNA's #35, #38) of 2 GNA's reviewed for abuse during an annual recertification survey. The findings include: Review of facility reported incident (FRI) MD00183120 on 05/25/23 revealed an allegation of an injury of unknown source. Resident #359 was observed on 09/05/22 with edema, bruising, and discoloration to the left 4th and 5th fingers. The injury extended into the knuckle and lateral aspect of the left hand. Resident #359 suffers from cognitive impairment and was unable to tell staff what had happened. The facility initiated an abuse investigation at this time. Resident #359's physician was notified, and orders were obtained for pain medication and an X-ray of the left hand/fingers. The X-ray showed that Resident #359 showed a proximal fifth finger fracture with minimal displacement. Further review of the…

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

Based on staff interviews and a review of the facility's self-report investigations, it was determined that the facility failed to thoroughly investigate alleged violations and employee-to-resident abuse. This was evident for 2 (Resident #6 and #18) of 22 facility reported incidents of abuse allegations investigated during the annual survey. The findings include: 1) On 5/22/23 at 10:26 AM, a review of facility-reported incident MD00188046 revealed that a Geriatric Nurse Aide (GNA #8) observed a Licensed Practical Nurse (LPN #20) slap Resident #6 on 1/13/23. Further review of the facility follow-up self-report dated 1/13/23 stated that LPN #20 stated that the resident swung his/her arm at LPN #20's face and knocked her shield off. LPN #20 stated that when the resident did that, LPN #20 put her arm up to block the resident from hitting her in the face. The surveyor reviewed the facility's investigation on 5/22/23 at 1:00 PM. The review revealed that the Director of Nursing (DON) interviewed with GNA #8 and LPN #20. The facility incident investigation form stated that three 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 a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the bases leading up to a transfer of a resident to the hospital in the medical record including an accurate reason for the transfer. This was evident for 1 (Resident #349) of 5 residents reviewed for hospitalization. The findings include: On 6/5/23 complaint intake, MD00169068 was reviewed related to resident #349. Based on a review of the complaint intake the resident passed on 7/8/21. A review of resident #349's closed medical record on 6/5/23 at 9:00 AM revealed that the resident was transferred out of the facility to a hospital on 6/8/21 and transferred back to the facility on 6/17/21. A review of the medical record did not reveal a change in condition assessment which would have described the resident's condition, and what interventions were performed for the resident, prior to EMS notification and transfer out of the facility. The Hospital Transfer Form dated 6/8/21 was the only document that indicated the resident's transfer to the…

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

Based on medical record review and interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1(#142) of 5 residents reviewed for hospitalization during the annual survey. The findings include: A review of Resident #142's closed medical record on 5/10/23 at 1:02 PM revealed the resident was transferred to the hospital on 4/11/23 due to a change in medical condition. The eINTERACT change of condition note that documented Resident #142 was transferred to the hospital indicated that the resident's family was updated, however, there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer. On 5/22/23 at 3:24 AM the DON was asked if there was any documentation to show, who was notified in writing of the facility-initiated transfer of the resident to the hospital on 4/11/23 and a copy of the written notification. The DON indicated that notifications were done by phone and that…

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

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#73 and #349) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) Review of resident #73's medical record on 5/23/23 revealed resident #73 was transferred to a hospital due to abnormal blood work on 2/16/23 at 12:45 PM. The Hospital transfer form and SBAR Communication Form (situation, background, assessment, and recommendation) were written by a registered nurse (staff # 46). A review of both documents did not reveal that resident #73 was informed of the facility-initiated transfer and what was done to prepare the resident for transfer to the hospital. On 05/26/23 at 2:43 PM, staff #46 was interviewed as he was sitting at a computer to look up and review his documentation regarding the transfer of resident #73 to the hospital on 2/16/23. The registered nurse was unaware of the protocol to document the orientation and preparation of…

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

Based on medical record review and interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#142) of 5 residents reviewed for hospitalization during the annual survey. Findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 5/10/23 at 1:02 PM, a review of Resident #142's closed medical record revealed Resident #142 was transferred to the hospital on 4/11/23 for a change in medical condition. Further review of Resident #142's closed medical record documentation revealed the responsible party was notified, however, there was no written documentation that the resident or their responsible party was given a copy of the bed hold policy. On 5/22/23 at 3:24 PM, the Director of Nursing (DON) was asked about the notification process. She stated that it was done verbally by phone and that a written…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to accurately complete a resident's Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #67) of 2 residents reviewed for position and mobility, and 1 (Resident #97) of 3 residents reviewed for misappropriation of property during this annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated process for clinical assessment of residents in Medicare and Medicaid certified nursing homes. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The Assessment Reference Date (ARD) is the date the assessment is due to be completed and includes a 7-day look back period for assessment details of the resident. A contracture is a permanent tightening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan. This was evident for 1 (Resident #67) of 5 residents reviewed for baseline care plan. The findings include: 05/19/23 at 10:56 AM Resident #67 was interviewed and said that he/she did not remember being invited to or attending any care plan meetings or receiving any written care plan documents. Resident #67 also stated that he/she did not know if his/her spouse attended care plan meetings. On 05/25/23 at 11:47 AM, a record review revealed that the resident was readmitted to the facility on [DATE] and a baseline care plan was created on 4/27/23. Review of a printed copy of the baseline care plan provided by the facility revealed that the baseline care plan for Resident #67 had a blank signature line. On 5/24/23 at 1:30 PM, an interview with Unit Manager (Staff #18) was conducted. When asked about the facility ' s process for the baseline care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint, reviews of active and closed records, and staff interviews, it was determined that the facility staff failed to administer eye medications to a resident as prescribed by the resident's physician. This was evident for 1 (Resident #352) of 13 residents reviewed for quality of care during an annual recertification survey. The findings include: A review of complaint MD00180778 on 05/31/23 revealed an allegation Resident #352 did not receive his/her eye medications as instructed by the physician. A review of Resident #352's closed medical record on 05/31/23 revealed that Resident #352 had been admitted to the facility on [DATE] with diagnoses that include a history of a torn retina, retina detachment, and glaucoma. Resident was seen by an ophthalmologist on 06/22/22. Resident #352 was given 2 prescriptions for eye drops at that time. The first eye medication order was for MURO 128, 5 %, place one drop into the right eye four times a day. The second eye medication order was for Durezol, 0.05%,…

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

Based on observation and interviews it was determined that the facility failed to ensure that the resident's environment remained free of accident hazards. This was evident for 1 of 3 unit nourishment areas observed. The findings include: On 6/5/23 at 12:25 PM, a tour of the nourishment rooms was conducted. In the Unit #1 nourishment room, a partially full, 32 ounce bottle of One Shot drain cleaner was found on the counter next to the microwave oven. There was no lock on the door. On 6/5/23 at 12:25 PM, the Corporate Director of Nursing (Staff #25), who was on the unit, was shown the bottle of One Shot drain cleaner on the counter. She immediately removed the bottle. When asked if there were any wandering residents who may have access to the unlocked nourishment room, she stated that there was one resident on the unit who wanders but that resident was under a one to one observation. On 6/6/23 at 11:10 AM in an interview with the Corporate Nurse (Staff #23), he stated that locks had been placed on all of the nourishment room doors.

Based on a complaint, reviews of a medical record, and staff interviews, it was determined that the facility staff failed to 1) ensure follow-up with the pain doctor and 2) ensure documenting pain assessment evidenced by no pain assessment recorded for a resident whose pain noted by a geriatric nurse aide. This was evident for 2 (Resident #44 and #356) of 5 residents reviewed for pain management during the annual survey. The findings include: 1) During an interview with Resident #44 on 05/18/23 at 11:40 AM, the resident stated that he/she had chronic knee, ankle, shoulder, and left-side pain. He/she also explained his/her routine pain medications were working, but the facility did not arrange a follow-up pain doctor's appointment. A review of Resident #44's medical record on 05/24/23 at 2:42 PM revealed that the resident was admitted to the facility in December 2021 with a past medical history that included, but was not limited to, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, embolism, and thrombosis of deep vein of the right upper extremity. Further 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 medical record review and staff interview it was determined the physician's progress notes were not in the resident medical records the day the resident was seen. This was evident for 1 (#73) of 5 residents reviewed for hospitalization during the annual survey. The findings include: On 5/23/23 at 8:04 AM a record review was done for Resident #73. Review of resident #73's attending physician (staff #41) notes revealed multiple progress encounter notes that were created a few days after resident #73 was seen. An encounter note with an Effective Date (Date of Service) of 2/22/23 was created and signed by the physician on 2/28/23. An encounter note with an Effective Date of 3/24/23 was created and signed by the physician on 3/28/23. An encounter note with an Effective Date of 5/12/23 was created and signed by the physician on 5/17/23. Copies of the sample notes were requested on 5/26/23 and reviewed with the nursing home administrator and the director of nursing at 4 PM on 5/26/23. The director of nursing acknowledged the notes were not done on the day of the visit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint and reviews of a closed clinical record, it was determined the facility failed to timely provide a medication to meet the needs of a resident. This was evident for 1 (Resident #355) of 14 complaints reviewed during a recertification survey. The findings include: A review of complaint MD00170436 on 06/05/23 revealed an allegation Resident #355 was not provided with quality care. Resident #355 was admitted to the facility on [DATE] with diagnoses that include but are not limited to prostate cancer and testicular hypofunction. A review of Resident #355's closed medical record on 06/05/23 revealed a physician order, dated 07/08/21, instructing the nursing staff to apply an Androderm 2 MG/24 HR, transdermal patch, one time every other day for hypogonadism. A review of Resident #355's July 2021 medication administration record (MAR) on 06/05/23, revealed that the nursing staff was unable to administer Resident #355's medicated patch from 07/09/21 thru 07/25/21 due to that patch not being delivered…

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

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow the physician-ordered blood pressure parameters for administration. This was evident for 1 (#29) of 6 residents reviewed for unnecessary drugs during the annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). On 5/24/23 at 10:21 AM a review was conducted of Resident #29's medical record. A review of the November 2022 physician's orders revealed an order for Losartan 50 mg a medication used to treat blood pressure. Give 1 tablet by mouth one time a day related to Essential Hypertension. The order stated to hold for Systolic Blood pressure (SBP) less than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, and reviews of administrative records, it was determined that facility staff failed to keep medication carts locked when unattended, and keep medications labeled/in their packaging. This was evident for 1 of 3 nursing units observed during the annual recertification survey. The findings include: During an observation of the first-floor nursing unit on 06/02/23 at 9:58 AM, the nurse surveyor observed an unlocked and unattended medication cart (Unit 1 cart C) outside in the hall by room [ROOM NUMBER]. LPN #42 Came out of the room and acknowledged that S/he failed to lock the medication cart before entering room [ROOM NUMBER] to pass medications to a resident. During an observation of medication cart for Unit 1, cart C on 06/02/23 at 10:25 AM, the surveyor observed a medication cup with pills (5 pills) in the top drawer of the medication cart. The pills were not in their original packaging, nor could they be identified. LPN #42 Stated that these pills were for another…

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

Based on medical record review and interview it was determined that facility staff failed to follow up on dental care. This was evident for 1 (resident #44) of 2 residents reviewed for dental during the annual survey. The findings include: On 5/26/22 at 10:00 AM the surveyor had an interview with Resident #44. During the interview the resident stated s/he needed to follow up with dentist regarding oral surgery which was not arranged. Further review of Resident #44's medical record revealed that the resident was seen by a dentist on 9/29/22 for referral oral surgery for extracting teeth. However, no follow-up schedule was arranged. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 5/31/23 at 8:55 AM. The NHA stated that Resident #44 had a consultation with an outside dentist and the resident refused surgery at that time. However, there was no documentation regarding Resident #44's refusal.

Based on record review and staff interviews, it was determined that the facility failed to maintain medical records that are complete and accurately documented. This was evident for 1 (Resident #67) of 5 residents reviewed for pressure ulcers. The findings include: Pressure ulcers (commonly called bedsores) are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. Bedsores can develop over hours or days. Most sores heal with treatment, but some never heal completely. Pressure ulcers are categorized by their stage (1-4, or unstageable) which indicates their depth. Assessment also includes, but is not limited to, the location on the body, the size, any observed evidence of healing or worsening, and whether or not it was present on admission. On 05/30/23 at 12:42 PM in an interview with the DON, Staff #3, the DON stated that Resident # 67's left medial knee pressure ulcer resolved on 4/20/23, reopened 5/7/23, and the resident was seen 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 reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that the facility failed to confirm, and agency geriatric nursing assistant (GNA) had received abuse education prior to allowing the agency GNA to work with residents. This was evident for 1 (staff #35) of 2 GNA's reviewed for abuse education during an annual recertification survey. The findings include: Review of facility reported incident (FRI) MD00183120 on 05/25/23 revealed an allegation of an injury of unknown source. Resident #359 was observed on 09/05/22 with edema, bruising, and discoloration to the left 4th and 5th fingers. The injury extended into the knuckle and lateral aspect of the left hand. Resident #359 suffers from cognitive impairment and was unable to tell staff what had happened. The facility initiated an abuse investigation at this time. Resident #359's physician was notified, and orders were obtained for pain medication and an X-ray of the left hand/fingers. The X-ray showed that Resident #359 showed a proximal fifth finger fracture with…

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

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1. assess medication usage and 2. assess the resident's skin condition. This was found to be evident for 1 out of 8 residents (Resident #46) reviewed for pressure ulcers and 1 out 7 residents (Resident #42) reviewed for unnecessary medication during the investigative stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. On 1/28/19 Resident #42's medical records revealed an MDS with an assessment reference date (ARD) 11/3/18 which documented that the resident had not received any psychotropic medication during the 7 day look back. Review of the medical records reveals an order for…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to develop a care plan related to a resident's activities preference/needs. This was evident for 1 out of 5 residents (Resident #122) reviewed for activities. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1. Observation of Resident #122 on 1/17/19 at 9:06 AM, 11:31 AM and 1:32 PM, in the same position with the television on in the room. The assigned GNA (Staff #43) had entered the room at 11:31 AM and stated that she was in there to change his/her position. When Resident #122 was observed again at 1:32 PM s/he was in the same position in bed with the television on. There was no other noted interaction occurring with the resident. The room was noted as dark on all observations that day. Review of the medical record on 1/23/19 for Resident #122…

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

Based on medical record review and interview with staff it was determined that the facility failed to have effective systems in place to ensure residents and or responsible parties were included in the development and review of a resident's care plan (Resident #56); and the facility failed to revise care plans related to a residents transition to long term care (Resident #56); significant weight loss (Resident #127 and #122); activity preferences (Resident #131); development of a rash (#108); and a series of falls (Resident #115). This was found to be evident for 6 out of 38 residents reviewed during the investigative portion of the survey. The findings include: Minimum Data Set (MDS) is a standardized assessment tool used to assist with planning residents' care. 1) On 1/24/19 review of Resident #56's medical record revealed a diagnosis of dementia. A Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/25/18 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11 out of 15 indicating mild cognitive impairment. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and observation it was determined that the facility failed to: have an effective system in place to ensure restorative nursing services were put in place after a resident was discharged from therapy (Resident #87 and #122); and to provide adequate assistance to the resident for nutritional intake while providing independence (Resident #57). This was found to be evident for 2 out of 2 residents reviewed for Rehab and Restorative services and 1 out of 4 meal observations. The findings include: 1) On 1/23/19 review of Resident #87's medical record revealed the resident had resided at the facility for several years and had a current care plan for: Restorative Therapy to improve functional ability. This care plan was initiated on 9/27/18 and included the following: Ambulate 80 feet with rolling walker with contact guard by Restorative Aide; Participate in program two times a week. Review of the Physical Therapy Discharge Summary, signed 8/3/18, revealed the following…

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

Based on medical record review, observation and interview with facility staff it was determined that the facility failed to provide activities for an individual based on their assessment. This was evident for 3 of 5 residents reviewed for activities (Resident #122, #131 and #41). The findings include: 1) Observation of Resident #122 was observed on 1/17/19 at 9:06 AM, 11:31 AM and 1:32 PM, in the same position with the television on. The assigned GNA Staff #43 had entered the room at 11:31 AM and stated that she was in there to change his/her position. When Resident #122 was observed again at 1:32 PM s/he was in the same position in bed with the television on. There was no other noted interaction occurring with the resident. The room was noted as dark on all observations that day. Review of the medical record on 1/23/19 for Resident #122 revealed diagnosis including history of multiple strokes with subsequent resuscitation. The residents assessed Brief Interview for Mental Status (BIMS) was not completed as the resident was unable to participate in the assessment. Brief 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.

Based on observation and interview with facility staff, it was determined that the facility staff failed to promote dignity for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect by failing to provide privacy for the resident who needed to use a bedside commode. This was found to be true for 1 (Resident #100) out of 1 resident reviewed for dignity. The findings include: During the initial interview and tour on 01/17/19 at 02:35 PM upon entering Resident #100's room the bedside commode was noted to be in the middle of the floor. During an interview with the resident he/she revealed that the bedside commode was in a bad place and that it does not provide privacy from the other roommates nor does it provide privacy from any one else entering the room. The resident also reported that it had been this way since he/she moved to the room. The resident further reported that the facility had not done anything to provide privacy. During a tour of the resident's room with the Director of Nursing (DON) and maintenance on 1/28/19 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.

Based on observation, interview with the resident and facility staff it was determined that the facility failed to accommodate the toileting needs of the resident by not accommodating the wheelchair size used by a resident. This was true for 1 out of 4 residents (Resident #100) reviewed for activities of daily living in the investigative stage of the survey. The findings include: During observation and interview with the Resident #100 on 1/17/19 the surveyor observed the resident sitting in a large wheelchair and a bedside commode placed in the middle of the room. Further observation revealed that the other resident in the room had to walk past the bedside commode to exit the room. During an interview with Resident #100 on 1/23/19 the resident revealed that he/she was not satisfied with the location of the bedside commode, and that he/she was unable to go into the bathroom due to the size of the door frame. The resident also verbalized that there was no privacy. The surveyor, Director of Nursing (DON) and maintenance toured the resident's room on 1/28/19. They acknowledge that the…

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

Based on medical record review and interview with staff, it was determined that the facility failed to document and provide showers according to a resident's preference. This was found to be evident for 1 out of 4 residents (Resident #131) reviewed for activities of daily living. The findings include: An attempt to interview Resident #131 occurred on 1/17/19 at 9:06 AM. Resident #131 was able to answer general questions but not the screening questions to complete a resident interview. During an interview on 1/24/19 at 12:50 PM a family member to Resident #131 complained that Resident #131 was not getting regular showers according to his/her preferences. A review of the resident's medical record on 1/18/19 at 10:11 AM confirmed that the resident had a Brief Interview for Mental Status score of 5 showing that s/he had severely impaired cognition. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. Surveyor re-attempted to meet with resident on multiple occasions, however s/he was either in the process of having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to notify a resident's representative (RP) regarding 1. weight loss and 2. when the residents gastrostomy tube was dislodged. This was evident during the review of 1 of 12 residents (Resident #122) reviewed for nutrition. The findings include: 1A. Review of the medical record on 1/17/19 at 3:08 PM for Resident #122 revealed diagnosis including history of multiple strokes with subsequent resuscitation. Further review revealed Resident #122 had a significant weight loss according to an einteract change in condition evaluation of 7.5% from admission on [DATE] until 1/14/19. The resident's weight went from 232 lbs.(pounds) to 200.8 lbs. Further review revealed a weight loss between 10/24-10/29/18 from 232 lbs. to 220 lbs. and on 11/5/18 the resident's weight was noted at 208 lbs. an additional 12 lbs. weight loss for a total of 24 lbs. in 12 days. Further review of the medical record failed to reveal in the…

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

Based on medical record review and interview with the facility staff, it was determined that the facility failed to provide adequate notification and detailed notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment. This was evident in 2 of 3 residents (Resident #148 and #144) reviewed during beneficiary protection notification. The findings include: Advance Beneficiary Notice (ABN) is a written notice from Medicare, given to residents before receiving certain items or services notifying you that Medicare may deny payment for that specific procedure or treatment. The ABN gives you information to make an informed choice about whether to get items or services, understanding that you may have to accept responsibility for payment. The ABN notices should be given out with the Notice of Non-Medicare Coverage. 1. On 1/28/19 Resident #148 Beneficiary Protection and Notification task was conducted. This review revealed that the last covered day for Skilled Rehabilitation/Nursing was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and other pertinent documentation and interviews it was determined that the facility 1) failed to ensure allegations of abuse were thoroughly investigated by facility staff as evidenced by failure to document a statement from one of three identified eye witnesses. This was found to be evident for 1 out of 7 residents (Resident #41) reviewed for abuse during the survey. The findings include: On 1/18/19 review of Resident #41's medical record revealed a Minimum Data Set assessment dated [DATE] that assessed the resident as totally dependent on staff for activities of daily living. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps in the planning of care. Further review of the medical record revealed Resident #41 has a court appointed guardian of person due to lacking sufficient understanding or capacity to make or…

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

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to follow the standard of nursing practice in regard to care of a gastrostomy tube. This was evident in the review of 1 of 5 residents for hospitalization. (Resident #122). The findings include: 1. Review of the medical record for Resident #122 on 1/17/19 at 3:08 PM revealed diagnosis including a history of stroke and cardiopulmonary arrest on gastrostomy tube (gtube) feedings unable to take in any nutrition orally. Further review of the medical record for Resident #122 revealed that on 11/2/18 and 11/4/18 Resident #122 pulled out his/her gastrostomy tube. The gastrostomy tube was reinserted by the staff on duty. According to the nursing notes on 11/2/18, Nurse #44 documented that the resident pulled out his/her gastrostomy tube and an 18 French (fr.) catheter was replaced. On 11/4/18 the same nurse (#44) documented that the resident pulled out his/her gastrostomy tube and documented that a gastrostomy tube was immediately replaced. Review of the facility policy on…

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

Based on record review, observations and interviews it was determined that the facility failed to identify environmental hazards and/or assess individual resident risks of an accident, including the need for supervision and/or assistive devices for Resident #115. This was evident for 1 out of 1 investigated for accidents during the survey process. The findings include: On 1/17/19 at 9:38 AM during observation of Resident #115 it was noted that the Resident's wheelchair was across the room out of reach. On interview at the same time, the Resident expressed fear of falling again because he/she could not reach it and it took a long time for someone to come help. A record review conducted on 1/18/19 at 2:49 PM revealed that Resident #115 had 4 falls between 12/24/18 and 1/4/19. An interview was conducted on 1/23/19 at 10:00 AM with Nurse #37. When the surveyor asked the staff member if he/she was aware that Resident #115 had multiple falls he/she answered, yes. When asked what interventions had been put into place to ensure the safety of the Resident and to avoid future falls, the 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 with facility staff, it was determined that the facility failed to identify and modify a residents' diet regimen when a significant weight loss occurred. This was evident during the review of 2 of 10 residents reviewed for nutrition. (Resident #122 and #127) The findings include: 1. Review of the medical record for Resident #122 on 1/17/19 at 3:08 PM revealed diagnosis including a history of stroke and cardiopulmonary arrest, on gastrostomy tube feedings unable to take in any nutrition orally. Review of the dietary admission assessments completed on 10/24/18 revealed that the dietitian noted that the resident was 'obese and unkempt.' The dietitian further documented that gradual weight loss would not be undesired r/t (related to) obese weight status. The resident was weighed on 10/29/18 and was noted to weigh 220 lbs. a 12 lb. weight loss in 5 days for a resident on tube feeding, a 5.6% weight loss. On 11/1/18 a dietary assessment was completed and noted that the resident had a significant weight loss x 1 week and documented that it…

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

Based on medical record review and interview with staff it was determined that the facility failed to ensure residents were seen by a primary care physician at least once every 30 days for the first 90 days and failed to ensure a resident was seen at least once every 60 days. This was found to be evident for 1 out of 6 resident's (Resident #56) reviewed for unnecessary medications. The findings include: On 1/24/18 review of Resident #56's medical record revealed the resident was admitted to the facility in late May of 2018. The resident was seen by primary care providers on several occasions in June and July. Further review of the medical record failed to reveal any documentation that the resident was seen by a primary care physician or other primary care provider at all from 7/25/18 thru 10/25/18. On 1/24/19 at 2:46 PM surveyor discussed the concern with the unit nurse manager #9 that the resident is to be seen at least every 60 days and requested any additional documentation of primary care physician notes. The unit nurse manager indicated she would follow up with medical records.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and interview with staff it was determined that the facility failed to ensure sufficient staff to provide restorative nursing services. This was found to be evident during the review of Rehab and Restorative services and has the potential to affect all residents. The findings include: On 1/23/19 review of Resident #87's medical record revealed the resident had resided at the facility for several years and had a current care plan for: Restorative Therapy to improve functional ability. This care plan was initiated on 9/27/18 and included the following: Ambulate 80 feet with rolling walker with contact guard by Restorative Aide; Participate in program two times a week. Review of the Physical Therapy Discharge Summary, signed 8/3/18, revealed the following Discharge Plans and Instructions: Pt [patient] d/c [discharge] from PT [physical therapy] at this time with restorative nursing to cont gait and exercises with pt. On 1/23/18 review of the Restorative Care Documentation Form revealed the following Instructions: Gait 100' [feet] with RW [rolling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and employee file review and interviews it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) and nurses demonstrated skills competency prior to being allowed to work independently with residents. This was found to be evident for 1 out of 3 recently hired GNAs (GNA #40) and 1 out of 1 newly hired nurses. The findings include: 1) On 1/25/19 at 2:01 PM the education specialist nurse #41 reported that newly hired GNAs meet with a preceptor and keep a skills checklist with them for however long they are with the preceptor. She went on to report that the GNAs cannot work on the floor by themselves until the checklist is completed. Review of the Initial Skills Competency Checklist revealed it to be three pages long and included more than 70 specific skills that a GNA may need to perform. These skills included, but were not limited to: -active and passive ROM; -mouth care; transfers from bed to chair; -incontinence care; -routine Foley catheter care; -and restorative care including feeding, toileting and grooming. Each skill…

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

Based on clinical records review and interview with the facility staff the facility failed to ensure when a resident was displaying mental adjustment concerns the facility failed to follow up or acknowledge the behavioral health recommendation. This was true for 1 out of 38 (#100) residents reviewed in the investigative stage of the survey. The findings include: On 1/25/19 Resident #100's medical records were reviewed. This review revealed a physician note dated 9/15/18 with concerns related to the resident's behavior and significant risk for health hazard. Further review of the physician note revealed the following: I do believe this patient had made him/herself a non-resuscitative candidate. It is likely he/she may have been significantly depressed. So,`I have asked the resident to think about this and with social work involvement I will reevaluate the patient required request to be a non-resuscitative candidate. Review of the physician note dated 9/16/18 revealed the following: Reactive depression. Unrelenting I do believe that the resident has made him/herself a Do Not…

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

Based on medical record review and interview with staff it was determined that the staff failed to have a system in place to ensure that physician response to the pharmacist recommendations were followed and that pharmacist recommendations was reviewed/addressed by the physicians in a timely manner This was evident for 1 of 7 residents (Resident #100) reviewed for unnecessary medications in the investigative stage of the long term care survey process. The findings include: On 1/25/19 Resident #100's medical records were reviewed. This review revealed that the pharmacist had completed the monthly medication reviews and made a written recommendation to the physician on 12/20/18. This pharmacy review revealed the following: The resident has been receiving Temazepam 30 mg qhs (every night) for insomnia since admission in September 2018. In order to achieve the minimum effective dose can we please attempt a reduction to 15 mg qhs. If no GDR (gradual dose reduction) is warranted, can documentation please be added to the medical records. On 12/26/18 the physician response was: I agree with…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that a resident was free from unnecessary medications by ensuring that residents who receive psychotropic medications are evaluated every 14 days for continued use. This was found to be evident for 1 (Resident #41) of 5 residents reviewed for unnecessary medications during the facility's annual Medicare/Medicaid survey. The findings include: A medical record review was conducted for Resident #41 on 1/22/19 at 10:07 AM. Review of the physician orders revealed an order for Ativan 0.5 mg via gastric tube (tube placed into the stomach for nourishment) as needed for 3 months. An interview was conducted with the Unit Nurse Manager (Staff #10) on 1/22/19 at 12:03 PM and s/he was asked to explain why the resident had an order for Ativan 0.5 mg for 3 months. Staff #10 did not provide an explanation, but instead stated, I will make a copy of the order for you. An interview was conducted with the Director of Nursing (DON) on 1/22/19 at 1:55 PM and s/he was made aware of the order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to ensure medical records were accurately documented as evidenced by 1) failure of the primary care physician to document the correct code status in the progress notes, 2) failure to ensure physician progress notes were documented in the medical record, and 3) failure to ensure resident assessment information was accurately documented in the physician progress notes. This was found to be evident for 3 out of 38 residents (Resident #56, #96 and #100 ) who had investigations completed during the investigative portion of the survey. The findings include: 1. On [DATE] review of Resident #56's medical record revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) that included orders for No CPR. Further review of this MOLST form revealed that it had been completed on [DATE] after a discussion with and informed consent of the resident. Review of the primary care physician's (staff #28) notes dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 completion of a resident council meeting, review of pertinent documentation and interview with facility staff, it was determined that the facility failed to implement an acceptable plan to address resident concerns related to staff failure to answer call bells timely. This was evident secondary to the resident council task. The findings include: Review on 1/22/19 of the last 12 months of resident council meeting minutes revealed that of the 12 months reviewed, 7 included repeated complaints either individually or collectively related to staff failure to or the delay in staff answering the call bell. During a resident council meeting on 1/22/19 at 1:00 PM, the concern regarding staff not answering call lights was again reported to the surveyor. The facility's response to the residents' complaints each month of the complaint was for the respective Unit Manager to monitor and educate staff on the importance of answering call bells timely. These concerns were reviewed with the Director of Nursing on 1/24/19 at 7:51 AM. The current activities director (staff #17) was not present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interviews with facility staff it was determined the facility failed to adhere to infection control practices and procedures during a dressing change. This was evident for 1 (Resident #41) of 3 residents reviewed for pressure ulcers and failed to use proper hand sanitation between residents on two separate observations of staff passing out lunch trays to residents. The findings include: 1) Record review conducted on 1/17/19 for Resident #41 had a stage 4 pressure ulcer (bed sore) to sacrum (bottom of the spine). A dressing change observation was conducted on 1/28/19 at 11:10 PM. A Registered Nurse (Staff #31) did the dressing change for Resident #41. The nurse used the table next to the resident's bed that contained medical supplies as his/her working field. The nurse did not create a clean field. The nurse was observed retrieving additional gauze from the box of gauze on the table to pack the resident wound. The nurse did not change his/her gloves prior to packing the resident wound and retrieving gauze from the box on the table.…

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

Based on observation and interview with staff it was determined that the facility failed to provide privacy to a resident when the resident needed to complete bathing and toileting. This was true for 1 out of 1 resident (#100) reviewed for privacy during the investigation stage of the survey process. The findings include: On 1/25/19 Resident #100 was interviewed. During the interview the resident voiced concern about not having privacy. The resident further reported that when the privacy curtains are around the resident it does not provide full privacy and other residents, or visitors would be able to see him/her, and the resident verbalized that he/she felt embarrassed. During a tour of the resident's room with the maintenance director and the Director of Nursing on 1/28/19 the resident was sitting in a chair. The surveyor explained to the resident the purpose for the visit. The surveyor asked the maintenance director to pull the resident's privacy curtain around the resident and bed with the bedside commode next to the bed. The curtain was not able to provide full privacy to 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 of the facility's lunch time meal, the facility failed to ensure that residents who were eating in the first floor activity room/dining room were able to all sit together at the main table as there were not enough places for the resident chairs to congregate and have social interaction at meal time. This observation was true for 2 of 4 dining room observations made during the survey and affected residents #75, #124 and #22. The findings include: During an observation on 1/16/19 at 12:22 PM of the first floor activity/dining room when residents arrived to the dining room walking or ambulating in a wheel chair, the residents were placed at a long set of tables in the middle of the room. There were three residents, #75, #22, and #124, that were in wheel chairs that arrived at 12:26 PM. They were placed away from the main table due to no places open to sit at the long table. The three residents were placed behind the main table and were given bedside tray tables to use. During a second observation on 1/17/19 at 12:25 P.M. of the first floor activity/dining room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 other pertinent documentation and interview with staff it was determined that the facility failed to 1. ensure their staff were trained on activities that constitute abuse as well as procedures for reporting incidents of abuse as evidenced by failure of staff to identify inappropriate touching of a dependent resident as abuse and failure of staff to immediately report this abuse to the Administrator once it was identified; 2. to ensure all nursing and geriatric nursing assistant staff received education regarding these specific issues after the educational deficit was identified by administration; and 3. to ensure all nursing staff received annual abuse training (Nurse #18 and GNA #29) . These failures directly affected 1 of 7 residents (#41) reviewed for abuse but has the potential to affect all the residents. The findings include: On 1/18/19 review of Resident #41's medical record revealed an 11/9/18 primary care provider note documenting a history of a brain injury 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.