Potomac Valley Rehabilitation And Healthcare

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents. The findings include: 1) While observing the lunch tray line on 3/20/25 at 11:54 AM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #148 that listed food items that were to be served: 1-3 oz BBQ chicken on BUN, 4 oz Calico coleslaw, 1/2 slice lemon cake, 4 oz apple juice, 8 oz milk 2%, 8 oz coffee. However, continued observation failed to show that Resident #148's tray contained 4 oz of coleslaw and 8 oz of 2% milk. The food service manager was present and was made aware of the concern that Resident #148's tray did not contain 4 oz of calico coleslaw and milk. She confirmed the concern. In an interview on 3/24/25 at 9:30 AM, the director of food services stated that the cook had used a 2 oz scoop to serve Resident #148's coleslaw on 3/20/25. The regional food…

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

Based on observations, record review, and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: An initial tour of the facility's kitchen with the food services supervisor on 3/17/25 at 8:50 AM revealed the following: -An opened container of French salad dressing labeled with the date opened as 2/10/25. Staff indicated that it should only be kept for one month after opening. -Leftover ground sausage links labeled with the date prepared as 3/1/25. The staff stated it was supposed to be kept for a day. - A bag of pancakes was found open without a label indicating its opening date. Staff confirmed that all opened food items should be labeled with the opening date to ensure proper freshness. - A plate of leftover cold salad had no label of the date it was prepared. A plate of leftover chef salad was not labeled with the date it was prepared. The staff stated that it should have been labeled. Later that day, a review of the facility's policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' medical records were complete and accurately documented. This was evident for three (Resident # 104, #3 and #145) out of 37 resident's reviewed during the survey. The findings include: A Medical Orders for Life-Sustaining Treatment (MOLST) form is a medical order that reflects a patient's wishes regarding end-of-life care. It contains orders regarding the administration of cardiopulmonary resuscitation (CPR); and can contain additional orders for items like transfer to the hospital and the use of dialysis. 1)On [DATE] at 1:32 PM, the surveyor reviewed Resident #104's medical records and found a MOLST form dated [DATE]. This MOLST included orders for: Do Not Resuscitate and Do Not Hospitalize. Further review of the medical record revealed a progress note, dated [DATE], which revealed the family expressed concern over the current MOLST orders and indicated the primary care provider was contacted by 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 observation and interviews it was determined that the facility failed to treat residents with dignity. This was evident for 1 resident (Resident #157) of 32 residents observed during the recertification survey. The findings include: On 3/19/25 at 10:06 AM Resident #137 was observed seated in a Geri chair in the hallway outside of the facility's rehabilitation department. Physical Therapy Aide (Staff #4) was observed to drag the resident in the Geri chair backwards down the hall to the resident's room. On 3/19/25 at approximately 10:11 AM, Staff #4 was interviewed in Resident #137's room and she confirmed that she pulled the resident backwards down the hall. She did not acknowledge that this was a concern. On 3/19/25 at 10:14 AM an interview with the Nursing Home Administrator (NHA) was conducted to review the observation of Resident #137 being pulled backwards through the hallway. On 3/19/25 at 11:01 AM an interview with the Director of Nursing (DON) was conducted to review the concern and she confirmed that she was aware of what happened and had already provided 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 records review and interviews, it was determined that the facility failed to ensure financial records were made available to residents through quarterly statements. This was evident for 1 (Resident #90) of 1 resident reviewed for personal funds. The findings include: Resident #90 had been residing in the facility since 2023. An interview with the resident was conducted on 3/17/25 at 10:58 AM. During the interview, the resident indicated that s/he had a personal funds account managed by the facility but did not know how much was in it. When the resident was asked if the facility provided him/her with quarterly statements, s/he answered No, I would like to know. A review of Resident #90's medical records on 3/20/25 at 9:34 AM, revealed a progress note by the previous social worker (Staff #17) with a reference date of 8/12/24. The progress note documented a discussion between Staff #17 and the resident about salon services and that the resident had funds in the business office account. On 3/20/24 at 9:46 AM, the Business Office Manager (BOM Staff #18) was interviewed 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 record review and interviews it was determined that the facility failed to offer information and education to residents regarding advance directives. This was evident for 2 residents (Resident #40, #95) of 5 residents reviewed for advance directives. The findings include: 1). On 3/17/25 at 2:14 PM a review or Resident #40's medical records failed to reveal any advance directives documents. On 3/19/25 at 9:31 AM further medical record review revealed two social worker assessments, one dated 1/13/25, and one dated 10/15/24, written by social worker (SW #16). Both assessments indicated that the resident did not have an advance directive, and that no information was offered to the resident. Further review revealed additional social worker assessments dated 7/15/24, 4/18/24, 3/18/24, and 12/19/23 that were documented by SW #17 that also indicated the resident did not have an advance directive, and that no information was offered to the resident. On 3/19/25 at 10:15 AM an interview was conducted with SW #8. She explained the facility's process regarding advance directives 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #32) of 3 residents reviewed for communication and sensory, 1 (Resident #119) of 2 residents reviewed for limited range of motion (ROM) and 1 (Resident #145) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR). The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process…

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

Based on record reviews and interviews, it was determined that the facility failed to provide residents with the necessary assistance to complete an activity for daily living. This was evident for one (Resident #213) of four residents reviewed for activities of daily living. The findings include: 1) Resident #213 resided in the facility for about a month. On 3/18/25 at 3:08 PM, the complaint details related to MD00215554 were reviewed and indicated that the resident was not provided necessary assistance to maintain his/her weight. On 3/25/25 at 9:25 AM, a review of Resident #213's admission comprehensive assessment with a reference date of 2/11/25, coded the resident as needing supervision or touching assistance when eating. This is when the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. A review of the Geriatric Nursing Assistant's (GNA) task documentation for a) Eating (Support provided) was reviewed and compared to b) Meal intake (What percentage of the meal was eaten), on 3/25/25 at 10:26 AM. That…

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

Based on record reviews, observation and interviews, it was determined that the facility failed to ensure appropriate services and care were provided to a resident with an indwelling urinary catheter by failing to secure the urine collection bag. This was evident for 1 (Resident #142) of 2 residents reviewed for urinary catheter. The findings include: A Foley catheter is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons. Another name for a Foley catheter is an indwelling urinary catheter. The catheter is held in the bladder by a water-filled balloon, which prevents it from falling out. Securing a urine collection bag is crucial to prevent leaks, reduce the risk of infection, and ensure proper catheter function, as well as prevent damage to the bladder neck or urethra. An observation of Resident #142 was conducted on 3/18/25 at 10:14 AM. At this time, the resident was observed sleeping in bed with the urine collection bag lying directly on the floor, under the bed. 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 observation, record review, and interview, it was determined that the facility failed to have a system in place to ensure resident's nutritional status was accurately assessed. This was evident for 1 resident (Resident #128) of 5 residents reviewed for nutrition. The findings include: On 3/18/25 at 10:26 AM Resident #128 was observed as he/she walked in the hallway next to his/her room. A Geriatric Nursing Assistant (GNA) walked next to the resident. The resident appeared very tall, much taller than the GNA. On 3/18/25 at 11:01 AM a record review of Resident #128's height documentation revealed documentation dated 8/22/23 that the resident's height was 68 inches. On 3/20/25 at 3:49 PM an interview was conducted with the facility dietitian (Staff #12) and she was asked if she assessed Resident #128 in person. Staff #12 said yes. When asked if 68 inches was an accurate height for this resident, she said she thought so. When asked how any discrepancy would be determined, she said that nursing staff measured and documented residents' height and weight. She further explained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #43, and #512) of 3 residents reviewed for pain management. The findings include: 1) Oxycodone is used to relieve moderate to severe pain. It belongs to the group of medicines called opioid analgesics (pain medicines). Non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. Resident #43 was admitted to the facility in late 2020. A review of the resident's medical record on 3/19/25 at 9:15 AM revealed an order for Oxycodone to be taken every 4 hours as needed for severe pain. No other documentation was found to indicate other measures or interventions to manage the resident's pain. On 3/19/25 at 9:29 AM, Resident #43's electronic Medication Administration Record (eMAR) for February and March 2025 were reviewed. The review revealed that the…

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

Based on record review and interviews, it was determined that the facility failed to ensure that a resident with a history of trauma received the appropriate trauma-informed care. This was evident for one (Resident #145) out of one resident who was reviewed for mood and behavior. The findings include: A record review on 3/18/25 at 3:32 PM included a hospital discharge summary for Resident #145 that recorded a history of post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). A continued review showed a Trauma-informed screen completed on 9/9/24 and 2/14/25, which noted that Resident #145 had a history of trauma. Further review contained a care plan initiated on 9/10/24 and revised on 2/14/25 for the history of trauma. However, the review failed to show what the triggers were for the specific traumatic event and how to mitigate or eliminate them to ensure the Resident was not traumatized again. In an interview on 3/20/25 at 2:58 PM, the director of nursing confirmed that the Resident's care…

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

Based on observation, staff interviews, and record review it was determined that the facility failed to ensure that staff accurately reconciled controlled medications using acceptable standards of practice. This was found to be evident on 2 out of 4 nursing units. The findings include: During observation of the facility narcotic books, it was observed that 3 out of 3 licensed personnel on 3 different care units had inaccurately documented narcotic reconciliation and 1 out of 3 licensed personnel inaccurately documented administering a narcotic. Typically, a reconciliation count for narcotics is conducted at the end-of-shift with the oncoming licensed personnel counting and the outgoing licensed personnel verifying the accuracy; both licensed personnel verify the accuracy via documented initials in the narcotic book. Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications. The reconciliation identifies loss or potential diversion of controlled medications so as to minimize the time between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to ensure that the attending physician document in the resident's medical record included the rationale for not changing medications after being identified as an irregularity. This was evident for 1 (Resident #43) of 5 residents reviewed for unnecessary medications. The findings include: Resident #43 had been a resident of the facility since 2020. A review of the resident's medical record indicated that the resident was hospitalized and was readmitted on [DATE]. In an interview with the Director of Nursing (DON) on 3/19/25 at 10:04 AM, she reported the facility's process with Medication Regimen Review (MRR). The DON indicated that when reports are printed out for identified irregularities, the attending physician would write their response on the actual report and after implementation of the response, the reports are scanned into the resident's medical records. On 3/19/25 at 10:32 AM, Resident #43's medical records were reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and record review, it was determined that the facility failed to maintain and secure controlled medications in a separately locked, permanently affixed compartment. During observation of facility medication storage refrigerators, it was observed that 1 out of 2 refrigerators were found to have an unlocked storage compartment that contained controlled medications. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The findings include: On 3/20/25 at 12:24 PM Nurse #28 accessed the locked medication refrigerator on the Delaware Unit when it was observed that the inside controlled compartment containing Lorazepam (a scheduled IV drug) was unlocked and opened. Nurse #28 acknowledged that it shouldn't be like that. Nurse #28 did not possess or know the whereabouts of a key to lock the compartment. Eventually, Nurse #28 retrieved from Nurse…

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

Based on record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure dental recommendations were followed through. This was evident for 1 (Resident #123) of 2 residents reviewed for dental care. The findings include: Resident #123 was admitted to the facility in 2023. On 3/17/25 at 10:28 AM, the resident was interviewed and reported having 2 bad teeth that were discovered sometime before Christmas. The resident stated: a dentist came in and x-rayed it and told me they needed to be pulled. I had abscess in the gums, they gave me antibiotics and it went down for a while but came back. An interview with the Director of Nursing (DON) was conducted on 3/21/25 at 9:12 AM. During the interview, the DON reported on the facility's process with providing dental care to the residents. The DON also reported that notes from dental visits should be in the resident's progress notes or uploaded in the medical record depending on the resident's insurance. Resident #123's medical record was reviewed with the DON but did not find the notes…

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

Based on observation, interview, and record review it was determined that the facility failed to follow accepted infection control procedures. This was found to be evident for two (Resident #32 and #111) out of the 32 residents observed during the initial stage of the survey. The findings include: 1) An observation on 3/17/25 at 10:23 AM showed signage on Resident #32's door that indicated that the Resident was on droplet precautions. Staff were required to wear masks, gowns, and gloves upon entry to the Resident's room. The observation also showed a supply of gowns in a clear plastic container at the entrance of the Resident's room. Droplet precautions are infection control measures that prevent infection transmission through respiratory droplets, such as coughs, sneezes, talking, or heavy breathing. Continued observation noted a geriatric nurse assistant (GNA Staff #20), in Resident #32's room and providing morning care to the Resident. GNA #20 wore gloves and a mask, but the observation failed to show that she wore a gown. GNA #20 was questioned then and stated that she was…

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

Based on medical record review and interview, the facility failed to provide a psychiatric evaluation for a resident that alleged abuse (resident #15). This is evident in 1 of 17 residents reviewed during a complaint survey. Findings includes: Review of Resident #15's medical records on 12/20/24 at 9:20am revealed the resident alleged that LPN #31 abused him/her on 8/24/22. Continued review resident #15's medical records revealed no evidence that the resident was offered a psychiatric evaluation/consultation after the alleged 8/24/22 abuse event. On 12/20/22 at 10:30am, the Director of Nursing (DON) confirmed that there was no evidence of a psychiatric evaluation/consultation offered to the resident after the alleged 8/24/22 abuse event.

Based on interview, record review, and facility policy review, the facility failed to retain a complete medical record for five years from the resident discharge date for 1 (Resident #16) of 17 sampled residents. Findings included: A facility policy titled, Medical Record Management, dated 01/09/2020, indicated, 1. Closed patient medical records are to be filed by discharge date . Keep until ten (10) years from discharge. 2. Closed patient medical records are to be kept 10 years plus five years from the date of majority (Date of majority is determined by state law. It is currently 18 years). An admission Record revealed the facility admitted Resident #16 on 09/14/2020. Per the admission Record, the resident discharged from the facility on 02/16/2021. Resident #16's medical record revealed no evidence of the resident's treatment administration records (TARs), medication administration records (MARs), or certified nursing assistant (CNA) task records for the period the resident was in the facility. During an interview on 12/19/2024 at 8:15 AM, the Director of Nursing (DON) stated she…

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

Based on observations and staff interview, it was determined that the facility's staff failed store opened food and condiments with a to print use-by dates on opened packages and containers of food stored in the facility's kitchen freezer and refrigerator. The findings include: On 1-06-2020 at 8:30 AM, during the initial kitchen tour, the surveyor observed multiple packages of previously opened food items were without a use-by date on them in the freezer. Previously opened packages of breakfast and deli meats, vegetables, and cake batter were not dated in the freezer. Additionally, a container of mayonnaise and a container of Italian dressing in the walk in refrigerator were opened, but did not have a use-by date printed on the containers. On 01-07-2020 at 3:36 PM, an interview with the facility administrator revealed no additional information

Based on clinical record reviews, and staff interviews, it was determined that the facility staff failed to follow an advance directive for 1 of 4 residents reviewed for advance directive care (Resident #143). The findings include: An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On 01-07-2020, a review of Resident #143 clinical record revealed that the resident had an advance directive signed on 10-12-2018 which stated the resident was required to be certified incompetent for making medical decisions by two licensed physicians before Resident #143's named health care agent shall be granted authority to make health care decisions on their behalf. Further review of the clinical record revealed that on 12-19-2019 the attending physician certified Resident #143 as incompetent for making medical decisions. As of 01-08-2020 facility staff had failed to…

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

Based on the review of clinical records and staff interviews, it was determined that the facility failed to complete the required Minimum Data Set (MDS) quarterly assessment for 1 of 33 residents reviewed during the survey (Resident #1). The findings include: The MDS quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's condition are monitored. On 1-08-2020 at 4:00 PM, a review of Resident #1's clinical record revealed a Minimum Data Set (MDS) quarterly assessment completed on 8-21-2019. There was no evidence in the clinical record that Resident #1 had a quarterly assessment completed for the following quarter (due on 11-21-19.) On 1-08-2020 at 4:46 PM, a surveyor interview with Staff #1 stated Resident #1 should have had a quarterly assessment completed on 11-21-2019, however, it was not completed. On 1-08-2020 5:19 PM, surveyor interview with the Director of Nursing revealed no additional information.

Based on the review of the clinical record and staff interview, it was determined that facility's staff failed to obtain a laboratory test as ordered. This finding was evident for 1 of 1 residents reviewed for the hydration care area (Resident #24). The findings include: On 1-07-2020, a review of the clinical record for Resident #24 revealed the resident had an elevated blood urea nitrogen level (BUN) of 59. The BUN is a blood test which shows how well the kidneys and liver are functioning. As a result of the elevated BUN, the nurse practitioner ordered a repeat Comprehensive Metabolic Profile (CMP) lab test every two weeks on 12-11-19. Further review of the clinical record revealed no evidence that the CMP lab test ordered to be drawn on or about 12-25-19 had been completed. On 1-08-2020, at 10:15 AM, an interview with the Bermuda unit manager revealed that upon surveyor intervention the physician was notified of the missed lab and ordered the CMP to be drawn on 1-09-2020 for Resident #24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, clinical record review, and interviews with facility staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs. This finding was evident for 1 of 33 residents (#67) selected for this survey. The findings included: On 11-09-18 at 9:15 AM, surveyor observation revealed resident #67 had uncontrollable tremors to his/her face and arms. Surveyor review of resident #67's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and extrapyramidal disorder. Extrapyramidal disorder is a group of disorders marked by abnormal involuntary movements. There was no evidence in the clinical record that the facility assessed the severity of resident #67's tremors or developed a care plan to address the diagnoses of Parkinson's disease or extrapyramidal disorder since admission. On 11-15-18 at 7:15 AM, surveyor interview with the…

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

Based on surveyor observations, review of the clinical record, and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice in medication administration for residents. This finding was identified for 2 of 33 residents selected for the survey. (#141 and #26) The findings include: 1. On 11-14-18, surveyor observation of Licensed Practical Nurse (LPN) #1 during medication pass revealed that the LPN administered 8 medications to resident #141 at 11:15 AM. However, review of the medication administration record revealed that these 8 medications were scheduled to be administered at 8 AM. On 11-14-18 at 11:30 AM, surveyor interview with LPN #1 revealed that the LPN did not administer the medications timely because he/she was waiting on one of the medications to be delivered from the pharmacy. According to the Maryland Nurse Practice Act 10.27.10.03B (2) (b), the LPN shall demonstrate knowledge and comply with: Relevant professional practice standards; relevant statutes and regulations governing licensed practical nursing; and 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 surveyor review of the clinical record and facility staff interview, it was determined that the pharmacy failed to ensure timely delivery of medications to the residents. This finding was evident for 1 of 6 (#141) resident records reviewed during the unnecessary medication review. The findings include: On 11-14-18 surveyor review of the clinical record for resident #141 revealed physicians orders, written on 11-12-18, for an antibiotic to be administered to the resident to treat pneumonia. Further review of the clinical record revealed a nurses note, written on 11-13-18 at 1:14 PM, that the antibiotic was not given and the facility staff was waiting on the pharmacy to deliver the medication. In addition, a nurses note, written on 11-13-18 at 11:30 PM, documented that staff had called the pharmacy because the antibiotic had still not been delivered by the pharmacy. On 11-14-18 at 11:30 AM, surveyor interview with LPN #1 revealed that the pharmacy did not deliver the antibiotic until 10 AM on 11-14-18.