Collingswood Rehabilitation And Healthcare Center

Based on observations and interviews with staff, it was determined that the facility failed to attend to and answer call bells in a timely manner for dependent residents (Resident #149). This was evident during a tour of the first floor when a call bell was observed to be active and was subsequently validated during the recertification/complaint survey.The findings include: During a tour of the facility on 8/08/25, at 12:50 PM, a call bell screen on the 1 [NAME] unit showed that a call bell from Room [number of the room] had been active for 113 minutes. When the surveyor asked Staff #14 (a nurse) about the screen, she confirmed that the call had been on for 113 minutes. She added, someone is working on fixing something in that room.The surveyor immediately checked the room and found only Resident #149 lying in the bed. No other staff were present, and there was no evidence of a construction procedure. The resident was vulnerable, with a tracheostomy and tube feeding. While the surveyor was in the room, Staff #26 (Geriatric Nursing Aide) entered. After Staff #26 exited the room, 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 review of the medical record and interview with facility staff, it was determined that the facility failed to notify the resident's physician and/or responsible party (RP) following an accident/change in condition. This was evident for 1 of 3 residents (Resident #160) reviewed for urinary catheters during the facility's recertification survey. The findings include:An indwelling urinary catheter, often referred to as a Foley catheter, is a flexible tube inserted into a patient's urethra (the tube that carries urine from the bladder to the outside of the body) and remains in place to collect the urine into a drainage bag. Urinary catheters can be ordered for several reasons such as urinary incontinence (leaking urine or unable to control when you urinate), urinary retention (being unable to empty your bladder), during and/or after a surgery, or related to other medical conditions such as a spinal cord injury. However, urinary catheters are associated with an increased risk of urinary tract infections…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of medical records and a staff interview, it was determined that the facility failed to provide written notification of its bed-hold policy to the resident or their representative when the resident was transferred to an acute care facility. This was evident for three (Resident #8, #66, and #154) of five residents reviewed who were transferred to an acute care facility.In Maryland, the bed hold policy for long-term care facilities is governed by state regulations and Medicaid guidelines. Nursing homes must provide a written bed hold policy to residents at the time of admission and upon transfer to a hospital or for therapeutic leave. The policy details the duration of the bed hold, the rights of residents to return to the facility, and the the cost of holding the bed. 1) On [DATE], at 1:33 PM, the surveyor reviewed Resident #154's medical records. The records showed that on [DATE], around 4:40 AM, Resident #154 was found unresponsive. Staff initiated CPR and called 911. EMTs arrived around 4:55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #54) of 6 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:A care plan is developed for residents to guide the care that they receive in the facility. It should be individualized and outlines the interventions used to address the residents' needs. 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 (IDT) including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable).A review of Resident #54's…

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

Based on medical record review and interviews the facility failed to provide services to maintain hearing. This was evident for 1 of 2 (Resident #3) reviewed for communication difficulty and/or sensory problems (vision and/or hearing) during the recertification/complaint survey.The findings include: On 07/31/2025, at 11:12 AM, Resident #3 was interviewed and stated that he/she had lost their hearing. Resident #3 reported requesting to see an ENT (Ear, Nose, and Throat) a month prior, but the nurse informed him/her that their insurance would not cover the visit.08/06/2025 at 8:15 AM, a review of Resident #3's medical record revealed no indication of an appointment for an ENT examination, nor any care plan addressing hearing difficulties.Further review of Resident #3's medical record progress notes revealed the following:-According to the Nurse Practitioner progress note dated on 06/30/2025, at 10:05 PM, the Nurse Practitioner assessed the resident, who reported left ear complaints and admitted to a hearing change, describing the ear as stuffy. Dark brown, dry, impacted earwax was…

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

Based on medical record review and staff interviews it was determined the facility failed to implement wound consults timely which resulted in residents not receiving wound care treatments. This was evident for 2 (Resident #63 and #127) of 7 residents reviewed for pressure ulcer/injury during the recertification/complaint survey. The findings include:1) On 08/01/2025, at 8:44 AM, a review of Resident #63's medical record revealed a wound progress note from 02/11/2025, at 5:43 PM. This note, signed by a wound Nurse Practitioner, documented a Stage 4 sacral wound. Recommended treatments included daily (and as needed) cleansing of the wound with wound cleanser, application of Dakins moistened fluffed gauze, and Zinc Oxide Paste to the periwound to the base of the wound, secured with bordered foam and an ABD pad.Continued review of Resident #63's Treatment Administration Record (TAR) revealed a physician's order for sacral wound care. The order, effective from 7:00 AM on 02/07/2025 to 7:08 AM on 02/13/2025, prescribed daily cleansing with normal saline, application of Medihoney, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with facility staff, it was determined that the facility failed to provide appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for 1 of 2 residents (Resident #160) reviewed for urinary catheters during the facility's recertification survey. The findings include:An indwelling urinary catheter, often referred to as a Foley catheter, is a flexible tube inserted into a patient's urethra (the tube carries urine away from the bladder to outside the body) and remains in place to collect the urine into a drainage bag. Urinary catheters are associated with an increased risk of urinary tract infections as well as other adverse events and should be used only when clinically indicated and ordered by a physician. Urine output is an important clinical indicator and can provide insight into a patient's status and guide their care. Normal urine output is approximately 0.5 to 1.0 mL/kg/h…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate pain management for a resident. This was evident for 1 (Resident #13) out of 1 resident reviewed for pain during the recertification/complaint survey.The findings include: A pain scale is a numerical scale, usually 0-10, used to determine the severity of a person's pain. Parameters (Instructions in an order on when a medication can be given) for a pain scale are used to determine which pain medication would be given according to a person's severity of pain.On 08/06/2025 at 9:03 AM, while reviewing Resident #13's medical record, a Physician order was found that was dated 07/05/2025 for Tylenol to be given every 6 hours as needed for Mild Pain- Scale 1-3.Further review of Resident #13's medical records revealed a care plan dated 11/09/2023 with a focus of: I have pain and/or potential for pain related to Gout, sacral wound, BPH (benign prostatic hyperplasia), CKD3 (chronic kidney disease stage 3) with interventions of : 1) Anticipate my need for pain…

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

Based on observation of medication carts and staff interview it was determined that the facility staff failed to ensure controlled substance medications are monitored to ensure accuracy. This was evident for 1 out of the 9 facility medication carts. The findings include: The medication cart for the 1 [NAME] unit revealed that the controlled substance logbook had gaps of where two nursing staff signed to verify each resident's controlled substance medication was counted and matched the number of pills, capsules, etc that were left. The controlled substance logbook had gaps under the signature page which showed no signatures for nurses starting their shift or signature for nurse ending their shift for the following: day shift on 6/2/25, day shift on 6/12/25, evening shift on 6/16/25, day shift on 6/18/25, day shift 6/21/25, day shift on 6/22/25, day shift on 6/27, and on night shift on 7/4/25. Staff #59 was shown that there were gaps in the sign on/sign off section of the controlled substance logbook and she replied Oh, I see.

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 evident for 1(Residents #125) of 1 resident reviewed for unnecessary medication during the recertification survey.The findings include:An interview concerning the Medication Regimen Review (MRR) report was conducted with the Assistant Director of Nursing (ADON) on 8/6/25 at 12:43 PM. The ADON stated that the pharmacist would send her and the unit managers the MRR via email. The ADON printed out the recommendations and provided the unit managers with copies to ensure the recommendations are addressed by the physician. the physician will sign and put the copy in the binder. The binder is stored in the Director of Nursing (DON)'s office; however, a copy of the completed recommendation is not placed in the paper chart. The ADON also stated that the facility is going to change this process to make sure a copy is placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration task it was determined that the facility nursing staff failed to ensure residents receive medication according to physician's orders. This was evident for 2 medications out of the 26 medications observed as part of the medication administration task during the recertification/complaint survey. The findings include: Resident #121 was observed at 11:11 AM on 8/6/25 to have been administered insulin at 11:11 AM instead of the 9:00 AM scheduled administration time. This represented a delay of one hour and eleven minutes beyond the medication administration window of one hour before or one hour after the scheduled time. Resident #91 was observed to have received insulin at 11:12 AM on 8/6/25 instead of the 9:00 AM scheduled administration time. This represented a delay of one hour and twelve minutes beyond the medication administration window of one hour before or one hour after the scheduled time. The facility administration team was informed of the findings at the exit conference on 8/8/25.

Based on observations of medication rooms and staff interviews, it was determined that the facility staff failed to ensure a medication refrigerator maintained proper temperature. This was evident for 1 out of the 2 medication rooms that were observed as part of the medication administration task during the recertification/complaint survey. The findings include: This surveyor observed the medication refrigerator of one west on 8/8/25 at 11:20 AM. The freezer compartment was filled approximately 3/4 of the way with a solid piece of ice. This finding was shown to the Unit Manager who replied Oh, I have to defrost. The thermometer read 28 degrees Fahrenheit. The thermometer was shown to the Unit Manager who said Probably because it was so close to the freezer. I'll move it or get another thermometer.

Based on record reviews and staff interviews, the facility failed to adequately monitor and track residents receiving antibiotics. This deficiency was evident in 1 (Resident #11) of the 3 residents reviewed for antibiotic use and the facility's antibiotic stewardship program during the recertification/complaint survey.The findings included:Background on Antibiotic Stewardship: Effective antibiotic stewardship requires a facility to develop and implement robust policies, procedures, or protocols to ensure residents needing antibiotics are treated appropriately. This is crucial for minimizing the risk of adverse drug reactions, preventing unnecessary antibiotic administration, and mitigating the development of antibiotic-resistant organisms. A facility-wide process for monitoring antibiotic use is essential, with results and feedback consistently reported to nursing staff and prescribing clinicians.On 8/05/25, at 9:40 AM, the surveyor reviewed Resident #11's medical records regarding his/her antibiotic use. The review revealed that Resident #11 had wounds on the left lower legs with 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 resident interview, staff interview, and observation, it was determined that the facility staff failed to ensure a call system operated correctly for each room. This was evident for 1 resident (#85) out of 60 residents in the survey sample. The findings include: While interviewing Resident #85 on 7/31/25 at 11:22 AM it was observed that the call bell system was alerting staff to the fact that the resident needed assistance. This surveyor asked the resident about the call bell going off. The resident replied that it will not turn off. The unit manager came into the room at 11:25 AM and asked if the resident needed assistance. The resident replied No, it comes on by itself and will not turn off. It has been like this for two days. Staff respond, ask what do I need, and when I reply nothing, they turn it off and leave but it comes back on. Resident then added that it had been like this for two days. The Unit Manager said she would take care of it and left. This surveyor asked the resident for clarification as to how long this has been going on. The resident replied, Two days.…

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

Based on review of a complaint, interview, and observation of resident wheelchairs, it was determined the facility failed to provide maintenance services necessary to keep all wheelchairs in a sanitary, comfortable, and well-maintained condition. This was evident on 2 of 3 nursing units observed during the complaint survey. The findings include: 1) On 5/6/25 at 2:00 PM a review of complaint MD00216562 alleged that Resident #3 went out to an appointment. The resident attended the appointment in a wheelchair. The complaint alleged that the family and resident were embarrassed about the condition of the wheelchair and the padding. The complaint alleged, the doctor/nurse was also taken aback by the stench that we have complained about for months. Upon unzipping the pillow, we were all appalled, disgusted, and I, embarrassed, by the urine and fecal matter present in the gel pad and the inside of the pillow cover. The complaint stated, the presence of urine and fecal matter in and of itself can cause other issues to include wounds in the area subjected to such filth. The complaint stated…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (Resident #22, #24, #18, #3) of 46 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1a) On 5/13/25 at 10:50 AM a review of Resident #22's medical record was conducted. Review of the weight section of Resident #22's medical record documented on 12/14/23 the resident's weight was 128.0 lbs. The next weight was taken on 1/5/24 and was 102.2 lbs. which was a 25.8 lb. or 20 percent weight loss in 3 weeks. Review of the MDS Assessment with an…

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

Based on complaint, medical record review, and interview, it was determined the facility failed to ensure a custom-made wheelchair was available for a resident during transport to an appointment. This was evident for 1 (Resident #4) of 28 residents reviewed for complaints during a complaint survey. The findings include: On 5/12/25 a review of complaint MD00215793 was conducted, and it was alleged that Resident #4 obtained a broken ankle at the facility. Review of an investigation done by the facility revealed staff written statements that Resident #4 did not have a fall. Staff statements documented that Resident #4 was transferred with 2 people from the bed to the wheelchair in a Hoyer lift per the care plan. A written statement from Geriatric Nursing Assistant (GNA) #37 documented the resident was sliding from the wheelchair. GNA #37 and 4 other staff members helped pull the resident up and reposition the resident. Despite being repositioned, Resident #4 continued to slide from the wheelchair. At that time Resident #4 was transferred to a different wheelchair by staff. 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.

Based on medical record review and interview, the facility staff failed to notify a resident's physician timely for a change in condition (Resident #10) and failed to timely notify a resident's physician, responsible party, and dietician of a significant weight loss (Resident #22). This was evident for 2 of 28 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to notify Resident #10's physician for a low blood pressure timely. Review of Resident #10's medical record on 5/7/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include heart failure. Heart failure occurs when the heart can't pump enough blood to meet the body's needs. Further review of Resident #10's medical record revealed a nurse's note on 10/27/24 at 11:40 PM stated outgoing nurse reported that resident's blood pressure just suddenly dropped to 70/54, writer went to resident room blood pressure assess 81/54. Another nurse's note on 10/28/24 at 1:14 AM stated, writer assessed patient and no distress noted, paged provider about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 3 (Residents #6, #1, #18) of 13 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) On 5/8/25 at 12:13 PM a review of facility reported incident MD00212791 was conducted and revealed Resident #6 was noted with a laceration to the right thumb area on 12/17/24 at 5:40 PM. Resident #6 was non-verbal and cognitively impaired and could not verbalize how the injury happened. Review of the facility's investigation revealed the injury happened on 12/16/24. Licensed Practical Nurse (LPN) #19 confirmed that he worked on 12/16/24 and stated that the physical therapist had reported to him that the resident was bleeding from the right thumb. LPN #19 stated he did not document the incident or notify the supervisor. Facility administration did not become aware of the incident until the next day.…

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

Based on medical record review and interview, the facility staff failed to have quarterly care plan meetings for a resident (Resident #12). This was evident for 1 of 7 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. Review of Resident #12's medical record on 5/6/25 revealed the Resident was admitted to the facility in November 2020 with a diagnosis to include dementia. Dementia is a general term 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 resident medical record, the facility failed to provide care (toileting/ turning/ positioning) on day shift for Resident # 37 who is extensive assistance with 2 person assistance. This is evident for 1 out of 1 person reviewed during the complaint survey. Findings include: MDS is a A Minimum Data Set (MDS) is a standardized, core set of data elements used for clinical assessment in various settings, including nursing homes and skilled nursing facilities. It provides a common language and format for collecting and analyzing data, ensuring consistency and comparability across different facilities and locations. The MDS helps identify resident care problems, informs individualized care plans, and is used for reimbursement and quality monitoring purposes. Resident was admitted to the facility on [DATE] and discharged on 9/17/22 due to a lack of care. On 5/6/25 at 9:28 AM, an investigation was conducted for Resident # 37. The Resident came to this facility for rehab after surgery for periprosthetic hip…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaints, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #10 and #13). This was evident for 2 of 28 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to address the recommendations of a consultant for Resident #10. Review of Resident #10's medical record on 5/7/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include anemia and thyrotoxicosis. Anemia is a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues and Thyrotoxicosis is a treatable condition that happens when you have too much thyroid hormone in your body. Further review of Resident #10's medical record revealed the Resident was seen by a Consultant on 12/18/24 for anemia, volume status and secondary hyperparathyroidism. Review of the Consultant's 12/18/24 note revealed the Consultant documented, The patient was seen this morning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documentation review, and interview, it was determined the facility staff failed to recognize a resident's weight loss and notify the physician and dietician promptly in order for interventions to be placed timely. This was evident for 1 (Resident #22) of 28 complaints reviewed during a complaint survey. The findings include: On 5/13/25 at 10:50 AM a review of complaint MD00202446 alleged the facility staff were not feeding Resident #22. A review of Resident #22's medical record was conducted and revealed a 12/15/23 note that Resident #22 was admitted for comprehensive rehabilitation and had admitting diagnoses that included cerebral infarction without residual deficits, hypertension, type 2 diabetes mellitus with hyperglycemia and a sacral wound. Resident #22 was prescribed a regular diet with moist ground meat, finely chopped vegetables texture, thin consistency. A physician's physical and history note dated 12/15/23 documented the resident was admitted to the hospital with weakness and decreased intake and weight loss. Review of a 12/15/23…

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.

Based on surveyor observation, record review and interview, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment by failing to have a process in place to accurately screen people entering the facility for signs and symptoms of COVID-19 and failing to monitor the screening results. This was evident during surveyor entrance to the facility and Infection Control review. The findings include: An observation was made upon entry to the facility on 7/26/22 at approximately 7:55 AM. Surveyor (#1) entered the front lobby and observed the reception desk to the left (approximately 40 feet from the front door) and main hallway to the elevators. The receptionist at the desk requested that the surveyor complete the screening process using a tablet kiosk located in front of the reception desk. A hand sanitizer dispenser was to the left of the kiosk. When the surveyor reached to apply hand sanitizer, a temperature reading, 96.3 F (degrees Fahrenheit) displayed on the front of the dispenser.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, it was determined that the facility failed to provide a safe, clean, homelike environment for their residents as evidenced by stains on the walls and ceiling tiles, bathroom vents not clean, cooling unit vents that were dusty and had debris on them, windows were cracked, and window screens had holes in them, failure to provide private closet space in each resident room, and failure to maintain a resident shower room in a safe and hygienic manner. This was found to be evident on 2 out of the 4 nursing units observed during the survey. The findings include: 1) On 7/25/22 at 10:49 AM, a tour of Resident #56's room revealed a brown substance splashed on the wall to the left of the bathroom door that was dried. 2) On 7/25/22 at 11:26 AM, a second tour of Resident #56's room revealed the cooling unit attached to the wall had food and paper in the air vents as well as a build-up of gray substance. The ceiling tiles in the right corner of the room had brown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to have an effective system in place to ensure residents and the resident's responsible representative were notified in writing of the reason for a transfer or discharge. This was found to be evident for 6 (Resident #26, #133,#196, #192,# 398, #533) out of 79 residents reviewed during the investigative portion of the survey. The findings include: 1) Review of Resident #26's medical record revealed the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted to the facility in January 2022 and had a discharge to the hospital in June 2022 with a re-admission in July. Additional review of the medical record revealed that a Notice of Intent to Transfer/Discharge Resident form was completed on 6/26/22. This form includes information regarding where the resident was transferred to and why, as well as information regarding rights to appeal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, complaints and interview, it was determined that the facility 1) failed to have an effective system in place to ensure that copies of the baseline care plans were provided to the resident and or responsible representatives and 2) failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication, and 3) failed to develop and implement a baseline care plan that addressed a resident's diabetes . This was found to be evident for 4 (Resident #26, # 104, #192) out of 6 residents reviewed for care plans and evident for 1 (#283) of 2 residents reviewed for communication and 1(#289) of 31 residents review for general concerns during the annual and complaint survey.during the survey. The findings include: 1) Review of Resident #26's medical record revealed the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted 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 interviews, it was determined that the facility failed to have an effective system in place to ensure that comprehensive care plans were established and implemented as evidenced by: failure to incorporate restorative nursing program into a resident's care plan (Resident #26); failure to ensure that goals related to mobility accurately reflected the resident's current status and interventions (Resident #48); failure to ensure that care plans addressing residents' assessed activity preferences was initiated and implemented (Resident #26 and #48) and failed to develop a resident centered activity care plan that addressed the resident's medical, physical, mental, and psychosocial needs and included measurable objectives. This was evident for 6 (Residents #23, # 26, # 48, #105, #21, #131 ) of 6 residents reviewed for care plans, 1 (#131) of 6 residents reviewed for and mobility and positioning, and 1 (#23) of 7 residents reviewed for accidents. The findings include: 1) Review of Resident #26's medical record revealed the resident had severely impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to provide an ongoing resident centered activities program to improve or maintain the resident's physical, mental and psychosocial well-being, and independence, and failed to provide activities that reflected the resident interests and preferences. This was found to be evident for three out of six residents (Residents # 75, #105, #21) reviewed for activities during the investigative portion of the survey. The findings include: 1. Review of Resident #75's medical record revealed that the resident was admitted to the facility November 2021 with primary diagnoses of morbid obesity, partial paraplegia, and schizoaffective disorder, bipolar. The resident was dependent on staff, needing extensive assistance with daily care activities and transfers. The most recent Brief Interview for Mental Status (BIMS) score was 15 out 15. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs.…

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

F689 Based on observation, staff interview, and record review, it was determined that the facility failed to maintain an environment free of hazards for residents as evidenced by a surveyor observation of a resident (Resident #113) with a fall risk bed that was not in lowest position. The findings include: On 8/01/22 at 5:48 AM, a tour of the 1 East Unit revealed Resident #113 lying sideways on the bed with his/her feet dangling off the side. Surveyor immediately alerted Geriatric Nursing Assistant (GNA) # 67. A subsequent observation of Resident #113 on 8/1/22 at 6:18 AM, revealed the resident was lying upright in bed, however the bed remained at waist level. An interview with GNA # 67 on 8/1/22 at 6:21 AM revealed that s/he did not know that Resident #113 was a fall risk. GNA # 67 and the surveyor walked to Resident #113's room and s/he confirmed the bed was not in the lowest position. GNA #67 reported that when she/he left the room Licensed Practical Nurse (LPN) #62 had been providing respiratory care to the resident, so she/he had not lowered the bed per staff #67. During an…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that physician progress notes were written, signed, and dated at each visit. This was evident for 2 (#33, #133) of 6 residents reviewed for positioning and mobility, and 1 (#23) of 7 residents reviewed for accidents. The findings include: 1) On 7/27/22 at 10:30 AM, a review of Resident #23's EMR (electronic medical record) revealed physician progress notes that were not written on the day that the resident was seen. There was a) a physician's progress note, with an effective date of 2/23/22 at 2:36 PM, that had a created date of 3/6/22 at 2:36 PM, b) a physician's progress note with an effective date of 4/25/22 at 9:11 PM that had a created date of 5/10/22 9:11 PM, and c) a physician's progress note, with an effective date of 6/9/22 at 7:56 PM, that had a created dated of 6/25/22 at 7:57 PM. 2) On 8/1/22 at 8:30 AM, a review of Resident #131's EMR revealed physician progress notes that were not written on the day the resident was seen. There was a) a physician's progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that medical records were complete as evidenced by 1) the failure to ensure that documentation of the Physicians' Certification of Incapacity to Make an Informed Decision was kept in the facility's medical record (Resident #26); failed to ensure that old MOLSTs were voided when a new MOLST was completed (Resident #48). Additionally, based on interview and review of the medical record, it was determined that the facility staff failed to maintain accurately documented resident records by failing to maintain an accurate account of residents' personal property. This was evident for 1 (#105) of 2 residents reviewed for personal property. Also, based on record reviews it was determined that the facility failed to maintain accurate medical records, by having contradictory CPR (Cardio-Pulmonary Resuscitation) orders active in the medical record. This was evident for 1 resident (#132) out of 3 closed records reviewed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that orders for life-sustaining treatment were made in accordance with residents' advance directives, . This was found to be evident for 2 (Resident #26, Resident # 113) out of 6 residents reviewed for advance directives. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. According to Maryland's Health Care Decision Act, unless otherwise provided in the document, an advance directive shall become effective when the patient's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision. 1) On [DATE], review of Resident #26's medical record revealed the resident was initially admitted to the facility in [DATE]. Review of the MOLST…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement a grievance policy as evidenced by staff failing to report resident concerns to a supervisor. This was evident for 1 (#59) of 9 residents reviewed for abuse. The findings include: A medical record review for Resident #59 was conducted on 8/2/22 at 10:24 AM and revealed a History and Physical progress note from Attending Physician #61 that documented Resident #59 was in the facility for ongoing medical management. Resident #59 was on hemodialysis due to Chronic Renal disease, and had the following diagnoses: high blood pressure, pain in left shoulder, blindness, and muscle weakness. Further review revealed a Minimum Data Set, (MDS) with an assessment reference date of 5/26/22, that documented in section C that Resident #59 scored 15:15 on the Brief Interview for Mental Status which indicated Resident #59 had no cognitive impairment. In section G it was documented that Resident #59 relied on staff for most daily functions, such as eating, toileting, bathing, personal hygiene, 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 implement their abuse policy by failing to recognize, report, and investigate a resident's missing wheelchair as misappropriation of resident property. This was evident for 1 (#94) of 2 residents reviewed for personal property. The findings include: On 8/10/22 at 10:30 AM, a medical record review for Resident #94 revealed a Minimum Data Set, (MDS) with an assessment reference date of 6/19/22, which documented in section C that Resident #94 scored a 12:15 on the Brief Interview for Mental Status, which indicated no cognitive impairment. Documentation in section G revealed that Resident #94 relied on staff for transferring him/her from bed to chair and relied on wheelchair for locomotion on the unit. During an interview on 7/26/22 at 11:23 AM, Resident #94 reported that he/she had brought a wheelchair from home when admitted to the facility. Resident #94 reported that an unidentified staff member had taken the wheelchair from Resident #94's room and told the resident she was borrowing 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 record review and staff interview, it was determined that the facility failed to protect their residents from a staff member who had been accused of abuse of a resident as evidenced by the staff member continuing to work with vulnerable residents after an allegation of abuse had been received. This was evident for 1 (#59) of 9 residents reviewed for abuse. The findings include: A review of an email sent to surveyor on 8/2/22 at 9:54 AM, revealed a police report that was filed on 7/29/22, for an allegation of abuse regarding Resident #59. An interview with the Administrator on 8/2/22 at 11:54 AM, revealed that she had a visit from 2 detectives regarding the abuse report, however, she was not given the alleged perpetrator's name. The Administrator reported that she had initiated an investigation. Administrator was informed of the complaint #MD00180931 which had named a perpetrator of Certified Nursing Assistant (CNA) #59. She stated she would investigate it and provide the results of the investigation to the survey team. A review of the facility's investigation file on 8/8/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to have an effective system in place to ensure that residents and the resident's responsible representative were notified in writing of the bed hold policy at the time of transfer to a hospital. This was found to be evident for 4 (Resident #26, #196, #192, #133 ) out of 12 reviewed for hospitalizations during the investigative portion of the survey. The findings include: A Bed-hold policy is the facility's policy regarding holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) Review of Resident #26's medical record revealed that the resident had severly impaired cognitive skills, and had two certification of incapacity to make informed decisions. The resident had a health care power of attorney (responsible respresentative). The resident was admitted to the facility in January 2022 and had a discharge to the hospital in June 2022 with a re-admission in July. Further review of the medical record revealed that a Notice 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 facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#131, #31) of 6 residents reviewed for positioning and mobility. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 7/25/22 at 12:10 PM, Resident #131 was observed wearing a right hand splint (brace), sitting at a table in the dining area. At the time, the resident was observed picking up food with his/her left hand, feeding self with staff supervision. On 7/27/22 at 9:32 AM, Resident #131 was observed wearing a right hand splint while walking independently in the hall, and, on 8/1/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the medical record and interview with staff, it was determined that the facility staff failed to review and revise the residents care plans after each comprehensive and quarterly assessment, failed to ensure that the residents and/or residents' representative were included in the development of the care plan and failed to update the resident's care plan when there was a change in their wishes for CPR and life sustaining measures. This was evident for 2 (#105, #23) of 4 residents reviewed for Care Plan. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Resident #105's representative was interviewed on…

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

Based on medical record review, review of complaints and interviews, it was determined that the facility failed to ensure that staff were able to access an interim supply of medications prior to the pharmacy's delivery of a resident's medication; failed to ensure that pain medication was administered according to the ordered parameters, failed to ensure that medication was administered as ordered; failed to ensure there were orders and a care plan to address the continued use of an indwelling urinary catheter, failed to provide care in accordance with standards of nursing practice by failing to follow physician orders, failed to reveal documentation to indicate that staff had attempted to obtain a urine sample, and failed to have an effective system in place to relay recommendations from consultations. This was found to be evident for 7 (Resident #193, #192, #197, #201, #202, #233, #21) out of 79 residents reviewed during the investigation stage of the survey. The findings include: 1) Review of Resident #193's medical record revealed that the resident was admitted to the facility…

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

Based on medical record review, interview and observation, it was determined that the facility failed to ensure tha wound treatments were completed as ordered and failed to ensure orders for treatment were included in the medical record. This was found to be evident for 1 (Resident #24) out of 5 residents reviewed for pressure ulcers. The findings include: On 8/2/22, review of Resident #24's medical record revealed the resident had wounds to the right foot with orders for daily dressing changes. On 8/04/22 at 1:20 PM, surveyor observed nurse #65 prepare for and complete Resident #24's dressing changes. While preparing for the dressing change, surveyor observed nurse #65 obtain supplies which included: one pad of calcium alginate silver; one pad calcium alginate plain and one honey coated absorbent dressing. Surveyor observed the nurse remove the old dressings and then proceeded to clean three wounds: one on the ankle, one on the lateral (outer) side of the foot and one on the medial (inner) side of the foot. The nurse proceeded to apply the silver alginate dressing to the ankle…

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

Based on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that restorative nursing services were encorporated into residents' care plans and provided by staff as recommended upon discharge from therapy; failed to ensure for therapy evaluations were acted upon and care plans were updated to reflect current goals and interventions, and failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion by failing to ensure that a resident's feet were supported when sitting in a wheelchair. This was found to be evident for 2 (Resident # 26, #33) out of 10 residents reviewed for activities of daily living (ADL) and 1 (Resident #48) out of 6 residents reviewed for mobility/positioning. The findings include: 1) Review of Resident #26's medical record revealed that the resident had severely impaired cognitive skills, required extensive assist for bed mobility and total dependence on staff for transfers and bathing. On…

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

Based on observation, record review and interviews, it was determined that the facility failed to have an effective system in place to ensure assessment of residents for the use of side rails, and that the resident and or the responsible representative were educated regarding the risks and benefits prior to the installation of side rails, and failed to ensure the mattress appropriately fit the bed in which side rails were being used. This was found to be evident for 2 (Resident #26 and # 188) out of 7 residents reviewed for accidents. Bed rails (also known as side rails) and grab bars are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. All bed rails should be used with caution, especially with older adults and people with altered mental status, physical limitations, and certain medical conditions. The findings include: Review of Resident #26's medical record revealed 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.

Based on record review and staff interview, it was determined that the facility failed to ensure that Certified Nursing Assistants working during the blanket waivers issued during the COVID - 19 pandemic had been appropriately trained when the waiver ended. This was evident for 2 (Staff #59 and Staff #60) of 2 staff reviewed. The findings include: An interview with Staff #60 on 7/27/22 at 11:11 AM revealed that she was a Certified Nursing Assistant and had not been certified as a Geriatric Nursing Assistant. A review of employee record for Staff #59 on 8/8/22 at 2:45 PM, revealed a Maryland Certification as a Nursing Assistant and not a Geriatric Nursing Assistant. Staff #59 had been hired in March 2020. On 8/8/22 at 3:01 PM, an interview with the Administrator revealed that she thought the waiver for GNA certification had been extended and would bring the guidance to the survey team. A review of the state licensing board revealed that Staff #59 had been a certified as a nursing assistant in 2020, no Geriatric certification had been issued. Staff #60 had been certified as a nursing…

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

Based on review of medical records and interviews, it was determined that the facility failed to ensure that narcotics removed from the resident's supply were administered to the resident as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was found to be evident for 1 (Resident #193) out of 5 residents reviewed during the survey. The findings include: Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, and osteoarthritis. Review of a physician progress note, with an effective date of 4/10/22, revealed the resident had decreased range of motion of the left hip secondary to pain and that the resident was on oxycodone and Tylenol for pain. Oxycodone is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely respond and act upon a pharmacist's recommendations when notified of an irregularity,failed to ensure that the attending physician document in the medical record when an irregularity had been reviewed and what, if any action was taken, failed to ensure that the pharmacists findings were included in the resident's medical record or maintained within the facility and readily available for view, and failed to develop and maintain a policy that included the time frames for the physician to respond when notified of an irregularity in a residents monthly drug review. This was evident for 2 (#131, #23) of 6 residents reviewed for Advanced Directives. The findings include: 1) On 8/1/22 at 9:00 AM, a review of Resident #131's medical record revealed in a Consultant Pharmacist Report, dated 5/15/22, that the pharmacist requested the physician evaluate if a Trazodone (antidepressant) dosage reduction could be attempted at that time, which was followed by a handwritten…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to ensure that residents were free from excessive medication as evidenced by administration of narcotic pain medication outside of the ordered parameters. This was found to be evident for 1 (Resident #193) out of 5 residents reviewed during the survey. The findings include: 1) Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, and osteoarthritis. Review of a physician progress note, with an effective date of 4/10/22, revealed the resident had decreased range of motion of the left hip secondary to pain and that the resident was on oxycodone and Tylenol for pain. Oxycodone is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track 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 interviews, it was determined that the facility failed to assess and document the indications for administering a PRN (as needed) psychotropic medication to a resident. This was evident for 1 Resident (Resident #188) out of 5 residents reviewed regarding unnecessary medication. The findings include: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. On 8/3/2022 at 3:06 PM, review of Resident #133's medical record revealed that the resident was admitted for rehab following a hospitalization with diagnoses including, but not limited to, anxiety disorder. Further review revealed a physician order for Alprazolam tablets .5mg by mouth every 8 hours as needed for anxiety related to adjustment disorder with mixed anxiety and depressed mood. These orders were in effect from 7/19/22-7/28/2022. Alprazolam is an antianxiety medication. On 8/5/22 at 9:12 AM, review of the medication administration Record (MAR), revealed the administration of Alprazolam on 7/19/2022, 7/24/2022, 7/26/2022 and 7/28/2022.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#50, #286) of 6 residents observed with 34 medication administration opportunities resulting in an error rate of 5.88 % by 2 Licensed Practical Nurses. The findings include: 1) ER (extended release) initials that follow the name of the medication means the medication will be released in the blood stream over an extended period. Breaking or crushing the pill form of the medication may cause too much of the medication to be released at one time which could cause serious side effects. EC and ER medications should not be crushed. On 8/11/22 at 9:23 AM, during an observation of medication administration, LPN, Staff #39, was observed dispensing 9 pills into a medication cup for Resident #50. One of the pills was Potassium Chloride ER. Staff #39 was then observed to crush the pills and mix the crushed pills in applesauce for the resident to take by mouth. Staff #39 committed an error while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that residents were free from significant medication errors as evidenced by the failure to administer an anticoagulant medication on two consecutive days to a resident who recently had surgery, thereby putting the resident at increased risk of developing a blood clot. This was found to be evident for 1 (Resident #193) out of 79 residents reviewed during investigative stage of the survey. Additionally, the facility failed to ensure that residents receive their medications as prescribed as evidenced by staff failing to administer a resident's medication as prescribed. This was found to be true for 1 (Resident #94) out of 79 residents reviewed. The findings include: 1) Review of Resident #193's medical record revealed the resident was admitted to the facility for rehabilitation in April 2021 after a hospitalization for a hip replacement. The resident also had diagnoses of, but not limited to, high blood pressure, osteoarthritis and anemia. Review of a physician progress note, with an effective…

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

Based on observation and staff interview, it was determined the facility staff failed to ensure that all medications and biologicals were stored and labeled properly. This was evident for 1 (#5) of 6 residents reviewed from medication administration and 3 of 4 medication carts reviewed for medication storage during the survey. The findings include: 1) On 8/12/22 at 9:26 AM, during a medication observation, Staff #38, LPN was observed administering medication to Resident #5. Following the medication observation, a review of Resident #5's August 2022 MAR (medication administration record) revealed a physician's order for Flonase Suspension (Fluticasone Propionate) 2 sprays in both nostrils one time a day was signed off as given to Resident #5, on 8/12/22 at 9:00 AM, however, the administration of the Flonase was not observed by the surveyor. On 8/12/22 at approximately 2:30 PM, during an interview, Staff #38 stated he/she had administered the Flonase to Resident #5 prior to the med pass observation, he/she then opened the medication cart to show the surveyor the resident's Flonase,…

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

Based on observation and interview, it was determined that the facility failed to ensure that clean dishes were stored in a manner to prevent contamination. This practice has the potential to affect all residents who consume food provided by the facility kitchen. The findings include: On 7/25/22 at 8:28 AM, surveyor observed several bins containing bowls. The bins were open with no cover. Several of the bowls inside the bins were open side up with visible water pooling in the bottom of the bowl. The kitchen staff (staff # 51) identified these as clean bowls. He was alerted to the water at the bottom of the bowls. He removed the bowls that contained water. He stated that the clean dish bin should not be this close to washing area. He then closed the lid to the bin. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganisms can grow. During an Interview with Kitchen staff #51 on 7/25/22 at 8:30 AM, he stated that the dishes are dried in the dishwasher. The dried dishes are stored in the clean area…

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

Based on review of the Quality Assurance and Performance Improvement (QAPI) Program plan and interview with staff, it was determined that the facility failed to develop a facility specific QAPI plan. This deficient practice has the potential to affect all of the residents. The findings include: As part of the initial entrance conference conducted with the Administrator on 7/25/22, a copy of the facility's QAPI plan was requested. A QAPI plan is the written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improve. The plan should describe how the facility will conduct its required QAPI committee functions. The QAPI plan must describe in detail the scope of the QA committee's responsibilities and activities, and the process addressing how the committee will conduct the activities necessary to identify and correct quality deficiencies. Review of the QAPI Program documentation revealed the following under Implementation: 1. The QAPI Committee oversees implementation 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 clinical record review and staff interviews, it was determined that the facility staff failed to invite residents and/or their representative for interdisciplinary care conferences (an interdisciplinary team is made of the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, the resident and the resident's representative if practicable) to review and revise residents' care plan after each assessment. This finding was evident for 4 of 34 residents reviewed for care plans (Resident #17, #39, #88, #126). The findings include: MDS (Minimum Data Set) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Quarterly review assessment is an assessment due no less frequently than every 92 days. 1. On 12-04-19 clinical record review of Resident #88 revealed that they had MDS quarterly review assessments with an ARD (assessment reference date) of 05-22-19, 08-22-19, 09-20-19, 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 clinical record review and interviews with facility staff, it was determined that the facility failed to provide behavioral monitoring and behavioral interventions for 10 of 11 residents selected for review of psychotropic medications (Residents #26, #37, #49, #54, #59, #85, #108, #123, #128, #343). The findings include: 1. On 12-04-19 at 09:50 AM, A review of Resident #108's clinical record revealed the resident was prescribed routine psychotropic medications in August 2019. Further review of the clinical record revealed no documented evidence that non-pharmacological behavioral interventions were attempted by the staff. Furthermore, there was no documented evidence that the facility staff were monitoring the resident's targeted behaviors to assess whether the psychotropic medications were effective or ineffective. On 12-04-19 at 02:30 PM, interview with the Director of Nursing revealed no additional information. 2. On 12-04-19 at 12:29 PM, the review of Resident #26's clinical record revealed that the resident received psychotropic medications at the facility. Further review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 surveyor observation and interviews with facility staff, it was determined that the facility failed to provide personal privacy and confidentiality of patient information by discarding patient names and medication labels in the common trash. This finding was evident for 4 of 40 sampled residents (Residents #30, 35, 104, and 109) and on 2 of 5 medication carts reviewed for medication storage and labeling during the survey (carts #1 and #2) . The findings include: 1. On 12-05-19 at 11:35 AM, surveyor observation of 1 [NAME] unit's medication cart (cart #1) revealed medication labels with the names of residents #30 and #35 in the common trash. On 12-05-19 at 11:35 AM surveyor interview with the 1 [NAME] Unit Manager revealed it is the facility's protocol to discard medication labels with patient information in the secured shredder box. On 12-05-19 at 1:00 PM, interview with the Director of Nursing revealed no new information. 2. On 12-05-19 at 11:50 AM, surveyor observation of the 2 [NAME] unit's medication cart (cart #2) for rooms 265-277 revealed medication labels 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to identify discharge plans in the comprehensive care plan. This finding was evident for 4 of 34 (#39, #75, #127, and #242) residents selected for review during the survey. The findings include: 1. On 12-05-19 at 1:00 PM, the review of Resident #242's clinical record revealed he/she was admitted to the facility in November 2019. There was no evidence that a care plan to address the resident's discharge plan was developed. On 12-05-19 at 2:00 PM, interview with the Director of Nursing revealed no additional information. 2. On 12-05-19 at 1:30 PM, a review of Resident #75's clinical record revealed he/she was admitted to the facility in July 2019. There was no evidence that a care plan to address the resident's discharge plan was developed. On 12-05-19 at 2:00 PM, interview with the Director of Nursing revealed no additional information. 3. On 12-05-19 at 1:45 PM, surveyor review of resident #127's clinical 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.

Based on clinical record review and interviews with resident and staff, it was determined that the facility staff failed to follow physician's orders for 2 of 34 residents reviewed during the survey (Residents #192 and #442). The findings include: 1. On 12-03-19, clinical record review revealed that Resident #192 was admitted to the facility with multiple wounds. A review of the physician's orders for the resident revealed an order for barrier cream to be applied to the area of moisture associated skin damage (MASD). MASD is inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. Further review of the clinical record revealed Resident #192 had an initial wound evaluation and treatment on 11-27-19 by a wound physician. After evaluation, the wound physician ordered that Silver Sulfadiazine be applied on Resident #192's area of MASD twice daily. He had also ordered to float (off load) Resident #192's heels in bed. However, as of 12-04-19 there was no documented evidence that the facility staff…

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

Based on the review of a clinical record and interviews with a resident and with the facility staff, it was determined that the facility staff failed to refer 1 of 1 residents, selected for communication-sensory review for, services (Residents #126). The findings include: On 12-03-19 at 9:47 AM, an interview was conducted with Resident #126. The resident was alert and oriented at the time of the interview. The surveyor was informed that the resident had poor vision and it was getting worse. The resident revealed that the facility was informed but noted that no follow up or information concerning an appointment was provided to the resident. On 12-04-19 a review of Resident #126's clinical record revealed a care plan for impaired visual function related to glaucoma, initiated on 03-25-19. On 12-04-19 at 3:30 PM, surveyor interview with the 2 [NAME] Unit Manager revealed that she was familiar with the needs of Resident #126 to be seen for a vision assessment. She stated We talked about it. Resident #126 is on the list for appointments. We recently made a change to vendors, which…

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

Based on clinical record review and interviews with facility staff, it was determined that the facility staff failed to document a resident's negative medical change leaving the clinical record incomplete. This finding was evident for 1 of 34 residents selected for review during the survey (Resident #126). The findings include: On 12-06-19, surveyor review of the clinical record for Resident #126 revealed diagnoses that included but were not limited to Parkinson's Disease, dementia, anxiety disorder, major depressive disorder, brief psychotic disorder and adjustment disorder with depressed mood. The resident was routinely seen by the facility's attending physician, a facility nurse practitioner, a psychiatrist, and a psychiatric nurse practitioner. Further review of Resident #126's record revealed that on 05-23-19, the psychiatrist added a physician certification of incapacity to make informed decisions form to Resident #126's record, declaring that the resident was incapable of making an informed decision for treatment(s) based on the condition of Parkinson's Disease and dementia.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrative record review, and staff interview, it was determined that the facility staff failed to review and revise the facility's Infection Prevention and Control Program (IPCP) policies and procedures annually. In addition, the facility staff also failed to put the date changed on oxygen tubing and nebulizer tubing (Nebulizer tubing is an essential accessory that connects nebulizer kit to nebulizer compressor) and store them to prevent possible infection. This finding was evident for 2 of 3 residents reviewed for respiratory care (Resident #442, Resident #34). The findings include: 1. On 12-09-19 administrative record review revealed that the facility staff reviewed and revised IPCP policies and procedures on 05-09-18. Per federal regulation, the facility staff must have reviewed and revised the IPCP policies and procedures on 05-09-19. However, there was no evidence that it was done annually. On 12-09-19 at 09:12 AM, interview with the Assistant Director of Nursing (ADON) revealed no additional information. 2a. On 12-02-19 at 9:35 AM surveyor observation revealed…

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

Based on record review and surveyor interview, it was determined that the facility failed to administer influenza and pneumococcal immunizations and to provide education regarding benefits and potential side effects of each vaccination. This was evident for 2 of 7 residents selected for review of immunizations during this survey ( Residents #54 and #85). The findings include: 1. On 12-06-19 at 10:38 AM, surveyor review of Resident #54's clinical record revealed they did not receive the influenza immunization. There was no evidence that facility staff offered the influenza immunization to the resident. On 12-06-19 at 12:49 PM, interview with Staff #5 revealed that she did not know why Resident#54 had not received the Influenza immunization. On 12-09-19 at 09:35 AM interview with Director of Nursing (DON) revealed no further information. 2. On 12-06-19 at 12:49 PM, surveyor review of Resident #85's clinical record revealed they did not receive the pneumococcal immunization Resident #85's clinical record indicated the physician had placed an order on 10-14-19. However, there was no…

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

Based on surveyor observation and interviews with residents and facility staff, it was determined that the facility failed to ensure a resident's bed was in safe operating condition (Resident #242). This finding was evident for 1 of 93 rooms observed during the survey. The findings include: On 12-02-19 at 11 AM, surveyor observation of Resident #242's bed revealed the bed controller cord was frayed. On 12-02-19 at 11:05 AM, interview with Resident #242 revealed the bed controller intermittently worked and they reported the malfunctioning equipment to the staff last week but nothing had been done. On 12-02-19 at 02:55 PM, interview with the administrator revealed no new information.