Crescent Cities Nursing & Rehabilitation Center

Based on observation, record review, and interviews, it was determined that the facility failed to identify and provide appropriate treatment and services to assist a resident in attaining their highest practicable mental health well-being. This deficiency was evident for one of one resident (Resident #111) reviewed for behavioral and emotional well-being during the recertification/complaint survey.The findings include:During an initial tour on 2/24/26 at 9:28 AM, Resident #111 was observed screaming, yelling, and crying in their room. A nursing staff member stated to the surveyor, [Resident #111] has psychological issues.In an interview on 2/24/26 at 10:31 AM, a family member of Resident #111 stated the resident had no prior history of dementia or mental health issues. The family member noted, On 12/24/25, [Resident #111] was found to have a knee fracture due to age and bone fragility. Facility staff told me the screaming and crying were due to pain. Now, they have scheduled a psychological consultation. I just have to trust the facility.On 2/27/26 at 11:59 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was true for 3 (Residents #171, #3 and #116) of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: Clopidogrel is a prescription antiplatelet medication used to prevent serious blood clots, reducing the risk of heart attacks and strokes. Humalog sliding scale is a personalized, doctor prescribed chart that tells how much rapid-acting insulin to inject based on the blood sugar reading before a meal. Sliding means the dose changes: higher blood sugar = more insulin; lower blood sugar = less insulin. Tizanidine is a prescription medication to relax tight, stiff, and spasming muscles. 1) On 3/02/2026 at 9:34 AM, a review of Resident #3's medical records revealed medication orders that read: Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day 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 record reviews, observations and interviews, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 of 26 medication administration opportunities which resulted in an error rate of 7.69%. Findings Included:A Percutaneous Endoscopic Gastrostomy (PEG) tube is the placement of a flexible gastric tube into the stomach. On 02/27/2026 at 10:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #31 administering medications to Resident #87. LPN #31 crushed and administered acetaminophen 500mg via a gastric feeding tube. On 02/27/2026 at approximately 11:00 AM the surveyor reviewed Resident #87's medication orders and Medication administration records which revealed an order for acetaminophen 325mg Oral 2 tablets. The surveyor reviewed the medication orders with LPN #31 and she stated that she didn't know why she thought she saw 500mg on the Resident's order. On 02/27/2026 at approximately 11:00 AM, the surveyor also observed that LPN #31 administered a multivitamin 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication was stored in a locked compartments under proper temperature controls. This was true for Resident#172's room observed during the initial tour of the facility. Findings included: On 02/24/2026 at 12:14 PM, during the initial tour of the facility, the surveyor observed prescribed skin cream on Resident #172's window ledge unattended. The medication container was prescribed to Resident #172 and had instructions to refrigerate medication. On 02/24/2026 at 12:18 PM, in an interview, Licensed Practical Nurse (LPN) #27 was asked why the resident's medication was at bedside and she stated that they recently provided personal care to the resident.On 02/24/2026 at 12:14 PM, a review of Resident's #172's Treatment Administration Record revealed that resident had an order for Greers [NAME] Cream, apply to Perineal topically two times a day for Erythema Interigo. On 02/27/2026 at 03:55 PM, in an interview with the Director of Nursing (DON), the DON was informed of the surveyor's findings 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 observation and interview, it was determined that the facility failed to ensure food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 of 1 test tray temperature observation. The findings include: On 2/24/2026 at 10:11 AM, Resident #1 complained that hot foods were usually served cold. On 2/25/2026 at 12:08 PM, the surveyor conducted a lunch tray line observation and requested the Certified Dietary Manager (CDM) to include a tray on the first cart that was going to the unit. At 12:26 PM, the steel cart which contained the meal trays for the first unit with the test tray came out from the kitchen and arrived in the unit at 12:28 PM. However, there was a seven- minute delay before staff began distributing trays, and the final tray was served at 12:44 PM. Both the CDM and the [NAME] Dietary Manager (RDM) witnessed the observation. The RDM proceeded to test the food on the test tray using the facility's food thermometer and recorded the following:- fried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to ensure a therapeutic diet was prescribed for a resident. This deficiency affected one (Resident #57) of three residents reviewed for dietary services during the recertification/complaint survey.The findings include:During an interview on 2/24/26 at 11:30 AM, Resident #57 expressed that the provided meals did not accommodate their medical conditions. The resident stated, I am waiting for a kidney transplant. Because of that, I really need a controlled diet for diabetes and end-stage renal disease. However, the facility has been serving me foods I should not have, such as spinach, bananas, and soda.On 2/25/26 at 11:55 AM, the surveyor reviewed Resident #57's diet order, which specified a Heart-healthy diabetic diet-regular texture, thin liquid consistency. A review of the medical record confirmed diagnoses of Diabetes and End-Stage Renal Disease (ESRD). A review of progress notes dated 1/21/26 at 9:48 PM indicated that a facility nurse documented concerns from the resident and their…

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

Based on observations and interviews, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions as required. This is evident for 1(Resident #87) of 7 Residents observed for medication administration during the facility task portion of the survey process. Findings Included:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) (CDC website 2025).A Percutaneous Endoscopic Gastrostomy (PEG) tube is the placement of a flexible gastric tube into the stomach.Personal protective equipment (PPE)is an equipment worn such as gloves, gowns, masks, respirators, and eye protection designed to create a physical barrier between healthcare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint and a facility report incident, reviews of a closed and active medical record and all pertinent administrative records, and staff interview, it was determined that the facility staff failed to 1) follow physician orders to obtain weights, and 2) provide care to a resident when a staff member called out during the day shift on 01/12/2025. This was evident for 3 (Residents #19, #1, #21) out of 30 residents reviewed during a complaint survey. The findings include: 1. Review of complaint MD00218857/358373 on 09/08/2025 revealed allegations that Resident #19 did not receive quality care during his/her stay. Review of Resident #19's closed medical record on 09/08/2025 revealed the Resident #19 was admitted to the facility on [DATE] from the hospital with diagnoses that included a gastrostomy tube, congestive heart failure, and protein-calorie malnutrition. On 05/02/2025, Resident #19's physician gave orders to the nursing staff to obtain a weight, 3 times a week, on Resident #19, and notify 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 complaint, reviews of closed and active medical records, reviews of the facility enteral feeding tube policy, and staff interview, it was determined that the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for 5 (Residents #19, # 25, #26, #27, #28) of 30 residents reviewed for tube feeding during a complaint survey.The findings include:There are risks associated with residents using feeding tubes for nutrition. These risks include aspiration (accidentally inhaling your stomach contents), accidental dislodgement (tube moving out of place or coming out), bleeding and perforation (hole in the wall of your bowel or intestine), infection near the site, pain, and stomach leakage to name some. Appropriate treatment and services are required to prevent complications of enteral feeding.A review of the facility Enteral Feeding Tubes policy on 09/08/2025 revealed the following:Effective date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a closed medical record, and interview with facility staff, it was determined that the facility failed to notify a resident's representative of 1) the risk and benefits of a surgical procedure and 2) to seek permission to perform the surgical procedure. This was evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey. The findings include:Review of the complaint #MD00212895/358358 on 9/11/2025, revealed an allegation Resident #25's responsible party was not notified in advance of a wound care nurse practitioners plan to perform a debridement of Resident #25's sacral wound and bilateral heel wounds.Review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included but not limited to a cerebrovascular accident with right side weakness, aphasia, dysphagia, cognitive communication deficit, a sacral pressure ulcer, and a feeding tube placement. Resident #25 was totally dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, a closed medical record and a patient fund account, and interviews with facility staff, it was determined that the facility staff failed to disperse the remaining account funds to a discharged resident (Resident #23) within 30 days. This is evident for 1 of 30 residents reviewed during compliant survey. The findings include:Review of complaint MD00213913/358365 on 09/10/2025 revealed and allegation Resident #23 had not received the remaining disbursement of funds after being discharged from the facility. Resident #23 alleges that there is $2,513.14 the facility is still holding from in his/her patient fund account. A review of Resident #23's closed medical record on 09/10/2025 revealed that Resident #23 was discharged from the facility on 03/31/2025. A review of Resident #23's financial summary on 09/10/2025 at 3:03 PM revealed a sum of $1,920.96 is currently owed to Resident #23 from the facility.In an Interview with the facility Administrator and Business Office Manager (BOM) on 09/10/2025 at 3:03 PM, the facility BOM confirmed that Resident #23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, a closed medical record, and all pertinent administrative records and staff interview, it was determined that the facility staff failed to immediately notify a resident's physician and responsible party regarding a change in condition on 07/06/25 at 3 AM. This was evident for 1 (Resident #15) of 30 residents reviewed during a complaint survey.The findings include:The facility staff failed to immediately notify Resident #15's physician and representative when Resident #15 had an unwitnessed fall with injury on 07/06/25 at 3 AM.Review of complaint 2580338 on 08/21/25 revealed an allegation Resident #15 had been abused by the facility staff on 07/06/2025.Review of Resident #15's closed medical record on 08/21/25 revealed the Resident was admitted to the facility on [DATE] with diagnoses that include pneumonia, respiratory failure and vascular dementia. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Resident #15 also only spoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon complaint, reviews of a closed medical record and all other pertinent administrative documents, and staff interview, it was determined that facility staff failed to ensure that incidents of injuries of unknown source were reported to the State Agency (OHCQ) in a timely manner. This was evident for 2 (Resident # 15, #25) of 30 residents reviewed during a complaint survey.The findings include:The Office of Health Care Quality (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 injuries of unknown origin are to be reported to the Office of Healthcare Quality in a timely manner.1) The State Survey Agency (SA) received a complaint on 08/04/2025 (Intake 2580338) with complainant allegations indicating that Resident #15's had been abused by the facility staff. Resident #15's daughter came into the facility to check in on her relative, Resident #15, the morning of 07/06/2025.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a resident's closed medical records, and staff interviews, it was determined that the facility staff failed to provide activities of daily living (ADL) care in accordance with the resident's plan of care. This was found to be evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey.The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, toileting, bathing, and mobility.The State Survey Agency (SA) received an additional complaint on 01/05/2025 (Intake MD00212895/358358) with complaints indicating that Resident #25's had not received incontinence care timely. A review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted from the hospital on [DATE] with diagnoses that include cerebrovascular accident with right side weakness, percutaneous gastrostomy tube (feeding tube), and a tracheostomy. Resident #25 is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to keep a resident's drug regimen free from unnecessary drugs by crushing a medication that should not be crushed. This was evident for 2 (Residents #19, #7) of 30 residents reviewed during a complaint survey. The findings include:1) Review of complaint MD00218857/358373 on 09/08/2025 revealed allegations that Resident #19 did not receive quality care during his/her stay.Review of Resident #19's closed medical record on 09/08/2025 revealed the Resident #19 was admitted to the facility on [DATE] from the hospital with diagnoses that included a gastrostomy tube, congestive heart failure, and protein-calorie malnutrition. On 05/02/2025, Resident #19's physician gave orders to the nursing staff to obtain a weight, 3 times a week, on Resident #19, and notify the physician if there is a 2-pound increase in weight. On 09/08/2025 at 12:43 PM a review of Resident #19's medical record was conducted.Review of Resident #19's May 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for ?????? (Residents #15) of 30 residents reviewed during a complaint survey.The findings include.A medical record is the official documentation of 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) The State Survey Agency (SA) received a complaint on [DATE] (Intake 2580338) with allegations indicating Resident #15 had been abused by the facility staff. A review of Resident #15's closed medical record on [DATE] at 1 PM revealed that Resident #15 was admitted to the facility on [DATE]. Resident #15's closed record was reviewed on [DATE] which revealed a Maryland Medical Orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of 39 sampled residents (Resident (R) 23) was treated with dignity and respect during meals. Specifically, staff stood over the R23 while assisting the resident with eating, staff did not offer R23 an alternate for lunch when the resident continued to spit out his/her food, and staff failed to remove a large tube of A&D Medicated Ointment (used during incontinent care to treat rashes and protect the skin) off of R23's bedside table prior to placing his/her meal tray on the table. Findings include: Review of the facility's policy titled, Patient Rights, dated 01/23/20, revealed, The Health and Rehabilitation Center promotes the education and exercising of the legal rights of all patients. Review of the R23's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/24 and located under the MDS tab of the electronic medical record (EMR), revealed the resident was readmitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Resident Council Minutes, and facility policy review, the facility failed to serve food that was palatable for five of five residents (Resident (R) 29, R35, R48, R55, and R133) reviewed for food palatability out of 39 sampled residents. This failure had the potential to cause unmet nutritional needs for 145 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Meal Delivery,' dated 01/29/24, revealed, . Patients will be served meals in a courteous and dignified manner. The policy recorded that the nursing department will deliver meals to patients with the requirements that include delivering meals within 30 minutes of their delivery to the unit. Review of the facility's undated policy titled, Meal Times [sic] and Frequency revealed that meals will be served in a timely manner to maintain food quality and safe and palatable food temperatures. 1. Review of Resident Council meeting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, medical record review and interview with facility staff, it was determined that the facility failed to provide and review admission agreement with the appropriate resident or representative (RP). This was evident for 2 of 39 (#813 and #830) residents reviewed during a recertification/complaint survey. The findings include: 1. Review on 11/6/24 at 10:45 AM of the complaint #MD00205155 revealed concerns related to the reviewing and signing of the admission contract. Resident (R) # 813 was admitted to the facility in early February 2024 and assessed on the admission minimum data set (standardized clinical assessment that evaluates a resident's health needs and functional capabilities) as having a brief interview of mental status (BIMS-mandatory tool used to screen and identify the cognitive condition of residents) of '00' which would indicate severe cognitive impairment. On R #813's admission, there was an identified representative that met with the facility social worker and business office according to the progress notes. A review of the resident's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that the correct person was identified to make medical treatment decisions on the Maryland Order for Life Sustaining Treatment (MOLST) form. This was evident during the review of 1 of 3 (#818) MOLST forms, reviewed during a recertification/complaint survey. The findings include: Review of the medical record for Resident (R) # 818 on [DATE] at 12:38 PM revealed diagnosis including diabetes mellitus and frequent falls. Upon admission to the facility in October of 2022, R# 818 arrived with a completed MOLST stating that s/he was a full code, to attempt cardiopulmonary resuscitation (CPR), according to section 1 CPR status based on the patient's request dated [DATE]. However, on [DATE] a new MOLST form was completed with section 1 filled out to say that R#818 was now to be a 'do not resuscitate/do not intubate.' This decision was now based on the residents' surrogate decision maker. On the back of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure an injury of unknown origin was reported within two hours and investigative results were reported within five working days to the State Survey Agency (SSA) for one of nine residents (Resident (R) 18) reviewed for abuse out of a total sample of 39, and for 1 (Resident #807) of 16 facility reports reviewed for abuse during the recertification/complaint survey. Findings include: 1) Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Crime, dated 10/17/23, indicated, . Immediately upon notification or any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency (SA), but no later than two hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of Facility Reported Incidents (FRI), and facility policy review, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 2 residents (Resident (R) 18, #12) out of 39 reviewed during a recertification/complaint survey. There was no evidence that the facility interviewed other current residents regarding the allegation. This failure had the potential to place all residents at risk of continued abuse. Findings include: 1) Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Crime, dated 10/17/23, indicated, . The Administrator must thoroughly investigate . The written follow-up investigative reporting document that is submitted must contain sufficient detail to demonstrate that a thorough investigation was conducted . Review of R18's admission Record, found under the Profile in the electronic medical record (EMR), indicated that R18 was admitted to the facility on [DATE] with diagnoses including right femur fracture,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 permit a resident to stay in their facility. This was evident for 1 (#810) of 2 residents reviewed for discharge complaints during the recertification/complaint survey. The findings include: On 11/8/24 at 10:55 AM a medical record review was conducted for Resident #810. On 8/11/24 the physician documented the resident was admitted for subacute rehabilitation services. According to a Discharge Planning Psychological Assessment completed on 8/12/24, the resident wanted to be discharged home. A capacity form was completed by the attending physician on 8/13/24 which noted the resident had capacity to make decision. A care plan note dated 8/19/24 read the resident was adamant to move back to his/her home. On 9/6/24 a progress note was entered that the resident was issued a Notice of Medicare Non-Coverage (a document that informs the resident of the date that their medication coverage will end and list their options to appeal 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 staff interview it was determined the facility failed to issue a 30-day transfer notice to a resident prior to transferring them to another facility. This was evident for 1 (#810) of 2 residents reviewed for discharge during a recertification/complaint survey. The findings include: A record review for Resident #810 on 11/14/24 at 9:04 AM revealed a progress note dated 9/6/24 that noted the resident had been issued a Notice of Medicare Non-Coverage (NOMNC). A progress note dated 9/10/24, noted the resident had been discharged to another facility. However, further review failed to reveal any documentation that the resident had initiated the transfer, the resident agreed with the transfer, or a 30-day discharge/transfer notice. On 11/13/2024 at 11:19 AM a review of the Notice of Medicare Non-Coverage (NOMNC) issued to Resident #810 revealed it was signed by the resident on 9/6/24 and stated the resident's benefits ended on 9/11/24. An interview with the Director of Social Services (DSS) on 11/12/24 at 12:17 PM confirmed it was not a resident - initiated…

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

Based on record review and staff interview it was determined that the facility failed to provide discharge planning for a resident. This was evident for 1 (#829) of 2 residents reviewed for discharges during a recertification/complaint survey. The findings include: On 11/13/24 at 1:11 PM a review of complaint #MD00196716 revealed that there were concerns regarding the facility's failure to provide a discharge date for Resident (R) #829. A medical record review for R #829 on 11/13/24 at 1:22 PM revealed a discharge planning progress note written by the Discharge Planner on 8/24/23 that noted the resident the plan was for the resident to go back home upon discharge. A progress note written by Nurse Practitioner (NP) on 8/25/23 revealed the resident had been admitted to the facility for aftercare of a right femoral fracture, high blood pressure, and cardiomyopathy. The resident was ordered occupational and physical therapy. A care plan note dated 8/29/23 noted that the discharge plans were the same. Further review revealed that facility failed to initiate a discharge care plan. 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 record review and interview it was determined the facility staff failed to ensure each resident received treatment and care in accordance with professional standards of practice by failing to 1) obtain a dental consult, 2) monitor resident behaviors as ordered by the physician, and 3) obtain a resident's stool sample and send the stool sample for laboratory analysis (#806). This was evident for 2 (#807 and #806) of 16 reports reviewed for abuse during a recertification/complaint survey. The findings include: 1) Resident (R) #807's medical record was reviewed on 11/13/24 at 10:11 AM. A Change in Condition Evaluation dated 3/26/24 18:52 revealed the nurse observed the resident's right lower jaw was swollen. Not painful when touched. The resident did not complain of pain and was in no acute distress. The Physician was notified and provided an order to schedule the resident for a dental appointment. Further review of the medical record failed to reveal a dental consult report. The DON was asked to provide the surveyor with any information regarding the dental consult 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 staff interview, it was determined that the facility failed to provide adequate monitoring of a resident's pain (R#12) resulting in the resident receiving delayed treatment for a fractured right ankle. This was evident for 1 of 39 residents reviewed during a recertification/complaint survey. The findings include: A Medication Administration Record (MAR) - a document that records when and how much medication a resident is administered. For as-needed pain medication, it also documents what pain score a resident is reporting and whether the pain medication was effective at easing that pain. Failure to maintain an accurate MARs prevents members of the healthcare team from knowing when and why medication has been given. This can result in medication mistakes, overdose, or denying practitioners information on how much medication a resident receives. On 11/4/24 at 11:00am, the surveyor reviewed a facility investigation dated 3/18/23 regarding the facility's inability to determine the cause of R#12's fractured right ankle. A review of R#12's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observations of medication pass, there were three errors observed out of 31 opportunities, resulting in a 9.68% error rate. This had the potential to place two residents (Resident (R) 13 and R114) at risk of not receiving the full benefit of their medication therapy. Findings include: 1. Review of the facility's policy titled, Administration Procedures for All Medications, revised 08/2020, indicated, . 5 Rights (at a minimum): At a minimum, review the five rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. Check the Medication Administration Record (MAR) . for the order. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information . 2. Prior to removing the medication from the container: 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 observation, interview, record review, and facility policy review, the facility failed to offer alternate meals for one of 39 (Resident (R) 23) sampled residents observed during meal time. R23, a severely cognitively impaired resident, showed signs she did not like the meal served but staff did not offer a substitute without prompting. This had the potential to have a negative impact on R23's nutritional status. Findings include: Review of the facility's policy titled, Meal Delivery, dated 01/29/24, revealed, . Nursing staff will offer alternatives to any patient who does not eat at least 25% of their meal or who refuses food. Nursing will notify the Dining Services Department of a patient's desire for an alternate and deliver the alternate to the patient . Review of the R23's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/24, revealed the resident was readmitted to the facility on [DATE] and had diagnoses that included depression and a cerebrovascular accident (CVA).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to follow up with outside resources for the care of residents (Resident #820). This was evident for 1 of 4 residents reviewed during a recertification/complaint survey for ordered appointments or services not rendered inside the facility. The findings include: Review of the medical record for Resident (R) #820 on 11/13/24 at 9:29 AM revealed admitting diagnosis including multiple pressure ulcers and deep tissue injuries of the left foot. R #820 was assessed by the facility wound physician on 10/6/22. This was a comprehensive skin and wound evaluation. According to the plan and consults the wound care team recommended a vascular consult with doppler exam for further evaluation of vascular assessment. It was noted that the staff and facility were aware and explained in detail. On 11/13/24, this was reviewed with the facility DON and the assessments and studies were requested as they could not be found in the resident's medical record. Follow up on 11/13/24 at 3:03 PM the facility Consultant Nurse reported 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 record review and interview with staff, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 1 (Resident #513) out of 33 resident records reviewed during the revisit survey. The finding include: On 1/8/2025 at 12:30PM, a review of Resident #513's treatment administration record (TAR) revealed a check sign entered on 1/3/2025 dayshift, which indicated that the stool specimen collection task had been completed and signed off by Licensed Practical Nurse (LPN) #13. On 1/9/2025 at 9:20AM, an interview with the Nursing Home Administrator (NHA)#5 revealed that there were no results for Resident #513's stool specimen in the electronic medical record because the specimen was never collected. The Surveyor was informed that LPN #13 signed off that the stool specimen was collected in the resident's TAR, but never actually completed the task because the resident never had a bowel movement. An interview with the Regional Clinical Nurse (RCN) # 9 on 1/9/2025 at 1:15PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing wound care for one of one resident (Resident (R) 204) reviewed on Enhanced Barrier Precautions (EBP) out of a total sample of 39. This failure increased the risk of spreading multi-drug-resistant organisms throughout the facility. In addition, the facility failed to ensure that one of six residents (R82) observed during medication administration was given medication in a manner to prevent possible cross-contamination. This failure had the potential to place R82 at risk for infection. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/26/24, indicated, . Employees providing high-contact patient care activities will follow EBP for patients who meet the criteria . EBP require the use of gown and gloves by staff during high-contact patient care activities as defined below .Wound 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 observations during an environmental tour and staff interviews, it was determined that the facility's staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 6 of 37 residents observed during the survey process (Residents #20, #25, #36, #53, #59, and #66). The findings include: 1. On 7/8/19 at 10:57 AM an observation of Resident #59's room (219B) revealed tattered blinds on the windowsill. 2. On 7/8/19 at 10:51 AM an observation in Resident #36's room (room [ROOM NUMBER]A) revealed a large amount of soft stool on the bottom of the bathroom toilet. The sides of the toilet were spattered with stool. This bathroom was shared between the residents residing in two separate rooms (rooms [ROOM NUMBERS]) and utilized by a total of four residents (Resident's #20, #36, #53, and #66). Further observations of the room revealed a red sharps container hanging on the interior wall. At the time of the observations the sharps container 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 the review of residents' medical records and an interview with a resident, it was determined that the facility failed to 1. develop a care plan for 1 of 2 residents reviewed for urinary catheters (Resident #45), 2. develop a care plan for 1 of 2 residents reviewed for tube feedings (Resident #108), and 3. develop a care plan for 1 of 1 residents reviewed for sensory deficits (Resident #10). The findings include: 1. Resident #45's medical record was reviewed on 7/9/19 at 11:28 AM. During the review, it was found that the resident had medical conditions that rendered him/her unable to control his/her bladder or to know when he/she has soiled himself/herself. On 7/9/19 at 12:00 PM observation of care for Resident #45 revealed the resident was noted to have an external urinary catheter device. The device maintained close contact with the resident's skin but did not enter the urinary canal. Resident #45's care plan was reviewed on 7/11/19. The care plan did not specifically address the care that the Resident #45 requires regarding the frequency of catheter changes, how to assess…

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

Based on observation, medical record review, and staff interviews, it was determined the facility failed to provide the appropriate level of assistance and services for 3 of 30 residents that require assistance with activities of daily living (ADLs) (Residents #65, 20, and #17). The findings include: 1a. On 7/8/19 at 11:18 AM during an interview with Resident #65, the resident stated he/she had not had a shower in a long time. When asked if he/she wanted showers he/she replied, yes. When asked how often he/she would like to have a shower the resident stated, twice a week. On 7/9/19 at 1:30 PM the medical record for Resident #65 was reviewed. It was noted that on 5/10/19, the resident was given a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The BIMS score is an evaluation, based on an interview, which assesses the resident's attention, level of orientation and ability to recall information. On 7/16/19 at 10:07 AM Unit Manager (UM) #6 was interviewed. UM #6 reported that Resident #65 received showers. UM #6 was unable to provide documentation to show when 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 staff interview, it was determined the facility failed to provide evidence that all nursing staff had received competency evaluations. This was evident for 3 of 4 employee selected for review during the survey (Staff #13, #14, and #15) and all nursing staff hired prior to 6/15/19. The findings include: The term 'nursing competencies' refers to routine evaluations of nursing staffs' capabilities and skills. On 7/15/19 at around 2:30 PM, a list of all nursing staff including their titles and dates of hire was requested from the Director of Nursing (DON). On 7/16/19 at approximately 9:30 AM, the list of nursing staff was provided, but did not include dates of hire. The DON stated the facility had the dates of hire but was unable to print out a list of the employees with the dates of hire on it. The DON was told by the surveyors that they needed to see some records of employees that had worked in the facility for greater than one year. On 7/16/19 at 1:12 PM, the Human Resources (HR) Director and Administrator presented to the surveyors to discuss the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews with the facility's staff, a review of the facility's infection control polices and observations, it was determined that the facility failed to: 1. follow acceptable infection control practices, 2. maintain the laundry area in a manner to ensure clean [NAME] and prevent or control the spread of infection, and 2) ensure that food service was provided to residents in a sanitary manner as evidenced by mobile food carts not having proper food protection in the form of sneeze guards on three of the sides. This was evident for 2 out of 3 residents reviewed for isolation precautions (#104, #109) and for 3 of 3 mobile food carts observed in the facility's kitchen. Clostridium difficile (C.diff) is a bacterium that causes diarrhea and colitis (an inflammation of the colon). It is estimated to cause almost half a million illnesses in the United States each year. About 1 in 5 patients who get C. diff. diff will get it again. Findings include: 1a. On 7/9/19 Resident #104's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the facility and staff interview, it was determined that the facility's nursing staff failed to ensure confidentiality of residents' medical record was maintained on the third floor nursing unit. This was evident on 2 out of 10 medication carts, one resident (Resident #52) with an order for blood pressure medication, and all residents on the unit with a prescription for a narcotic medication. The findings include: On 7/15/19 at 10:14 AM, a tour of the the third floor (Memory Care) unit was conducted. Observation of the unit revealed one unattended nursing medication cart that was parked in front of room [ROOM NUMBER]. Two empty medication pill packs were observed on top of the unattended medication cart. One pill pack contained zoloft (25 MG) tablets with an instruction to give Resident #52 one (1) tablet by mouth daily. This pill pack displayed Resident #52's prescription refill number. The second visible pill pack contained hydralazine (50 MG) tablets with the instructions give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, it was determined that the facility's staff failed to ensure information used to complete the quarterly Minimum Data Set (MDS) assessment for medication use was accurate and complete. This was evident for 1 of 57 residents selected for medical record review during annual survey process (Resident #122). The findings include: The Minimum Data Set (MDS) is a core set of screening questions. On 7/10/19 at 10:00 AM, a review of Resident #122's medical record revealed the resident was admitted to facility with multiple medical diagnoses, including prostate cancer. A review of section I of the resident's quarterly MDS outcomes, dated on 4/11/18, did not include Resident #122's cancer diagnosis as required. The facility must ensure each resident's needs are based on accurate MDS assessments.

Based on a record review, it was determined that the facility failed to develop a baseline care plan for the use of an antipsychotic medication for 1 of 1 resident reviewed for unnecessary medication (Resident #81). The findings include: On 7/11/19 at 9:00 AM the review of Resident #81's medical record revealed that he/she was admitted to this facility in June of 2019. Further review revealed Resident #81 received 25 mg of Quetiapine (Seroquel) at bedtime for agitation. There was no evidence in the resident's record to show there was care plan to address the use of Quetiapine 25 mg. A According to the resident's record, the pharmacy had not reviewed the medications since the resident was admitted to the facility.

Based on record review and staff interview it was determined the facility failed to provide evidence that all nursing staff received education in behavioral health. This was evident for 1 of 4 employee records reviewed during the survey (Resident #12) and and all nursing staff hired prior to 6/15/19. The findings include: On 7/15/19 at around 2:30 PM, a list of all nursing staff including their titles and dates of hire were requested from the Director of Nursing (DON). On 7/16/19 at 1:12 PM, the Human Resources (HR) Director was interviewed and stated the facility was had a change in ownership in February 2019 and the current owners were provided with partial records for employees. She stated that 29 new employees were hired on 6/5/19, these employees received new hire orientation and education under the current ownership . The HR Director went on to say that she did not have complete education records for the 115 nursing staff that were hired under the previous owner's administration (prior to 6/5/19). On 7/16/19 at 4:00 PM while discussing nursing education records with 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 staff interview it was determined the facility failed to provide evidence that all nursing staff had received education on abuse prevention. This was evident for 1 of 4 employee records reviewed during the survey (Staff #12). The findings include: On 7/15/19 at around 2:30 PM, a list of all nursing staff including their titles and dates of hire was requested from the Director of Nursing (DON). On 7/16/19 at 1:12 PM, the Human Resources Director was interviewed and stated the facility had a change in ownership in February 2019, and that she was given only part of the employee records. She stated 29 new employees were hired on 6/5/19 and they received new hire orientation and education from under the current owner's administration. She went on to say she did not have education records for the 115 nursing staff that were hired prior to 6/5/19. On 7/16/19 at 4:00 PM while discussing this with the Director of Nursing (DON), he stated he had the employee education records in his office. He went to his office and returned with records for nursing Staff #12, #13,…

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