Shady Grove Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff it was determined that the facility staff failed to: 1) ensure the resident's person-centered care plan was reviewed and revised in response to current interventions to meet the respiratory needs and 2) failed to ensure residents were offered the opportunity to participate in the care planning process by holding annual and quarterly care plan meetings. This was evident for 9 (#25, #38, #42, #49, #52, #54, #74, #82, & #95) out of 10 residents records reviewed for care planning during the recertification survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. The MDS…

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

Based on record reviews and interviews, it was determined that the facility failed to develop a care plan to manage the resident's new medical diagnosis. This deficient practice was evident for 1 (#25) of 10 residents reviewed for comprehensive care plans during the survey. The findings include: On 3/4/25 at 7:30AM, the surveyor requested documentation from the Director of Nursing (DON) #2 indicating that a care plan was developed following Resident #25's leg fracture on 8/21/24. During an interview with both the DON #2 and Social Worker (SW) #6 on 03/04/25 at 9:00 AM, they explained that a little over a month ago, the facility discovered that care plans were not being completed. They further stated that this issue was currently being addressed by the facility's Quality Assurance and Performance Improvement (QAPI) team. The DON #2 acknowledge that no care plan was developed following the resident's fracture. Review of Resident #25's medical records on 3/4/25 at 11:52 am, revealed that the resident was transported to the emergency department, diagnosed with a leg fracture, and return…

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 staff failed to adhere to professional nursing standards regarding implementing physician orders, medication administration times and documentation, and wound care orders/management and documentation. This deficient practice was evident in 8 (#25, #27, #82, #145, #79,) of 59 residents reviewed during the recertification survey. The findings include: 1. A review of Resident #82 physician's orders on 03/06/25 at 02:29 PM, revealed a current order dated 11/18/24, for weekly weights to be obtained every shift on Tuesdays for monitoring of GLP-1 medications. Further review of treatment administration records indicates that the weights were not documented as completed on 02/11/25, 02/18/25, 01/28/25, and 12/10/24, and there were no nursing notes explaining the missed weights. On 3/06/25 at 2:50 PM, during an interview with the Director of Nursing (DON) #2, when asked the expectation of nursing staff regarding physician orders, she explained that nurses are expected to follow the physician's orders. The surveyor…

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

Based on observations, record reviews, and interviews with staff, it was determined that the facility failed to ensure precautions were taken for residents' individual safety in need of supervision while smoking and failed to ensure smoking assessments were reviewed and revised due to a resident's current condition. This was evident for 4 (Resident #62, #63, #132, and #239) out of 15 residents reviewed for smoking. The findings include: On 2/28/2025 at 7:30AM, the Surveyor observed the facility's smoking area. There were no residents in the smoking area. On 2/28/2025 at 8:06AM, the Surveyor observed Resident #62 outside smoking. The Surveyor did not observe any staff providing supervision. There was a sign on the door that read, Supervised Smoking Times: 9:00AM-9:30AM, 11:30AM-12:00PM, 2:00PM-2:30PM, 6:00PM-6:30PM, and 9:30PM-10:00PM. On 2/28/2025 at 1:00PM, the Surveyor reviewed the facility's Smoker List as of 2/26/2025. According to the list, all residents identified as smokers did not need an apron, did not need supervision, had a nursing assessment for smoking, and a care plan…

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

Based on observations and interviews it was determined that the kitchen staff failed to store and label food to prevent potential foodborne illnesses, cover their hair to prevent food contamination, and failed to properly thaw food in the refrigerator. This deficient practice was discovered during the recertification survey. The findings include: On 02/27/25 at 8:34 am during the initial kitchen tour, the surveyor observed Dietary Aid #26 in the kitchen wearing a grey knitted hat with their hair exposed. Further observation of the freezer revealed: 1. an opened unlabeled and undated bag of exposed pepperoni 2. an opened undated bag of veggie patties 3. an opened box of hot dogs 4. an opened undated box of breaded oysters 5. a box of uncovered Tilapia dated 02/20/25 6. two bags of undated shrimp On 02/27/24 at 8:49 am when the surveyor checked the refrigerator and observed an undated and exposed American cheese and a box of un-thawed chicken on a sheet pan with a red substance on the fourth shelf on the left. During the surveyor's observations the issues were brought to the attention…

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 staff failed to 1) document a resident's personal belongings, 2) failed to maintain medical records in accordance with accepted professional standards and practices, and 3) failed to ensure residents' medical records were accurate and reflected their status. This deficient practice was evidenced in 9 (#41, #42, #58, #62, #63, #101, #102, #132, #239) of 29 resident record reviewed for accuracy of inventory during the recertification survey. The findings include: 1. On 02/27/25 at 11:03 am Resident #58 reported their white Nike Size 10 tennis shoes were missing and the facility staff had not replaced them. On 03/05/25 at 8:45 am the surveyor made Social Worker (MSW) #6 regarding Resident #58 reported their tennis were missing. The surveyor asked if a grievance was filed by Resident #58 concerning their missing tennis shoes. On 03/05/25 at 9:47 am MSW #6 provided three separate copies of Resident #58 Inventory of Personal Effects forms dated 05/11/21, 11/04/22, and 03/16/23. A note was written on each…

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

Based on observations and interviews it was determined that the facility staff failed to ensure residents had access to their call bells to notify the staff for assistance when needed. This deficient practice was evidenced in 7 (#45, #50, #89, #122 #124, #131, & #148) of 138 residents observed without their call bell during the survey. The findings include: On 02/27/25 at 7:48 am during the surveyor's initial observation rounds the surveyor observed multiple residents without their call bell within reach. At 7:52 am the surveyor observed Resident #148's call bell on the floor near the left side of the bed. Resident #131's call bell was hanging from the call bell system on the wall. At 7:58 am Geriatric Nursing Assistant (GNA) # 23 confirmed the surveyor's findings. At 8:08 am the surveyor observed Resident #45's call bell hanging over the side of their bed. GNA #24 confirmed the surveyor's findings. At 10:41 am the surveyor observed Resident #124's call bell hanging over the side of the bed. At 10:52 the surveyor observed Resident #89's call bell on the floor. At 10:55 am the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that facility staff failed to ensure a resident was dressed in their personal clothing as preferred. This deficient practice was evident for 1 (#287) of 138 residents observed for during the survey. The findings include: During observation of Senate Unit on 02/27/25 at 8:05 AM, the surveyor observed Resident #287 awake in bed wearing a hospital gown. A follow-up observation later that day at 2:15 PM revealed that Resident #287 was eating lunch in bed wearing a hospital gown. On 2/28/25 at 8:39 AM, the surveyor conducted rounds on Senate Unit and observed Resident #287 sitting in the dining room area, waiting for breakfast while wearing a hospital gown. The surveyor entered Resident #287's room to check the closet for personal clothing and confirmed that the resident had personal clothing available to wear. Review of Resident #287's medical record revealed that the resident was admitted to the facility on [DATE] with multiple medical conditions including…

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 staff failed to have a system in place to ensure that copies of the resident's Advanced Directives had been obtained and maintained in the resident's medical record; and failed to ensure that advance directives were discussed with residents and/or responsible representatives and proper information was provided. This was evident for 3 (#7, #27, & #101) out of 10 residents reviewed for Advanced Directives. 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. 1). On 3/3/2025 at 10:56AM, a review of Resident #7's electronic medical record revealed a Discharge Planning Psychosocial Assessment which indicated yes, the resident had an Advanced Directive. Further review failed to reveal any documentation of an Advanced Directive in the resident's electronic medical…

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

Based on record review and interview it was determined that the facility staff failed to ensure a resident received a skilled nursing facility beneficiary notice prior to discharge. This deficient practice was evidenced in 1 (#151) of 3 resident records for proper discharge documentation during the recertification survey. The findings include: On 03/04/25 at 10:41 am the survey provided MSW # 6 with three Skilled Nursing Facility Beneficiary forms to complete to verify the resident's received notification of discharge with the opportunity to appeal prior to their discharge. On 03/04/25 at 10:58 am MSW #6 provided documentation to verify one resident was discharged voluntarily, and two residents were not provided with a SNF Beneficiary Notice. The surveyor asked why the forms were not provided to the residents. MSW #6 verbalized the facility staff recognized there was a problem, and they are working on correcting the problem. Review of the documentation revealed Resident #151 did not receive SNF Beneficiary notice prior to being discharged .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility staff failed to provide a homelike environment for the residents by failing to make repairs in the residents rooms. This deficient practice was discovered during observations of 2 of 3 units in the facility during the survey. The findings are: On 02/27/25 at 7:48 am during observation rounds the surveyor observed rust on the tile behind the commode in the bathroom in room [ROOM NUMBER] and damaged drywall was behind the bed. At 10:52 am while the surveyor was in room [ROOM NUMBER], the surveyor observed the faucet in the bathroom with a steady flow of water. The surveyor was unable to turn the water off. At 10:55 am while in room [ROOM NUMBER], the surveyor observed damaged drywall below the window and there was a hole in the wall behind Resident #50's bed. At 11:10 am while in room [ROOM NUMBER] the surveyor observed missing drywall and exposed corner bead near the privacy curtain near Resident #112's bed. On 03/03/35 at 11:04 am 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 staff interview, it was determined that the facility failed to include the resident care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization. The findings include: On 03/03/25 at 10:12 AM, review of Resident #113's medical record revealed he/she was hospitalized on [DATE]. On 03/04/25 at 12:24 PM, an interview with Licensed Practical Nurse (Staff #18) revealed that the comprehensive care plan goals are not sent with the resident along with other required documents during transfers. On 03/13/25 at 1:55 PM, the concern was reviewed with the Director of Nursing (Staff #2) at the time of exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that facility staff failed to provide written notification of transfer and to ensure the responsible representative is provided a copy. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization. The findings include: On 03/03/25 at 10:12 AM, review of Resident #113's medical record revealed he/she was hospitalized on [DATE]. On 03/05/25 at 09:39 AM, an interview with the Director of Nursing (Staff #2) revealed that the resident representative was verbally notified, but that there was not a written notice sent to the resident representative with reason for transfer. The surveyor reviewed the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to document the orientation and preparation of a resident upon transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization. The findings include: On 03/03/25 at 10:12 AM, review of Resident #113's medical record revealed the resident has a diagnosis causing impairment of cognition and communication. On 03/03/25 at 10:13 AM, review of Resident #113's medical record revealed he/she was hospitalized on [DATE]. On 03/04/25 at 12:54 PM, further review of Resident #113's medical record failed to reveal documentation of the resident's orientation and preparation for the hospital transfer. On 03/05/25 at 09:39 AM, the surveyor reviewed the concern with the Director of Nursing (Staff #2).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, it was determined the facility staff failed to notify the resident/resident representative in writing of the bed hold policy upon transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization. The findings include: On 03/03/25 at 10:12 AM, review of Resident #113's medical record revealed he/she was hospitalized on [DATE]. On 03/04/25 at 11:47 AM, an interview with the Director of Nursing (Staff #2) revealed that the bed hold policy was sent with the resident and/or resident representative to sign and send back to the facility. She further indicated that Resident #113 was not able to make their own medical decisions and the facility communicated with the resident representative. On 03/04/25 at 11:50 AM, the surveyor requested bed hold documentation for Resident #113's hospital transfer on 11/27/24. On 03/04/25 at 1:34 PM, review of the bed hold documentation provided to the surveyor for the 11/27/24 transfer revealed a document titled,…

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 a resident's quarterly assessment was documented accurately on the Minimum Data Set (MDS). This deficient practice was evidenced for 1 (#25) resident out of in 4 residents reviewed for accurate MDS assessments during the survey. The findings include: MDS is a tool for implementing standardized assessments and for facilitating care management in nursing homes. The assessment is completed upon admission, annually, quarterly, during a significant change, and when a resident is discharged . The Resident Assessment Instrument (RAI) is a comprehensive, standardized assessment process used in long-term care facilities to identify residents' strengths, needs, and preferences, ultimately informing individualized care planning and monitoring. Review of Resident #25's medical records on 03/05/25 at 1:27 PM, revealed a physician progress note dated 9/7/24, documenting an acute comminuted fracture of the left leg. The note indicated…

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

Based on record review and interview with facility staff, it was determined that the facility staff failed to ensure Preadmission Screening and Resident Review (PASARR) forms were completed correctly. This was evident in 3 (Resident #27, #79, and #101) of 4 residents reviewed for PASARR screening. The findings include: PASARR is a federal requirement ensuring individuals with serious mental illness or intellectual/developmental disabilities are not inappropriately placed in nursing homes and receive appropriate care, either in the community or a nursing facility. 1) On 03/03/25 at 11:41 AM, review of Resident #27's medical record revealed a level I PASARR dated 4/17/2024 which indicated a level II screening should have been completed. Further review of the resident's medical record failed to reveal documentation of a level II PASARR. 2) On 03/03/25 at 11:55 AM, review of Resident #79's medical record revealed a level I PASARR dated 4/17/2024 which indicated a level II screening should have been completed. Further review of the resident's medical record failed to reveal documentation…

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 interviews it was determined that the facility staff failed to ensure residents were receiving showers regularly. This deficient practice was evidenced in 2 (Resident #20 & #58) of 27 residents who verbalized not receiving showers. The findings include: On 02/27/25 at 11:03 am during an interview with Resident #58 the resident verbalized they were not receiving showers regularly. On 03/03/25 at 11:42 am during an interview with Resident #20, he/she verbalized they had not received a shower since being admitted to the facility and nobody had ever asked if he/she wanted a shower. On 03/04/25 at 12:03 pm a review of the task section in Resident #20's electronic medical record (EMR) revealed, the resident was scheduled for a shower on Monday, Thursday, and PRN (as needed). There was no documentation to verify the resident had a shower since being admitted on [DATE]. Review of the MDS dated [DATE] the resident has a BIMS score of 14/15, indicating intact cognition. On 03/06/25 at…

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

Based on observations, record reviews, and interviews, it was determined that the facility staff failed to ensure a recommendation for diagnostic testing was completed, a resident was weighed monthly as ordered, and a resident representative was notified when a resident fell. This deficient practice was evident for 3 (#27, #42 #74) 27 residents reviewed during the recertification survey. The findings include: 1). During the initial tour of Senate unit on 2/27/25 at 7:38 AM, the surveyor heard Resident #74 crying. Upon entering the resident's room, the resident stated that both of their feet were in pain. On 2/27/25 at 12:58 PM, a review of the resident's medical records revealed a wound consult by Nurse Practitioner (NP) #9. The progress note indicated that Resident #74 was assessed on 02/27/25 for a new wound on the left heel and diagnostic imaging was recommended. On 03/04/25 a review of Resident #74's medical record revealed that the recommended diagnostic imaging had not been ordered. Review of Resident #74's medical records on 03/04/25, revealed that NP #9 reassessed the…

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

Based on record review and interview with resident and staff, it was determined that the facility failed to reorder a urinary sample for the purpose of diagnosing and treating which caused a delay in treatment for a resident with a Urinary Tract Infection (UTI). This was evident for 1 (Resident #18) out of 2 residents investigated for Urinary Catheters and UTI's during the survey. The findings include: On 2/27/2025 at 11:28AM, Resident #18 informed the Surveyor that they had a UTI. The resident stated that it hurt and no one did anything. The resident stated it took the staff too long to address the their concerns. On 2/28/2025 at 11:38AM, a review of Resident #18's electronic medical record revealed that the resident had a history of reoccurring UTI's. The resident had orders for continued medication therapy with cranberry tablets 450MG, 1 tablet by mouth one time a day and Hiprex 1GM, 1 tablet by mouth two times a day. A change in condition note for 2/18/2025 at 12:47PM stated that resident seemed different than usual. A physician order was placed for a urinalysis and a culture…

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 with resident and staff, it was determined that the facility staff failed to provide additional nourishment to a resident as ordered by the physician and failed to ensure a resident's diet was appropriate for their medical needs. This was evident for 2 (#98, #287) out of 5 residents reviewed for nutrition during the survey. The findings include: 1). On 2/27/2025 at 10:50AM, during an interview with Resident #98, the Surveyor was informed that he/she was supposed to get double portions for all his/her meals. The resident stated that his/her meal trays do not come with double portions and the meal ticket does not state double portions. The resident expressed the concern that due to his/her condition, they get really hungry, especially at breakfast. On 2/27/2025 at 12:00PM a review of Resident #98's electronic medical record revealed an active order for a Regular diet, Regular texture, Thin Liquids consistency, double portion. Further review revealed a Nutrition/Dietary Note dated 2/13/2025, which mentions Current diet order is…

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

Based on observations, record review, and interviews it was determined that the facility staff failed to failed to ensure each resident has a sufficient supply of prescribed pain medication and ensure a resident's pain was addressed. This was evident for 2 (#54, #74) of 4 residents reviewed for pain management during the survey. The findings include: 1). On 2/27/2025 at 10:25AM during an interview with Resident #54, the Surveyor was informed that the facility continuously runs out of the resident's pain medication that can be received as needed every 6 hours. The resident stated that his/her pain cannot be managed appropriately when this happens. The resident prefers to take his/her pain medication every 6 hours to effectively manage pain. Resident #54 stated that the facility ran out of his/her pain medication over the past weekend, 2/22/2025-2/23/2025. On 3/4/2025 at 11:28AM, during a review of Resident #54's electronic medical record, the Surveyor discovered that the resident was taking Oxycodone HCl 20MG (Controlled Drug), 1 tablet by mouth every 6 hours as needed for pain. 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 interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the initiation of a resident's bed rails. This was evident for 1 (Resident #113) of 1 resident reviewed for accident hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. On 03/03/25 at 08:17 AM, an observation revealed Resident #113 in bed with bilateral enabler bed rails On 03/04/25 at 12:16 PM, an interview with the Director of Nursing (Staff #2) revealed consent is obtained prior to initiation of the enabler bed rails. The surveyor requested documentation of consent obtained for Resident #113's enabler bed rails. On 03/04/25 at 01:00 PM, review of the document titled, Bed Side Rail Tool dated 12/2/24 revealed a check box 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 observation, record review, and interview with staff, it was determined that that facility failed to ensure a resident had orders in place to maintain immediate care needs of a resident with a Foley Catheter. This was evident for 1 resident (Resident #127) reviewed for indwelling catheters during the annual survey. The findings include: An indwelling (Foley) catheter is a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine. On 2/27/2025 at approximately 10:45AM, during an interview with Resident #127, the Surveyor discovered that the resident's Foley catheter was removed on 2/26/2025. The resident verbalized the need to urinate but was unable to and was not experiencing any abdominal pain at the time. The resident stated that he/she would let the nurse know if he/she was in pain. On 3/5/2025 at approximately 12:00PM, a review of Resident #127's electronic medical record revealed that orders for Foley catheter size and Foley catheter care and maintenance were discontinued on 2/28/2025. Further review revealed a medical 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.

Based on record reviews, and interviews, it was determined that facility staff failed to ensure the physician notes reflected a review of the residents total care. This deficient practice was evident for 1 (#82) of 27 residents reviewed for physician services during the surveyor. The findings include: On 03/03/25 at 12:53 PM during a review of complaint intake MD00205108 the complainant reported concerns related to Resident #82's dietary needs and medication management as it relates to the resident's a medical diagnosis of irritable bowel syndrome (IBS). Review of Resident #82 medical records on 03/03/25 at 12:55 PM, failed to reveal a documented medical diagnosis of IBS. On 03/11/2025 at 8:28 AM, a review of Resident #82's medical records revealed that the resident was evaluated by their gastroenterologist on 07/15/24. The specialist recommends discontinuing two medications and starting two new ones, and implementation of a dairy free diet based on the resident's IBS symptoms. Further review showed the recommendations were communicated to the nursing facility staff on 07/15/24 at…

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

Based on observation, record review, and interview with staff, it was determined that the facility 1) failed to ensure that an account of all controlled drugs was complete and accurate. This was found to be evident for 1 out of 4 narcotic lock boxes located in the medication carts observed during the medication storage facility task; and 2) failed to timely identify and remove a discontinued controlled drug from the narcotic box for disposition. This was evident for 1 (Resident #102) out of 3 residents reviewed for pain management during the survey. The findings include: Controlled Drugs (narcotics) are substances that have an accepted medical use, have the potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. 1. On 3/6/2025 at 10:09AM, during an interview conducted with Registered Nurse (RN) #20, the Surveyor was informed that narcotic counts for controlled drugs must be done by the incoming nurse and the outgoing nurse at change of shift. The nurses would verify the controlled drug count was accurate and sign the count on 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 medication administration observation, record review, and interviews with staff, it was determined that the licensed facility staff failed to ensure medication error rate of less than 5 percent. This was evident for 2 (Resident #96 and Resident #18) out of 5 residents observed during the medication administration task which resulted in an error rate of 11.54 percent. The findings include: 1. On 3/7/2025 at 9:19AM, the Surveyor conducted a medication administration observation with Licensed Practical Nurse (LPN) #21. LPN #21 prepared 8 pills in a medication cup for Resident #96. The resident was due for a Voltaren External gel to the right shoulder. LPN #21 informed the Surveyor that the resident likes to use the topical gel at night and would not be administering that medication. The Surveyor asked LPN #21 the process for documentation if a resident does not want a medication at the time of administration. LPN #21 informed the Surveyor that the medication would not be signed off as administered and a notation would be made in the electronic medical record regarding why. The…

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

Based on observation and interviews with staff, it was determined that the facility failed to ensure that all medications and medical treatment supplies were stored safely and labeled properly. This was evident for 1 room (Resident #98) out of 30 rooms observed and 1 medication cart out of 4 medication carts reviewed during the survey. The findings include: 1. On 2/27/2025 at 10:50AM the Surveyor observed Resident #98's nightstand and noted two small plastic jars of c-hydro1%-nystat-znox 1:1:1 cream labeled for Resident #98 and labeled refrigerate, and a small plastic jar of zinc oxide cream with no label. On 2/28/2025 at 1:50PM the Surveyor observed Resident #98's nightstand and noted two small plastic jars of c-hydro1%-nystat-znox 1:1:1 cream labeled for Resident #98 and labeled refrigerate, and a small plastic jar of zinc oxide cream with no label. These were the same medicated creams observed on 2/27/2025 and they were in the same location on the resident's nightstand. On 2/28/2025 at 1:58PM, during an interview, the Surveyor made Licensed Practical Nurse (LPN) #21 aware 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 observation, medical record review, and interviews it was determined that the facility staff failed to ensure that a resident who had poor dentition received dental services. This deficient practice was evidenced in 1 (#80) of 2 resident records reviewed for dental care during the recertification survey. The findings include: On 03/03/25 at 11:04 am the surveyor attempted to interview Resident #80 and observed the resident had poor dentition. On 03/05/25 at 9:24 am the surveyor asked Administrator #1 how the facility ensures that the residents are offered dental care. Administrator #1 verbalized dental care was offered to each resident. The resident or family member can make a request to be seen and the resident would be added to the caseload. On 03/05/25 at 2:10 pm Director of Nursing #2 informed the surveyor Resident #80 had not been seen by a dentist.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that facility staff failed to ensure availability of personal protective equipment (PPE) for enhanced barrier precautions (EBP) residents, and use appropriate infection control practice upon entering a resident's rooms. This was evident for 6 out of 18 rooms observed for PPE residents and 1 room observed for hand hygiene during the survey. The findings include: On Monday 03/10/25, the surveyor observed that gloves were missing from PPE carts outside of the following resident rooms: 7:34 AM room [ROOM NUMBER]B-EBP no gloves 7:35 AM room [ROOM NUMBER]A-EBP no gloves 7:36 AM room [ROOM NUMBER]-EBP no gloves 7:37 AM room [ROOM NUMBER]B-EBP no gloves 7:37 AM room [ROOM NUMBER]B-EBP no gloves 7:41 AM room [ROOM NUMBER]B-EBP no gloves On 03/10/25 at 7:46 AM, the surveyor observed central supply staff #35 restocking PPE carts outside resident rooms with gloves. During an interview with the central supply staff #35 on 03/10/25 at 7:47 AM, the surveyor informed him…

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

Based on observations and interviews it was determined that the facility staff failed to make necessary repair in the kitchen. This deficient practice was discovered during the recertification survey. The findings include: On 03/12/25 at 8:45 am while walking through the kitchen with Kitchen Manager #8 the surveyor observed missing insulation and metal inside and outside of the distal portion of the refrigerator's entry. There were four different areas in the kitchen with missing tile on the walls. At 9:00 am the surveyor reviewed the maintenance issues in the kitchen with Administrator #1 who verbalized they were working on correcting the maintenance concerns in the kitchen.

Based on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 1 (Resident #113) of 1 resident reviewed for accidents hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. On 03/03/25 at 08:17 AM, an observation revealed Resident #113 in bed with bilateral enabler bed rails On 03/04/25 at 12:16 PM, an interview with the Director of Nursing (Staff #2) revealed residents are assessed quarterly on the need for the enabler rails. She indicated that they are assessed for entrapment quarterly. The surveyor requested documentation regarding the entrapment risk assessment completed for Resident #113 ' s enabler bed rails.…

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 staff failed to notify the state agency of allegations of abuse within the two-hour allotted timeframe. This deficient practice was evidenced in 6 (Resident #25, #41, #108, #113, #138, & #144) of 12 facility reported incidents reviewed for allegations of abuse during the recertification survey. The findings include: 1. On 03/05/25 at 10:27 am a review of the facility reported incident (FRI) investigation related to MD000207607 revealed Resident #144 reported an alleged incident of sexual abuse that may have occurred on 07/01/24. Review of the self-report documentation revealed the staff became aware of the alleged incident on 07/03/24 at approximately 11:00 am. The alleged incident was reported to the state agency on 07/03/24 at 10:03 pm by the Smartsheet confirmation email. On 03/12/25 at 11:20 am during an interview with Director of Nursing (DON) #2 verbalized the Social Worker reported the alleged incident. DON #2 was made aware the Smartsheet report revealed Administrator #1 was made aware of the incident…

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 develop and implement written policies and procedures for investigating and reporting allegations of abuse. This deficient practice was evident for 1 (#25) of 4 resident reviewed for abuse during the recertification survey. The findings include: On 02/28/2025 at 9:30 AM, during an interview with the Director of Nursing (DON) #2, the surveyor asked about the facility's process for managing allegations of abuse involving residents. The DON explained that only confirmed injuries are reported to the state agency within 2 hours, and all other abuse allegations are reported by the end of the same day. The surveyor requested the facilities policy and procedures for abuse. On 02/28/25 DON #2 provided the surveyor with the facility's abuse policy. Upon review, the surveyor identified that the policy lacked information identifying how staff should identify abuse that was not directly observed. The policy did not outline procedures for…

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

Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of alleged incidents of abuse and an injury of unknown origin. This deficient practice was evidenced in 4 (#25, #109, #138, & #144) of 12 facility reported investigations reviewed during the recertification survey. The findings include: 1. On 03/12/25 at 10:27 am a review of the facility reported incident (FRI) investigation related to MD000207607 revealed Resident #144 reported an alleged incident of sexual abuse that may have occurred on 07/01/24. A review of the facility's investigation revealed there were multiple interviews from staff who failed to indicate their title. The surveyor requested a copy of the staffing sheet to verify interviews were done with the staff who worked during the time of the alleged incident. The staffing sheet provided by Director of Nursing (DON) #2 had the incorrect date. The surveyor was unable to confirm a thorough investigation was completed. On 03/12/25 at 10:48 am during an interview with DON #2 the surveyor asked who…

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 staff interviews, it was determined that the facility failed to assess residents quarterly for discharge planning goals. This deficient practice was evident for 2 (#52, #95) of 3 residents reviewed for discharge planning during the survey. The findings include: 1. On 02/28/25 at 9:42 AM, during an interview with Resident #95, they stated that they were not aware of their plan of care and wanted to know when they would be discharged . On 02/28/25, the surveyor informed the Director of Nursing (DON) #2 of Resident #95's concern. After the surveyor informed the DON #2 of the resident's discharge plan concern on 2/28/25, the DON #2 provided a document on 3/4/25 at 11:49 AM indicating that on 2/28/25, the Social Worker (#6) had scheduled an interdisciplinary team meeting to be held on 3/3/25 at 1:30 PM to discuss Resident #95's care plan. 2. A review of a complaint intake MD00206919 on 03/03/25 at 1:02 PM revealed that Resident #52 reported the social worker had failed to assist them regarding discharge. A review of Resident #52's medical records did not show…

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 complaint, observations, interviews, and review of facility policy, it was determined that the facility failed to have a system in place to allow for visitor access to the facility after hours. This was evident for 1 (MD00180288) of 1 complaint reviewed for visitor access. The findings include: Review of complaint #MD00180288 on 3/19/24 revealed an attempted admission on 12/2021, where the spouse brought Resident #59 directly to the facility from the hospital and was unable to gain access to the facility. According to the complainant, upon arrival to the facility, the family knocked on the door and called the facility with no response. They then had to call the police to gain access to the facility. On 3/20/24 at 7:04 AM this surveyor attempted to gain access to the facility via the front door. The door was locked with a sign that showed business hours start at 8:00 AM. This surveyor then called the facility at the number posted on their website. The phone rang for 5 minutes, this survey hung up and called back, and the phone rang for another 5 minutes.…

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 complaint, medical record review and interview, it was determined that the facility failed to notify the resident/representative (RP) of a change in condition. This was evident for 1 (#51) of 10 residents reviewed for wound care. The findings include: Review of the medical record for Resident #51 on 3/19/24 at 9:13 AM revealed diagnosis including hemiplegia (paralysis to one side of the body) after a cerebral vascular accident (CVA-stroke), chronic pain syndrome, presence of a gastrostomy tube and dementia. Further review of Resident #51's medical record revealed that upon initial admission to the facility on 12/20, multiple pressure ulcers were identified. These pressure ulcers were treated and healed and continued to be monitored. However, the sacral wound was documented as reopened on 9/21/21. The wound was documented as a stage 4 measuring 4.27cm x 7.89cm (centimeters), one week later it was measured by the wound physician at 6.3cm x 7.84cm. Continued review of the medical record failed to see any documentation that the resident's representative was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to report to the Office of Health Care Quality (OHCQ) an injury of unknown origin as required. This was evident for 1 (#19) of 61 residents reviewed during a complaint survey. The findings include: Review of Resident #19's medical record on 3/19/24 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include vascular dementia. Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Further review of Resident #19's medical record revealed a nurse's note documented on 10/9/22 at 10:15 AM stated, Patient was found with swollen left eye. Head to toe assessment done and revealed left eye swollen with patient unable to open eye. Review of the Resident #19's hospital record on 3/21/24 revealed on 10/9/22 at 6:51 PM a history and physical note stated, left swollen eye, patient from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that facility staff failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed after the resident remained in the facility past the original 30 days and to accurately complete the PASSR on readmission for a resident to ensure the resident received appropriate services while in a long-term care setting. This was evident for 1 (#4) of 1 resident reviewed for PASRR. The findings include: A Preadmission Screening and Resident Review is completed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. A medical record review on 3/21/24 at 10:00 AM for Resident #4 revealed a Preadmission Screening and Resident Review (PASRR) level 1 was completed on 10/14/22 that indicated the resident would be in the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff it was determined the facility staff failed to ensure the residents plan of care was updated when there was a change in the resident's pressure ulcer status and hold care plan meetings to include the interdisciplinary team, resident and resident's representative for a resident. This was evident for 1 (#8) and evident for 1 (#15) of 61 residents reviewed during the complaint survey. The findings include: Staging of a pressure ulcer/pressure injury is performed to indicate the characteristics and extent of tissue injury. The stages include: Stage 1- Pressure injury: Non-blanchable redness of intact skin. Stage 2- Pressure Ulcer: Partial-thickness skin loss with exposed dermis (underlying tissue). Stage 3- Pressure Ulcer: Full-thickness skin loss. Stage 4- Pressure Ulcer: Full-thickness skin and tissue loss. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss - the extend of tissue damage cannot be confirmed because the wound bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff it was determined the facility staff failed to ensure preventative measures prescribed by the physician were clearly communicated to all staff responsible for implementing the interventions. This was evident for 1 (#8) of 61 residents reviewed during the complaint survey. The findings include: Resident #8's medical record was reviewed on 3/19/24 at 9:36 AM. The record revealed an admission Nursing Assessment Note dated 4/22/23. The skin assessment section identified 3 areas which included an active wound on Resident #8's sacrum (lower back above the tailbone) that was present on admission. The documentation indicated the wound measured 7 cm (centimeters) long, and 5 cm wide. A Skin observation tool dated 4/24/23 at 12:38 PM described the sacral wound as open, Stage 3 Deep Tissue Injury, with drainage. The record revealed an initial assessment by the Wound Nurse Practitioner on 4/27/24. She assessed the resident and made treatment recommendations…

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, the facility staff failed to administer medication as ordered by the physician. This was evident for 1 (#35) of 61 residents reviewed during a complaint survey. The findings include: Review of Resident #35's medical record on 3/20/24 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed a physician order for Depo-Provera 150 mg every 3 months. Depo-Provera is a hormonal medication. It is used as a method of birth control and as a part of menopausal hormone therapy. Review of Resident #35's Medication Administration Records for October 2022 and January 2023 revealed the facility staff failed to administer Depo-Provera as ordered. Interview with the Director of Nursing on 3/22/24 at 8:30 AM confirmed the facility staff failed to administer Depo-Provera to Resident #35 in October 2022 and January 2023 as ordered.

Based on medical record review, observation, and interview, it was determined that the facility failed to 1) ensure a resident's pain medication was available as ordered by the physician and 2) ensure the pain medication orders had a clear indication for use, ensure a pain assessment was conducted, and to offer non-pharmacological pain management interventions. This was evident during the review of 1 (#41) of 4 residents reviewed for pain management and this was evident for 1 (#17) of 4 residents reviewed for pain management. 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. Non-pharmacological pain interventions - the management of pain without the use of pain medication. 1) Resident # 41 was identified during this complaint survey as having multiple behaviors in the facility affecting other residents via physical and verbal altercations including allegations of stealing property. During the review and interviews, Resident #41 asked to speak with this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#20) of 10 residents reviewed for accurate medical records during a revisit survey. The findings include. On 3/19/24 10:39 AM, the surveyor reviewed Resident #20's medical record. The review revealed that Resident was readmitted to the facility on [DATE]. Resident #20's physician's orders dated 3/18/24 revealed daily wound care management with the use of the wound vac. Further review of Resident #20's Electronic Medical Record and Treatment Administration Record did not reveal wound care management. On 8/19/23 at 11 AM, the Director of Nursing confirmed the findings and stated that the Nurse should have corrected the wound care management orders during the 24-hour chart checks. On 3/20/24, The Director of Nursing provided documents for in-service education for 24 hours chart checks to all nurses 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 surveyor observation, it was determined that the facility failed to have adequate ventilation to ensure good air quality circulation to keep all Nursing Units of the facility odor free. This was evident for 4 (200, 300, 400, and 500) of 5 nursing units. The findings include: On 3/19/24 at 11:15 AM Observation of Nursing Units 200, 300, 400, and 500 had a lingering smell of urine due to the lack of airflow. A tour of the Units with the Maintenance Director confirmed that the lack of air flow was caused by the exhaust fans. One exhaust fans motor needs to be replaced. A new exhaust motor was placed on order and the other 3 exhaust fans were fixed. On 3/21/24 at 9:00 AM the Director of Nursing was made aware of the concern and was aware of the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and facility staff interview it was determined that the facility failed to ensure nursing staff had the competency and skills to provide care to meet residents' needs. This finding was evident on all units. The findings include: 1. On 01-13-2021 at 1:28 PM, surveyor observed GNA #6 passing lunch trays. She picked up a tray and entered room [ROOM NUMBER]. She placed the tray on the bedside table. She assisted a resident with personal belongings, then set up the resident's food tray. GNA #6 did not have gloves on. She then left room [ROOM NUMBER] without performing hand hygiene. With her bare hands, she picked up another tray from the food cart in the hallway and entered room [ROOM NUMBER]. She placed the tray on the resident's bedside table, then wheeled a table to be within reach of the resident. She did not perform hand hygiene prior to setting up the resident's food tray. GNA #6 left room [ROOM NUMBER] without performing hand hygiene and removed another tray from the cart 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 clinical record and facilty staff interview, it was determined that the facility staff failed to review and revise residents' care plans in timely manner for 3 of 30 residents reviewed during the survey (Residents #51, #77, and #43). The findings include: 1. On 01-15-2021, Resident #51's record review revealed from 12-02-2020 to 12-14-2020, the resident lost 23.5 lbs of actual body weight. The resident weighed 243.5 lbs on 12-02-2020 and dropped to 220 lbs on 12-14-2020. On 12-16-2020, the facility's dietitian documented this as a potential weight error. Further review of Resident #51's record revealed on 01-06-2021, the resident weighed 214.5 lbs losing another 6.5 lbs in a period of three weeks. Resident #51's nutrition care plan was not reviewed and revised after he/she had significant weight loss identified on 12-14-2020 and 01-06-2021. On 01-15-2021 at 2:00 PM, an interview with the interim Director of Nursing revealed no additional information. 2. On 01-12-2021, a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, review of the clinical record, and staff interviews, it was determined that facility failed to ensure staff were familiar with facility policies related to CPR and could confirm residents' code status in an emergency. This finding was evident in 2 of 4 residents selected for review of the advance directive care (Resident #230 and #91) On 01-12-2021 surveyor review of the clinical record revealed a MOLST (Maryland Orders for Life Sustaining Treatment) form for Resident #91 that documented the resident's code status as do not resuscitate (DNR). On 01-12-2021 at 2:00 PM surveyor interview with the interim Director of Nursing (DON) and Administrator revealed that since the facility has moved to an all electronic health record (EHR) the process for documenting code status and how staff determine code status in an emergency was as follows: when a resident is admitted the MOLST is uploaded into the electronic health record and there is a banner at the top of the screen that indicates 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 clinical records, interviews with residents, family members and facility staff, it was determined that the facility staff failed to follow physicians' orders and to provide care in accordance with professional standards of practice. This finding was evident for 7 of 30 residents reviewed during the survey (Residents #31, #37, #56, #77, #82, #103, and #231). The finding include: 1. On 01-11-2021 at 6:45 AM during tour of COVID-19 positive unit, a surveyor observed Resident #103 ambulating with a walker. Further observation on 01-12-2021 at 11:15 AM revealed Resident #103 was in bed receiving oxygen via nasal cannula. On 01-12-2021 at 12:05 PM upon interview, licensed practical nurse (LPN) #2 stated that at 10:00 AM Resident #103 had a change in condition where the resident's oxygen saturation level was 84% (a normal saturation level is greater than 93%) on room air. LPN #2 placed the resident on 2 liters of oxygen via nasal cannula. However, LPN #2 further stated that he had not rechecked the oxygen saturation level to determine if the oxygen…

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, clinical record review and staff interview, it was determined that the facility's staff failed to ensure feeding and fluids were administered accurately for 2 of 2 residents selected for a tube feeding review (Residents #129 and #230). 1. On 01-12-2021, record review revealed Resident #129 was NPO (nothing by mouth) and required therapeutic jejunostomy (J-tube feedings). A J -Tube feeding is feeding through a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. Further record review of Resident #129's record revealed a physician's orders for tube feedings: Glucerna 1.7 at 70 ml/hr for 18 hrs for total volume of 1260 ml in 24 hour period; feeding pump is off from 12:00 PM to 6:00 PM. Surveyor observation revealed the following: On 01-13-2021 at 7:53 AM, Resident #129's feeding pump was running 70 ml/hr with amount 184 ml on the display as delivered. The total amount of feeding that should have been delivered at that time was about 970 ml. On 01-13-2021 at 11:45 AM, Resident #129's feeding pump was running 70 ml/hr…

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 clinical records, resident and staff interviews it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice and failed to provide medications as ordered by the prescriber for 2 of 30 residents reviewed during the survey (Resident #77 and #82). The findings include: 1a. On 01-14-2021 a review of the clinical record for Resident #82 revealed a physician's order for Acetaminophen/Codeine tablets 300 mg - 30 mg, give one (1) tablet every (six) 6 hours as needed for pain. The review of the controlled substance log revealed on 12-08-2020 one (1) tablet was documented as removed however, there was no evidence that is was administered to Resident #82 on the medication administration record. b. Further review of the clinical record for Resident #82 revealed a physician order for Acetaminophen/Codeine tablet 300 mg - 30 mg, give 2 (two) tablets every 6 hours as needed for pain. The review of the controlled substance log revealed on the following dates the medications were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and staff interviews, it was determined that the facility's staff failed to implement proper infection control and prevention practices related to performing hand hygiene while providing assistance to multiple residents, and ensuring a resident's (Resident #31) implanted venous port (medical port) was secured in a manner to prevent infection. The facility's practice placed vulnerable residents at risk of contracting health care associated infections. This finding was evident in 2 of 4 units observed for proper infection control practices during the survey (Capital unit and Senate Unit). The findings include: 1a. On 01-11-2021 at 9:28 AM, surveyor observed GNA #5 entering room [ROOM NUMBER] to deliver a breakfast tray. She assisted a resident with personal belongings, and then set up the resident's food tray. GNA #5 did not have gloves on. Without performing hand hygiene, GNA #5 left room [ROOM NUMBER]. She picked up another tray from food cart in the hallway and…

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

Based on record review, resident and staff interviews, it was determined that the facility staff failed to notify residents' physician and family of a significant weight change. This finding was evident for 2 of 7 residents selected for review of the nutrition care area (Residents #43 and #51). The findings include: 1. On 01-11-2021 at 2:49 PM, the surveyor interviewed Resident #51. Resident #51 reported losing almost 20 lbs in a month. The resident further reported the change in weight had not been discussed with the residents' attending physician. On 01-15-2021, a review of Resident #51's clinical record revealed the resident lost 23.5 lbs between 12-02-2020 to 12-14-2020 (from 243.5 lbs to 220 lbs). On 01-06-2021, the resident weighed 214.5 lbs, a decrease of 6.5 lbs. Resident #51's record revealed no evidence that the facility staff notified the resident's attending physician of a significant change in the resident's weight. On 01-15-2021 at 12:08 PM, an interview with the facility dietitian revealed no additional information. On 01-15-2021 at 2:00 PM, an 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 medical record review and staff interview, it was determined that the facility's staff failed to develop and implement a base line care plan for a pressure ulcer. This finding was evident for 1 of 30 residents reviewed during the survey (Resident #37). The findings include: On 01-12-2021 a review of Resident #37's clinical record revealed the resident was admitted to the facility with a stage III pressure ulcer on his/her left buttock. There was no evidence the facility staff developed a care plan to address the resident's pressure ulcer. On 01-15-2021 at 2:00 PM, an interview with the interim Director of Nursing revealed no additional information.

Based on resident record review and facility staff interview, it was determined that the facility staff failed to develop comprehensive patient centered care plans for 2 of 30 residents reviewed during the survey (Residents #51 and #130). The findings include: 1. On 01-14-2021 a review of Resident #130's clinical record revealed the resident had a base line discharge care plan on admission. However, there was no no evidence that the facility staff developed a comprehensive patient centered discharge care plan for the resident. On 01-15-2021 at 2:00 PM, an interview with the interim Director of Nursing revealed no additional information. 2. On 01-15-2021 a review of Resident #51's clinical record revealed the resident had a diagnoses of depression and anxiety disorder. The resident was on antidepressant medications. There was no evidence that the facility staff developed a comprehensive care plan to address the resident's depression and anxiety. On 01-15-2021 at 2:00 PM, an interview with the interim Director of Nursing revealed no additional information.

Based on surveyor observation, resident representative interview and staff interviews, it was determined that the facility's staff failed to provide assistance with activities of daily living to resident #108 who was dependent on staff for care. This was evident in 1 of 1 resident reviewed for ADL (activities of daily living) care area. The findings include: On 01-12-2021 at 11:14 AM, a telephonic interview with Resident #108's representative revealed the resident was admitted to the facility with upper and lower dentures, but the resident never has the dentures in place. On 01-12-2021 at 11:18 AM and on 01-13-2021 at 10:58 AM, surveyor observed Resident #108 without dentures. On 01-12-2021, record review of Resident #108 revealed inventory of personal belongings completed on 10-21-2020 listed the resident was admitted with upper and lower dentures. On 01-13-2021 at 2:00 PM, an interview with GNA Staff #6 revealed she was not aware that Resident #108 had dentures at the facility. GNA #6 found Resident #108's dentures in a plastic bag on the resident's bedside table. On 01-13-2021 at…

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

Based on surveyor observation, clinical record review and interviews with facility staff, it was determined that the facility failed to ensure residents were provided with an environment free of accident hazards. This was evident for 1 of 30 residents reviewed during the survey (#103). The findings include: On 01-12-2021 at 11:15 AM observation of Resident #103's room, revealed an oxygen tank standing unsecured near the resident's bed and was providing oxygen to the Resident via a nasal cannula. On 01-12-2021 at 11:30 AM upon interview, licensed practical nurse (LPN) #2 stated that Resident #103 was had shortness of breath at 10:00 AM. The resident's oxygen level was low, and the resident was placed on oxygen. Further interview with LPN #2 revealed obtained the oxygen tank for Resident #103, but did not secure the oxygen tank to prevent it from falling over. On 01-12-2021 at 12:00 PM interview with the unit manager for the Capital unit revealed no additional information.

Based on record review, resident interview and staff interviews, it was determined that the facility staff failed to address a significant weight loss for Resident #51. This finding was evident for 1 of 7 residents reviewed for adequate nutritional status during the survey. The findings include: On 01-11-2021 at 2:49 PM, the surveyor interviewed Resident #51. Resident #51 reported losing almost 20 lbs in a month. The resident further reported the change in weight had not been discussed with the residents' attending physician. On 01-15-2021, a review of Resident #51's clinical record revealed the resident lost 23.5 lbs between 12-02-2020 to 12-14-2020 (from 243.5 lbs to 220 lbs). On 12-16-2020, the facility dietitian documented the change in Resident#51's weight as potential weight error. However, there was no evidence that the resident was reweighed. On 01-06-2021, Resident #51 weighed 214.5 lbs, a decrease of 6.5 lbs. There was no nutritional assessment completed or interventions added to Resident #51's care plan after a significant weight loss. A nutritional assessment is used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility staff failed to maintain complete and accurate medical records for residents. This finding was evident for 2 of 30 residents reviewed during survey (Residents #77 and #231). The findings include: 1. On 01-15-2021, a review of Resident #77's clinical record revealed the resident did not receive am antipsychotic medication (Paliperidone ER Tablet Extended Release 3 mg 2 tabs) at 9:00 on 01-15-2021 as scheduled ordered. Further review of Resident #77's clinical record revealed nursing staff ordered resident #77's Paliperidone ER on [DATE]. According to nursing documentation, the medication was unavailable on 01-07-2021 and 01-08-2021. However a review of the resident;s medication administration record showed that staff documented providing the medication to the resident given since 01-01-2021, with the exception 01-07-2021, 01-08-2021, and 01-15-2021. On 01-15-2021 at 10:25 AM, an interview with Senate/Embassy unit manager…

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 staff interview it was determined that facility staff failed to follow proper infection control standards by improperly disinfecting glucose testing machines (glucometers) between resident use. This finding was identified on all units within the facility. The findings include: On 04-11-19 at 4:25 PM during medication pass observation, surveyor observed staff #10 performing a fingerstick blood glucose level on resident #279 to determine if the resident required an insulin injection Upon completion of the test, staff #10 wiped the surface of the glucometer with an alcohol pad , placed the glucometer back into the medication cart, and documented the results of the test in the clinical record of resident #279. Staff #10 then proceeded to resident #280 to do a fingerstick blood sugar. Upon completion of the fingerstick, staff #10 wiped off the glucometer with an alcohol swab and placed it back in the medication cart and documented the results of the fingerstick blood sugar. The Centers for Disease Control and Prevention Infection Prevention during Blood…

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 interview with facility staff, it was determined that the facility staff failed to ensure that interdisciplinary care plan conferences were conducted timely for residents. This finding was identified for 3 of 9 residents selected for the Care Plan review. (#12, #13, and #18.) The findings include: 1. On 04-10-19 surveyor review of the clinical record for resident #13 revealed that the resident had a surrogate decision maker designated as responsible for medical decisions. Further record review revealed that quarterly MDS (Minimum Data Set) assessments were completed by staff with Assessment Reference Dates (ARD) for 09-11-18, 12-12-18 and 03-14-19. The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, surveyor review of the clinical records, it was determined that facility staff failed to allow self-determination as it related to the provision of care. This finding was evident for 1 of 4 residents selected for review in the choices care area. (#22) The finding includes: On 04-09-19 at 2:10 PM, interview with resident #22 revealed a complaint that facility staff failed to provide showers, but rather gave daily bed baths. The resident stated preference was to be showered rather than to receive a bed bath. On 04-11-19 at 1:00 PM, interview with the Ambassador unit manager revealed that resident #22 was scheduled to be showered every Monday and Thursday. On 04-12-19 at 12:30 PM, review of the clinical record for the 30 day period between 03-14-10 and 04-12-19 resident #22 had only one shower documented since her admission on [DATE] as being given on 04-06-19. Further review of the clinical record revealed no documentation in the nursing progress notes or in the written plan…

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 facility staff failed to promptly notify the resident representative or responsible party when a resident had a significant weight loss. This finding was evident for 1 of 7 residents selected for review of the nutrition care area during the survey. (#41) The finding includes: On 04-11-19 at 09:03 AM surveyor review of the clinical record revealed that resident #41 weighed 114 lbs. on 02-05-19. Further review of April's weights for resident #41 revealed that resident weighed 102 lbs. This was a 12 pound or 11% weight loss in 60 days. On 04-04-19 the facility dietitian documented that resident #41 was assessed for significant weight loss. The dietitian added a house (nutritional) supplement twice daily to resident #41's diet, however, there was no evidence that resident #41's representative or responsible party was notified about the significant weight loss or the change in the resident's diet. On 04-11-19 at 10:10 AM, surveyor interview with the dietitian 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 family and staff interview, and review of facility policies and personnel files, it was determined that the facility staff failed to revise the abuse, neglect and exploitation policy to reflect screening of contracted (non-facility hired) employees. This finding was evident for 2 of 7 employee personal files reviewed during the survey. The findings include: On 04-08-19 at 10:29 AM, the responsible party for resident #276 informed the surveyor that the resident had alleged to them that he/she had been touched inappropriately by a male staff member. The responsible party reported the allegation to staff #4, but could not recall when the allegation had been reported as it had been a little while. The responsible party also informed the surveyor that the Ambassador unit manager was also made aware of the allegation. On 04-08-19 at 11:00 AM, surveyor made the director of nursing aware of the allegation. The director of nursing verbalized awareness of the allegation as staff #4 had directly reported the allegation to him/her on 03-25-19. As a result of the allegation of abuse,…

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 family and staff interview, and review of facility policy it was determined that the facility staff failed to report an allegation of abuse in a timely manner. This finding was evident for 1 of 2 residents during the review of facility reported incidents. (#276) The finding includes: On 04-08-19 at 10:29 AM, during a family interview, the responsible party for resident #276 informed the surveyor that the resident had alleged that he/she had been touched inappropriately by a male staff member. The responsible party stated the allegation was reported to staff #4. The responsible party also informed the surveyor that the Ambassador unit manager was also made aware of the allegation around the same time that staff #4 was informed. On 04-08-19 at 11:00 AM, surveyor made the director of nursing aware of resident #276's allegation. The director of nursing verbalized previous awareness on 03-25-19 that the responsible party of resident #276 had stated the resident did not feel comfortable with male caregivers which he/she did not believe it to be an allegation of abuse, and as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, family interview, and review of the clinical record it was determined that the facility staff failed to include interventions to address a resident's inability to speak or understand English in the baseline care plan. This finding was evident in 1 of 3 records selected for review of this care area. (#276) The finding includes: On 04-08-19 at 10:45 AM, during initial screening of residents, interview of responsible party at bedside of resident #276, it was determined that the resident's primary language was Mandarin, and the resident neither spoke nor understood English. On 04-10-19, review of the clinical record revealed the resident was admitted to the facility on [DATE]. Additionally, review of the clinical record also revealed a baseline care plan dated 03-22-19 which addressed two questions related to communication. #1. Can the resident communicate easily with staff? and 2. Does the resident understand the staff? Both responses were no, however the baseline care plan did not…

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

Based on surveyor review of the clinical record, it was determined that the facility staff failed to develop a plan of care to address a resident receiving an anticoagulant medication. This finding was evident in 1 of 2 residents selected for the care area of unnecessary medication (anticoagulant). The findings include: On 04-11-19 review of the clinical record for resident #279 revealed a physician's order for Lovenox 40 mg subcutaneously for deep vein clot prevention. (Lovenox is a blood thinner that helps to prevent the development of blood clots). The resident was significantly immobile due to a recent surgical procedure. Further review of the clinical record revealed that the facility staff failed to develop a care plan to address the increased potential for bleeding and other side effects associated with administration of anticoagulant medication. On 04-11-19 at 2:40 PM, interview with the director of nursing revealed no additional information.

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure the appropriate standards of nursing practice by obtaining physician clarification of a medication with conflicting indications/diagnosis for use. This finding was evident for 1 of 32 residents selected during the survey. (#176) The finding includes: On 04-11-19 surveyor review of the clinical record for resident #176 revealed documentation in February 2019, by the facility's consultant psychiatrist, in the continuation of the administration of the medication, Buspar 5 mg once daily for the treatment of depression and anxiety. Further review revealed the attending nurse practitioner documentation on the 04-03-19 readmission history and physical and the 04-10-19 follow up visit that resident #176's current medications included the administration of Buspar 5 mg once daily for the treatment of bladder spasms. Buspar is a medication prescribed primarily for the treatment of anxiety disorder. However, there was no documented evidence that licensed…

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 the clinical record and interviews with the resident and facility staff it was determined that the facility staff failed to follow physician's orders. This finding was evident for 2 of 32 residents selected for review during this survey. (#111, #126). The findings include: 1. On 04-08-19 at 3:43 PM, interview of resident #111 revealed that the resident alleged staff did not provide wound care as ordered by the physician. Surveyor observation on 04-08-19 of resident #111's wound revealed a date of 04-05-19, written on the wound vac dressing site (wound vac is a vacuum-assisted, negative pressure therapy to assist in the closure of a wound to help healing). A physician's order dated 03-14-19, revealed the following: Negative Pressure Therapy to abdomen site. Set unit to 125 mmHg continuous, Cleanse with Wound cleanser. Apply oil emulsion to wound base. Place black foam into the wound. Apply skin prep to intact skin around wound, cover with occlusive dressing and secure tubing per manufacturer guide. in the evening every Tuesday, Thursday, and Saturday. Further…

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 interview of facility staff, it was determined that the facility failed to ensure that PRN (as needed) orders for psychotropic drugs were limited to 14 days. This finding was evident in 1 of 5 residents selected for the unnecessary medication review. (#94). The findings include: On 04-11-19 at 11:10 AM surveyor review of the clinical record revealed that resident #94 was receiving the following psychotropic (any medication capable of affecting the mind, emotions or behavior) medications when admitted . Lorazepam (anti-anxiety) 0.5 milligram every 6 hours as needed for increased anxiety and Haloperidol 0.5 milligram every 6 hours as needed for agitation. Further review of resident #94's physician order sheets and medication administration record (MAR) for the month of April revealed that the psychotropic medications were ordered in December 2018. There was no evidence in the clinical record that indicated the attending physician, or the prescribing practitioner documented the rational for the extended use beyond 14 days as required.…

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 of medication pass, review of the facility's policy and procedure for medication administration and interview with facility staff, it was determined that licensed facility staff failed to ensure a medication error rate of less than 5 percent during the medication pass observation. This finding was evident for 2 medication errors out of 25 opportunities which resulted in a medication error rate of 8%. The findings include: 1. On 04-10-19 at 8:56AM surveyor observation of medication pass for resident #62 revealed that LPN (Licensed Practical Nurse) #2 administered scheduled AM medications to the resident. Further observation revealed this included the administration of Aspirin 81 mg enteric coated 1 tablet by mouth to the resident. However, review of the physician orders and the April 2019 MAR (Medication Administration Record) revealed that the attending physician had ordered Aspirin 81 mg chewable tablet by mouth once daily for CVA (stroke) prevention. The enteric coated Aspirin has a slower absorption and is used at times to prevent upset stomach,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations of medication pass and interview with the facility staff, it was determined that the facility failed to ensure that medication was appropriately stored and administered to residents prior to its expiration date. This finding was evident in 4 of the 7 medication carts in use by the facility. The findings include: On 04-10-19 at 9:15AM and 9:25AM, surveyor observation of the 3 medication carts located on the Capital unit, revealed that a house stock supply of a bottle of enteric coated Aspirin 81 mg was administered to residents on the unit. (Refer to F759 for additional information) Further observation revealed the expiration date of the the enteric coated Aspirin bottle was [DATE]. There was no evidence that there were any other house stock supply of enteric coated Aspirin inside the 3 medication carts for administration. On 04-10-19 at 9:35 AM, observation of 1 medication cart located on the Senate unit also revealed an opened bottle of house stock supply of enteric coated Aspirin…

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 resident and staff interviews, it was determined that the facility staff failed to coordinate care with an ophthalmologist for resident #113. This finding was evident in 1 of 4 residents reviewed during survey for the vision/hearing care area. The findings include: 1. On 04-09-19 at 10:41 AM, during surveyor interview, resident #113, verbalized frustration with not having a vision screening. The resident alleged that the physician discussed that the resident was to have his/her vision screened while on certain medications. However, the facility staff failed to arrange the necessary appointment. Review of the clinical record for resident #113 revealed a hospital discharge summary report dated 01-11-19 that included a follow up plan and follow up instructions. Those instructions included that an ophthalmologist appointment should be scheduled once a month while on the drug ethambutol. A phone number was provided in the event that no other ophthalmologist appointment could be scheduled independently. Surveyor review of the resident'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.