Bay Harbor Post Acute Healthcare Center

Based on record review, interview, and facility policy review, the facility failed to protect Resident #16's right to be free from physical abuse by another resident (Resident #49). This affected 1 (Resident #16) of 23 sampled residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. A facility policy titled, Identifying Types of Abuse, revised 09/2022, revealed, 1. Abuse of any kind against residents is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. The policy specified, 4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure therapy services were provided in accordance with physician orders for 1 (Resident #31) of 4 residents sampled for therapy services. Findings included:A facility policy titled, Physician Orders, updated 01/2025, revealed, 5. The provision of care and services in accordance with the physician orders will be documented in accordance with professional standards of practice. An admission Record revealed the facility admitted Resident #31 on 03/10/2025. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and muscle wasting and atrophy. The admission Record revealed Resident #31 was discharged home on [DATE]. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2025, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record for 3 (Residents #32, #31, and #30) of 48 sampled residents. Findings included:A facility policy titled, Guidelines for Charting and Documentation, revised in 04/2012, revealed, The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc.[et cetera, and so forth], and the progress of the resident's care; 2. Guidance to the physician in prescribing appropriate medications and treatments; 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; 4. Nursing service personnel with a record of the physical and mental status of the resident; 5. Assistance in development of a Plan of Care for each resident; 6. A legal record that protects the resident, care providers, and the facility; and 7. A source of al resident charges.…

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 3) On 1/17/2025 at approximately 9:25 AM, the Surveyor observed the Medication room at nursing station #1. There were 2 small black refrigerators sitting one on top of the other in the medication room. The inside of the bottom refrigerator door and interior shelves were dirty, covered with multiple areas of brown dried food stains and sticky cream-colored stains. The Surveyor observed a clear cup of cream-colored pudding covered with plastic wrap and labeled 1/11. 4) On 1/17/2025 at approximately 9:50 AM, the Surveyor observed the Clean Utility room. There was a Standard size refrigerator located in the corner of the room. Licensed Practical Nurse (LPN) #5 informed the Surveyor that was where resident stored personal foods. The Surveyor observed a January 2025 temperature log with no freezer or refrigerator temperature documentation. Inside the refrigerator, on the top shelf, there was an opened and unlabeled 8 oz pack of [NAME] bologna, 32 oz Wawa hazelnut non-dairy creamer, 64 oz Thick It Clear Advantage…

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 facility staff it was determined the facility failed to ensure a resident's dignity was maintained for residents. This was found to be evident for 6 (Resident #210, #130, #56, #91, #152, and #179) ) of 7 residents reviewed for dignity during the survey. Findings include: 1) On 1/15/25 at 5:45 PM while touring the units, a family member who was visiting with Resident #210 requested assistance of staff to transfer the resident to bed. A nurse who was on the unit summoned a GNA (#48) to the resident room. Approximately five minutes later another GNA # 54 and the assigned GNA (# 55) arrived to assist. GNA #48 brought the Hoyer lift to the resident room and the other 2 GNA's placed the apron drape underneath the resident. The resident agreed to allow the surveyors to observe the transfer. At this time, the three GNA's attached the apron drape that was underneath the resident to the lift and proceeded to lift the resident. They were unable to lift the resident as the battery was not working on the hoyer. GNA #48 removed the battery and went to get…

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 the facility staff failed to verify each resident on Unit 4 had their call bells readily available if assistance were needed and ensure a resident's needs were accommodated by scheduling a follow-up appointment in a timely manner. This was evident for 4 (Resident #119, #179, #210, and # 178) out of 5 residents reviewed for accommodation of needs during the survey. The findings include: 1. During observation rounds on 01/13/25 at 8:07 am the surveyor observed Resident #119 call bell on the floor. At 8:16 am while in Resident #179's room, the surveyor asked Geriatric Nursing Assistant (GNA) #31 where was the resident's call bell. GNA #31 verbalized the resident was unable to use their right arm and had minimal use of their left arm. GNA #31 proceeded to remove the call bell from behind the bed and place the call bell near the resident's left hand. While walking down the hall on Unit #4 on 01/13/25 at 8:38 am the surveyor entered room [ROOM NUMBER].…

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

Based on resident and staff interviews and record review, it was determined the facility failed to act promptly upon the recommendations of the resident council concerning issues of resident care and life in the facility. This was evident for 4 of 4 months of resident council meeting minutes reviewed. The findings include: On 1/15/25 at 2:15pm, an interview with 10 residents, including members of the resident council, was conducted. The residents voiced numerous concerns, many of which had also been identified by the surveyors. During an interview with the Life Enrichment Director (Staff #8) on 1/15/25 at 4:30 pm, copies of resident council minutes for November 2024, December 2024 and January 2025 were obtained. Minutes were requested for October 2024 but were not provided to the surveyor. Staff #8 stated that she sends council minutes and concerns to administration by using a Department Response Form. On 1/16/25 at 10:26 am during review of the Resident Council minutes provided by the facility, it was revealed that 20 issues were identified by the Resident Council in November 2024.…

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 reviews and interviews, it was determined that facility staff failed to assess the resident for an advance directive and did not offer assistance with creating an advance directive. This deficient practice was evident for 6 (#98, #76, #133 #185, #107, #547) out of 6 residents reviewed during the survey. The findings include: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On 1/13/25 at 10:57 AM, a review of Resident #98, #76, #133, #185, #107, #547's medical records revealed no evidence that the residents or their representatives were assessed for an advance directive, informed of their rights to have and advance directive, or provided with written material regarding an advance directive. On 1/13/25 and 01/14/25 the surveyor requested documentation from the Administrator #1 indicating that Resident #98, #76, #133, #185, #107,…

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 staff interviews it was determined the facility failed to provide adequate lighting, housekeeping and maintenance services to keep the residents' environment clean and in good repair. This was evident in 3 of 4 unit units observed during tours of the facility and resident rooms during the survey. The findings include: 1) During observation rounds on 01/13/25 at 7:50 am the surveyor entered the shower room located across from room [ROOM NUMBER], on the right side of the room in the corner was a white shower chair. Beneath the shower chair was a large amount of dried dark brown stool on the floor. Certified Nursing Assistant #29 confirmed the surveyor's findings and verbalized the shower room was used by the staff daily. 2) On 01/13/25 at 8:02 am the surveyor observed a cotton tipped swab on the left side of the commode in bathroom of room [ROOM NUMBER]. The cotton tipped swab remained in the same location when observed again by the surveyor later in the in the afternoon. On 01/15/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and resident interviews conducted during the resident council meeting, it was determined the facility failed to ensure the residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal and failed to promptly assist a resident in filing a grievance of missing personal property. This deficient practice was evident for 1 (#76) out of 1 resident reviewed during the annual survey. The findings included: 1) On 01/13/25 at 12:04 PM, during an interview with Resident #76, who was admitted [DATE], and their family member, they stated that the resident's jacket had gone missing during the week of Christmas. They reported the incident to a facility staff, but no one had followed up regarding the matter. On 01/14/25 at 03:15 PM, a review of Resident #76's personal property inventory record for December 2024 revealed that no personal property inventory had been completed. 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 resident interviews, staff interviews, and record reviews, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding activity needs for residents, a resident with weight loss and a resident with communication deficit. This was evident for 3 (#150, 116 & #179) of 5 residents reviewed for careplans during the survey. The findings include: 1. On 01/13/25 at 8:15 AM, Resident #150 was interviewed. During the interview, Resident #150 pointed out and stated to the surveyor that he/she had an August 2024, activities calendar posted on his/her room wall; therefore, he/she does not know what daily activities are being held at the facility. Also, Resident #150 did not have a Main Events calendar posted on his/her room wall; therefore, he/she was not aware of the facility's special events. On 01/15/25 at 8:34 AM, Resident #150's medical record was reviewed. The medical record review revealed that Resident #150's care plan stated that he/she should be provided with a monthly activity calendar and should be invited to special…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to provide nursing care within professional standards of practice. This was found to be evident for 5 (Resident #178, #297, #447, #150, and #158) out of 74 residents reviewed during the annual and complaint survey. The findings include: 1) On 1/15/2025 at 8:54 AM, during a review of Resident #178's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] after being hospitalized . Further review revealed a Discharge Summary from the hospital which included orders to follow up with Orthopedic Surgery Service in two weeks. The Surveyor also identified a physician's order dated 12/04/2024 for an Ortho follow up. During an interview conducted with the Director of Nursing on 1/15/2025 at 11:40AM, the Surveyor asked the DON to provide documentation verifying Resident #178's scheduled orthopedic appointment, transportation arrangements, and contact with the family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure that physician's orders were implemented and completed, ensure a residents' weight was monitored and ensure professional standards of nursing practice were followed when administering medications to residents. This practice was noted for 7 ( Resident #178, #297 #150, #116, #193, #188, #107) out of 74 residents reviewed during the survey. The findings include: 1) A percutaneous endoscopic gastrostomy (PEG) tube is a feeding tube that is surgically inserted into the stomach through the abdomen. It allows a person to receive nutrition, fluids, and medicine when they can't consume enough through their mouth. On 1/15/2025 at 9:00 AM, a review of Resident #178's electronic medical record revealed that the resident was admitted to the facility on [DATE] with a PEG tube in place. Further review failed to reveal any physician's order for PEG tube management at the facility. On 1/15/2025 at 11:48 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility leadership staff failed to ensure certified nursing assistants completed a state approved geriatric nursing assistant training program within four months of employment. This deficient practice was evident in 7 (#29, #61, #73, #74, #75, #76, #77) actively employed certified nursing assistants. The findings include: On [DATE] at 4:30 pm a review of Certified Nursing Assistant (CNA) #29's employee record revealed the CNA completed their CNA training on [DATE]. Their CNA certificate was issued by the Maryland Board of Nursing on [DATE]. According to the employee's record the CNA had been working at the facility past the four-month allotted timeframe to obtain their Geriatric Nursing Assistant (GNA) certification. On [DATE] at 8:38 am Administrator #1 verbalized the Nurse Aide Candidate Handbook the facility used under the [former owner's] policy indicated CNA's had 12 months to obtain a GNA certification. They were not aware of the four-month…

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

Based on medical record review and interview, it was determined the facility failed to ensure the pharmacist reports irregularities to the attending physician (Resident #133), and ensure that the Medication Regimen Review (MMR) of Residents #107 and # 150 was conducted at least once a month by a licensed pharmacist. This was evident for 3 of 7 residents reviewed. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review (DRR), is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1. A review of the medical record conducted on 1/15/25 at 10:58 pm for Resident #133, revealed a physician order from 8/26/23 for Phenobarbital 32.4 mg read as follows: Phenobarbital 32.4 tablet by mouth one time a day for seizures. The mg is missing from the order and could result…

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

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to their menu ticket. This was evident for 6 (Resident #136, #97, #176, #600, #193, #83, #599) of 6 residents randomly observed during meals, and 1 of 1 meal tray line observed during the survey. The findings include: 1a) On 01/14/25 at 09:13 AM, the surveyor randomly observed Resident #136 in her/his room eating breakfast. The surveyor observed Resident #136's meal ticket which indicated extra gravy or sauce on the side, hot cereal, orange juice, and coffee or hot tea. Resident #136's meal tray failed to include extra gravy or sauce on the side, hot cereal, orange juice, and coffee or hot tea. On 01/14/25 at 09:14 AM, an interview with Certified Nursing Assistant (CNA, Staff #29), who was in the room at the time of the observation revealed that she agreed that the listed items above were not on the resident's tray. CNA #29 also indicated that the kitchen did not have any orange juice and that by the time she passes out the trays to all…

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

Based on resident interview and surveyor observation it was determined the facility failed to provide palatable food with an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray. The findings include: On 01/15/25 at 11:23 AM, the surveyor observed the start of the lunch tray line in the kitchen. Staff were placing plates with food onto hot plates which were then placed into the tray carts for unit delivery. Hot plates are used to keep prepared food warm by serving it on a heated plate, ensuring that the meal stays at an appealing serving temperature for residents, especially those who may take longer to eat, preventing the food from cooling down too quickly when served on a cold plate. On 01/15/25 at 01:02 PM, Director of Operations (Staff #58) indicated that they had run out of hot plates at the time during the tray line. There were approximately 16 resident plates left to be made and sent to the unit. Staff #58 continued to place the following 16 plates on trays without a hot plate underneath onto the cart for unit delivery. 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 an interview with resident council members, it was determined the facility staff failed to ensure that suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. This was evident for 10 out of 10 residents present at the resident council meeting with the surveyor. The findings includes: On 1/15/25 at 2:15pm, a meeting with 10 residents for the resident council interview was held in the main dining hall. At this time, numerous resident complaints were voiced. All residents in attendance agreed that often there are no snacks at bedtime. The residents stated that bedtime snacks are brought to the unit not labeled and often not delivered to the rooms, there is typically only one choice of snack and no consideration of personal preferences. One resident stated they required special dietary considerations and that those considerations were never met by the evening snacks. Review of the resident council minutes on 1/15/25 at 3:30 pm 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 facility record reviews and staff interviews, it was determined that the facility failed to provide documentation indicating that facility staff members received screening, education, offering, of the current COVID-19 vaccination. This was evident for 5 staff members (Geriatric Nursing Assistants #64, 65, 66, 67 and 68) out of 5 staff members reviewed during the survey. The findings include: On 01/17/25 at 1:17 PM, Geriatric Nursing Assistant's #64, #65, #66, #67 and #68 facility records were reviewed. The facility record review revealed that Geriatric Nursing Assistants #64, #65, #66, #67 and #68 did not have documentation in their personnel records indicating that they received screening, education, offering, of the current COVID-19 vaccination. On 01/17/25 at 1:44 PM, the Infection Preventionist staff #4 was interviewed. During the interview, the Infection Preventionist staff #4 stated that he/she did not have documentation indicating that the 5 Geriatric Nursing Assistants received screening, education, offering, and current COVID-19 vaccination.

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 5 (Resident #48, #107, #160, #167, and #188) of 5 residents reviewed for accidents. 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. 1) On 01/13/25 at 11:59 AM, during the initial phase of the survey, the surveyor observed Resident #48 in bed with two 1/4 bed rails up on either side of the top end of the bed. 2) On 01/13/25 at 8:44 AM, during the initial phase of the survey, the surveyor observed Resident #107 in bed with two 1/4 bed rails up on either side of the top end of the bed. 3) On 01/13/25 at 8:44 AM, during the initial phase of the survey, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to keep a sanitary environment. This was evident for 3 of 4 units observed. The findings include: 1. On 01/13/25 at 07:48 AM, an observation of Unit 2 & 3 revealed linen on the floor outside of the bathroom next to room [ROOM NUMBER]. On 01/13/25 at 11:20 AM, an observation of Unit 2 & 3 revealed linen on the floor beside the dresser in Resident #56's room. On 01/15/25 at 12:32 PM, an observation in Resident #116's room revealed the resident's clothing and linen on the floor. The Director of Nursing (DON, Staff #2) confirmed the surveyor's observation. On 01/15/25 at 02:35 PM, an interview with Unit 2 & 3 Manager (Staff #30) revealed that the expectation is for staff to place soiled/dirty linen in resident room linen carts or the linen room upon completion of care or when identified. 2. On 01/13/25 at 08:37 AM, the surveyor observed a large vertical, rectangle- like area of missing wall paper on the unit 2 hallway across from room…

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

Based on medical record review and interview with facility staff and family, it was determined that the facility failed to notify the resident's responsible party (RP) when residents were had a change in condition/medical care. This was evident during a random observation for 2 of 2 residents (Resident #176 and #133) reviewed for notification during the survey. The findings include: 1. During observation rounds on 1/15/24 at 6:15pm while standing in the hallway near resident #210's room. Resident #176 family member began questioning the nurse staff # 85 on the medication cart as to where Resident #176 was located since s/he was not in the room. The nurse staff # 85 stated to the family member I know where the resident is. Who are you? The family member stated I am one the residents' responsible parties. Staff #85 stated the resident was transferred to the hospital for complaints of chest pain. The family member replied I was never notified. Why? The nurse stated, I don't know why. The nurse may have called the other contact person. The family member contacted the other family member…

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

Based on administrative review and interviews with facility staff it was determined the facility failed to prevent a resident from experiencing verbal abuse by an employee. This was found to be evident for 1 (Resident # 24) of 6 residents reviewed for abuse during the survey. Findings include: Intake MD00205342 was reviewed on 1/17/25 at 11:00 AM for allegations of abuse. According to the facility's investigation, GNA (Staff #56) was overheard by a Nurse (RN # 57) stating that she would hurt Resident # 24. Review on 1/17/25 of a written witness statement by the RN (#57) dated 5/3/24, revealed that while she was sitting at the nurse station, a GNA (#56) went to move Resident # 24 out of the way and the resident became verbally and physically aggressive. The Nurse heard the GNA say, Imma [sic] leave you alone because I know what you are and your mental isn't right, because other than that I would [expletive] you up. Further review of a signed written statement by the GNA (#56) revealed that she said the following to Resident # 24; Today is not my day, I would beat you up because…

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

Based on resident interviews and staff interviews it was determined that the facility failed to protect the residents from misappropriation of personal property and investigate resident's report of missing personal property. This was evident for 2 (resident #38 and #76) out of 4 residents reviewed during survey. The findings include: 1) On 01/13/25 at 11:26 AM, Resident #38 was interviewed. During the interview, Resident #38 stated that some of his/her clothing was missing after being laundered by the facility. On 01/13/25 at 12:45 PM, the Nursing Home Administrator staff #1 was interviewed. During the interview, he/she was made aware of Resident #38's grievance regarding his/her laundry missing. After surveyor intervention, the Nursing Home Administrator staff #1 stated that a Grievance Summaries would be completed. On 01/15/25 at 10:21 AM, Environmental Director staff #15 was interviewed. During the interview, Environmental Director staff #15 stated that he/she was not aware of the missing items and did not receive a Grievance Summaries regarding Resident #38's missing clothing.…

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

Based on review of the facility reported incidents and interviews, it was determined that the facility failed to report an injury of unknown origin in a timely manner to the state agency. This was found to be evident for 1(Resident #154) of 6 residents reviewed for abuse during the survey. The Findings include: During review of the facility reported incident MD00205829 on 1/17/25 at 8:58 am, it was found that an injury of unknown origin was reported to LPN (Licensed Practical Nurse) #14 by Resident #154 on 5/18/24 at 4:20pm. The Self Report Form from the facility was submitted to the State Agency on 5/19/24 with no time indicated by the DON (Director of Nursing). The report was received by the State Agency on 5/20/24 at 12:34pm. During an interview with the DON and the Administrator on 1/17/25 at 10:30 am, both were unable to indicate why the alleged incident and injury of unknown origin was not reported within the 2 hour requirement.

Based on medical record review, facility investigation report review, and staff interview it was determined that the facility failed to retain documentation related to the delayed reporting of a resident fall. This was evident for 1 out of 4 (#124) residents reviewed for falls during the survey. The findings include: On 01.15.25 the surveyor reviewed the facility report related to Resident # 124 that was submitted to OHCQ on 06.23.24. On 06.03.24 the resident complained of pain to the right hip and leg. The resident was treated for the pain, the medical director, nurse practitioner, and the resident representative were notified as well on 06.3.2024. On 06.03.24 resident #124 was admitted to the hospital and found to have a fracture of the right femur. The surveyor's review of the final facility reported submitted by the facility revealed the resident had fallen on 06.01.24, the LPN #24 did not document the completion of the assessment of Resident #124 or document that the fall had occurred at 10 PM on 06.01.24. The DON failed to retain documentation that the LPN #24 failed to report…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to code a resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #188) of 40 sampled residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process. On 01/13/25 at 2:52 PM, review of Resident #188's medical record revealed a progress note titled Wound Care Progress Note dated 1/3/25 which indicated the resident had a Deep Tissue Injury (DTI) on her/his sacrum. A Deep Tissue Injury (DTI) is a type of pressure sore where the tissue underneath the skin is severely damaged by pressure. The sacrum consists of the bottom or base…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility staff failed to have a care plan meeting with the interdisciplinary care team and failed to provide residents with a quarterly care plan meeting prepared and revised by the entire interdisciplinary team after the quarterly review assessment. This deficient practice was evidenced in 2 ( Resident #116 and Resident #150) of two records reviewed for care plan meetings during the survey. The findings include: 1. On 01/13/25 at 4:18 pm during an interview with Resident #116 the surveyor asked if they were participating in care plan meetings. The resident did not recall having care plan meetings. On 01/15/25 at 8:35 am a review of the resident's electronic medical record revealed there was no documentation to verify the resident had a multidisciplinary care plan meeting prior to 12/24/24. The resident was admitted to the facility on [DATE]. There was documentation of a navigation guide meeting on 11/01/24. There was no documentation to verify 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 clinical record review, staff interviews, and observations it was determined that the facility failed to offer alternative equipment for a resident whose electric wheelchair was broken in order to maintain the resident's mobility and opportunities to be out of bed and failed to provide basic activities of daily needs to a resident. This was evident for 2 (Resident #130 and # 116 ) out of 4 residents reviewed for activities of daily living during the survey. The findings include: 1. Resident #130 was diagnosed as a C5-C-7 quadriplegic as a result of a Motor Vehicle Accident several years ago who has limited mobility of his/her hands. On 01.13.25 at 09:20 AM the surveyor returned to resident #130's room. The resident stated that staffing was not sufficient. The resident stated that he/she had to ask for assistance and may wait a long time for the staff to return to his/her room. Also, the resident stated that he/she had not been out of bed for six months and that he's/her wheelchair had not been repaired for over six months. The resident also stated that he/she would prefer…

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 staff interviews, observations, administrative records reviews,and medical record reviews it was determined that the facility failed to document that a dependent resident consistently received activities of daily care such as showering and bathing or assistance with meals. This was evident for 1 out of 4 residents (#130) reviewed during the survey. The findings include: Resident #130 was diagnosed as a C5-C-7 quadriplegic as a result of a Motor Vehicle Accident several years ago who had limited mobility of his hands. On 01.13.25 at 09:05 AM during an observation tour of the clinical unit 8, the surveyor observed resident #130 in bed with a foley catheter, no foley bag cover was present. The resident had an over the bed table in front him/her with both his/her hands on the table. The surveyor observed that the there was a dirty hand splint lying on the table in front of the resident's hand. While the surveyor was speaking with the resident, GNA #53 entered the resident's room with a breakfast tray. GNA…

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 with facility staff it was determined the facility failed to ensure that one-on-one activities were provided for a resident. This was found to be evident for 1 (Resident #24) of 3 residents reviewed for activities during the facility's survey. Findings include: An observation was made on 1/13/25 at 1:01 PM and resident # 24 was lying in bed asleep. No activities were observed. Observation on 1/15/25 at 9:00 AM resident # 24 was observed sitting up in the bed with his/her legs noted to the side of the bed. No activities observed. While remaining on the unit from 9:00 AM-9:40 AM on the same date, the resident remained in the room when observed multiple times, sitting with legs to the side of the bed. No activity staff were observed entering the resident room and no one-one activities were observed. During an interview with the Life Enrichment Director (LED), Staff # 8 on 1/15/25 at 10:45 AM, she stated that anyone that does not come out for activities and is determined not to be active on their own, in their room will receive one-one activities…

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 facility staff it was determined the facility staff failed to use appropriate safety measures while transferring a resident with a Hoyer lift and keep a resident environment safe. This was found to be evident for 2 (Resident # 210 and # 154) of 6 residents reviewed for accidents during the survey. Findings include: 1. On 1/15/25 at 5:45 PM while touring the units, a family member who was visiting with resident # 210 requested assistance of staff to transfer the resident to bed. A nurse who was on the unit summoned a GNA (#48) to the resident room. Approximately five minutes later another GNA #54 and the assigned GNA (#55) arrived to assist. GNA #48 brought the Hoyer lift to the resident room and the other 2 GNA's placed the apron drape underneath the resident. The resident agreed to allow the surveyors to observe the transfer. At this time, the three GNA's attached the apron drape that was underneath the resident to the lift and proceeded to lift the resident. They were unable to lift the resident as the battery was not working. GNA # 48…

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 reviews, and interviews, it was determined that facility staff failed to monitor and address the nutritional needs of a resident who had a known significant weight loss. This deficient practice was evident for 1 (#107) of 1 resident reviewed during the survey. The findings include: On 01/13/2025 at 3:11PM, during a review of Resident #107's medical records, the surveyor identified that the resident's weight on 12/8/24, was 194 lbs, and on 1/6/25, it had decreased to 175 lbs, reflecting a weight loss of 9.79%. Review of Resident #107's treatment record for September 2024 to December 2024 revealed an order for monthly weights. On 12/08/24 a new order was written for Resident #107 to be weighed weekly, times four weeks, then monthly starting 12/08/24. There was no documentation to verify Resident #107 was weighed weekly. On 1/15/25 at 2:04 PM, a review of the Registered Dietician (RD) #21 progress notes for 11/13/2024, regarding weight changes reveals that Resident #107 weight had decreased by 20.6 lbs (9.3%) over the past two months. A review of the RD #21…

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 bed rails. This was evident for 5 (Resident #48, #107, #160, #167, and #188) of 5 residents reviewed for physical restraints. 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. The facility should obtain a signed consent form before the use of bedrails. 1) On 01/13/25 at 11:59 AM, during the initial phase of the survey, the surveyor observed Resident #48 in bed with two 1/4 bed rails up on either side of the top end of the bed. On 01/16/25 at 11:00 AM, review of the document provided titled MQS: Admission/readmission Evaluation Packet Section 2: Bed Rail Evaluation for Resident #48 failed to reveal alternatives attempted…

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 staff failed to ensure that the physician provided supervision of a resident with significant weight loss. This deficient practice was evident for 1 (#107) resident reviewed during the survey. The findings include: On 01/13/2025 at 3:11PM, during a review of Resident #107's medical records, the surveyor identified that the resident's weight on 9/17/2024, was 215.6 lbs, and on 1/12/25, it had dropped to 175 lbs. Further review of residents weight on 01/15/24 revealed a weight of 165 lbs. A review of the RD #21 progress notes for 1/13/2025, regarding weight changes reveals that Resident #107's weight had decreased by 19 lbs over the past month. No interventions were ordered until 1/13/25. During an interview with the Director of Nursing (DON) #2 on 1/15/25 at 4:21 PM, the surveyor asked why Resident #107's medical provider was not informed of the significant weight loss, the DON #2 was not able to provide an explanation why notification was not done. On 01/16/25 at 3:33 PM, the surveyor reviewed progress notes…

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

Based on observations, interviews, and record reviews, it was determined that facility staff failed to ensure adequate nursing staff to properly monitor residents. This deficient practice was evident for 1 (#133) out of 1 resident reviewed during the survey. The findings include: On 1/13/24 at 5:38 PM, review of complaint MD00204568 dated 4/2024 revealed, Resident #133 family member alleged the resident was being neglected by staff due to staffing issues. On 1/14/25 at 4:19 PM, during an interview with Resident #133's family member, they report concerns about multiple falls Resident #133 had on station 7. The family member also mentioned that on 7/28/24 at 11:49 AM, they received a voicemail message regarding another fall the resident had. When they returned the call and asked the nurse who was working on station 7, the nurse replied that no nurse was working on unit 7. On 01/15/25 at 8:41 AM, during an interview with geriatric nursing assistant (GNA) #19, they explained that stations 1, 2, 3, and 7 generally have one nurse assigned, while stations 4 and 8 have two nurses. GNA #19…

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

Based on observation and interviews, it was determined that the facility failed to post the required staffing data on the whiteboard and/or on the daily staffing board. The facility also failed to post the daily staffing schedule in a prominent place, readily accessible visually to visitors and residents. This was evident on three out of three nursing units. The findings include: On 01.13.25 at 08:45 AM the surveyor observed that on unit 7 the census board reflected the staffing assignment for Sunday, 01.12.25. Also, on unit 7 the daily staffing schedule was lying on the top of the counter and was not visible for visitors or residents. Additionally, at approximately 09:00 AM on unit 8 the daily staffing schedule was not posted so that visitors and residents could easily visualize the information. On 01.14.25 at 08:39 AM while performing an observation tour on Unit 2 and 3 surveyor observed the assignment board did not have written information regarding which clinical staff were assigned to each resident. There was no assignment sheet displayed that informed the residents or visitors…

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 failed to ensure that an account of all controlled drugs was complete and accurate and failed to provide the correct dosage of medication for a resident. This was found to be evident for 2 out of 2 narcotic lock boxes located in the narcotic medication carts and for 1 (Resident # 158) of 3 medication administration records reviewed for accuracy during the facility's survey. The findings include: Controlled Drugs 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 1/17/2025 at 8:45 AM, during an interview conducted with Licensed Practical Nurse (LPN) #5, 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 Controlled Drug Receipt/Record/Disposition (CDRRD) form in the narcotic count binder…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed (PRN), had an end date that was limited to 14 days. This was evident for 1 (Resident #59) of 5 residents reviewed for medications. The findings include: On 01/16/25 at 09:10 AM, record review of Resident #59's active orders revealed an order for hydrOXYzine HCI Oral Tablet 25 MG, give 25mg by mouth every 24 hours as needed for anxiety/itching/restlessness with a start date of 01/09/2025 and an end date of 02/08/2025. Hydroxyzine is used to help control anxiety and tension caused by nervous and emotional conditions. On 01/16/25 10:35 AM, review of the facility policy labeled Psychotropic Medication Use revealed that, PRN orders for psychotropic medications are limited to 14 days. On 01/16/25 at 11:26 AM, an interview with the Director of Nursing (Staff #2) revealed that the facility was supposed to avoid using psychotropic medications PRN (as needed). She further indicated if a psychotropic medication is ordered PRN, 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, record review, and interviews with staff, it was determined that the facility failed to ensure that all medications and biologicals were stored and labeled properly. This was evident for 3 out of 3 medication carts reviewed during the medication storage facility task completed during the survey. The findings include: Controlled Medications 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. On 1/17/2025 at 8:30 AM, during an observation of a medication cart across from nurses' station #1, the Surveyor identified house stock medication bottles of Melatonin 10 mg, Melatonin 5 mg, Melatonin 3 mg, Aspirin chewable 81 mg, acetaminophen 325 mg, and Vitamin D 25 mcg which were all opened and not labeled with the date the bottle was opened. Licensed Practical Nurse (LPN #5 was made aware of the Surveyors findings and stated she would discard the medication according to the facility policy. LPN #5 informed the Surveyor that once a new house stock medication…

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

Based on observation and interview, it was determined that the facility failed to ensure that the facility's kitchen had an eating assistive device for a resident. This was evident for 1 (Resident #23) of 223 resident meal tickets observed during the kitchen meal tray line. The findings include: On 01/15/25 at 11:45 AM, during the lunch tray line observation, Director of Operations (Staff #58) indicated that they did not have the scoop plate that was indicated on the meal ticket for Resident #23. A scoop plate is an assistive device that helps people eat independently by making it easier to push food onto a spoon or fork because of curved rim features. On 01/15/25 at 11:45 AM, an interview with Staff #58 revealed that physical therapy would have to order more because the kitchen had no scoop plates. On 01/15/25 at 11:46 AM, an observation during the same tray line revealed Resident #23's food prepared on a regular plate.

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that residents' records are accurate, complete and protected. This was found to be evident for 3 (Resident # 41 and # 105) of 40 sampled residents reviewed during the facility's survey. Findings include: 1. Review of resident # 41's medical record on 1/14/25 at 11:45 AM revealed the Preadmission Screening and Resident Review (PASARR) form that was completed on 11/10/22 did not have section (A)- Exempted Hospital Discharge filled out. The rest of the form was completed. 2. Review of resident # 105's medical record on 1/14/25 at 11:20 AM revealed the PASARR form that was completed on 11/18/21 did not have section (A)- Exempted Hospital Discharge filled out. The rest of the form was completed. An interview was conducted with the Director of Social Services staff # 13 on 1/15/25 at 1:50 PM and she was asked to review the PASARR form for the resident that did not have the top part completed. She stated that the first section (A)- Exempted Hospital Discharge is supposed to be…

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

Based on review of the facility documentation and staff interviews it was determined the facility failed to ensure that the Quality Assurance Committee met on a quarterly basis for the past year. This was found to be evident during the facility's survey. Findings include: On 1/17/25 at 2:00 PM the survey team requested documentation of the facility's Quality Assurance attendance sheets for January 2024 through December 2024. The documents provided by the facility consisted of information dated July 2024 through November 2024. At that time an interview was conducted with the Administrator (Staff#1) who stated that she was the designated person for the Quality Assurance Program. She stated that the facility obtained new ownership effective June 26, 2024. She went on to say that the current owners did not maintain documentation of the previous attendance sheets at the time of obtaining ownership and could not provide the attendance sheets for January 2024, February 2024, March 20024, April 2024, and May 2024. She was made aware that the facility is responsible for maintaining all…

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 3. On 01/13/25 at 8:12 AM, Licensed Practical Nurse staff #9 was interviewed. During the interview, Licensed Practical Nurse staff #9 stated that Resident #447 was on droplet precautions for respiratory syncytial virus. Also, Licensed Practical Nurse staff #9 stated that the facility's policy and procedure is that residents diagnosed with respiratory syncytial virus should have droplet precaution signage on the outside of his/her room door. During observation rounds on 01/13/25 at 8:23 AM, Resident #447's room was found to not have droplet precaution signage posted on the outside of his/her room. On 01/17/25 at 11:28 AM, Resident's #447's medical record was reviewed. The medical record review revealed that Resident #447 was diagnosed with respiratory syncytial virus on 1/9/25. Based on observations and interviews it was determined that the facility staff failed to maintain infection control practices and provide the appropriate signage outside the resident's room indicating the use of specific personal…

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, observation and interview, the facility failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for 5 of 8 nursing units observed during a complaint survey. The findings include: Based on multiple complaints of the facility's environment, the Surveyor began an environmental tour on 2/21/24 at 7:45 AM. The Unit Manger (Staff #12) and Surveyor on 2/21/24 at 7:55 AM observed the following: 1. room [ROOM NUMBER]'s shared bathroom: an unmarked and uncovered bed pan and basin on the floor, and unmarked and uncovered basin on the sink, laminate missing from the front panel of sink cabinet exposing plywood. 2. room [ROOM NUMBER]B's dresser (not in reach of the Resident #47 who is bed ridden) contained food in a plastic dish. Resident #47 was asked how old the food was and the Resident stated he/she did not know. 3. Outside room [ROOM NUMBER] on the floor was an oxygen concentrator, 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 review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate injuries of unknown origin and allegations of abuse, neglect, and misappropriation of resident property. This was evident for 6 (#7, #32, #38, #45, #53, #55) of 28 facility reported incidents reviewed during a complaint survey The findings include: 1. On 2/23/24 a review of facility reported incident MD00199622 was conducted and revealed on 11/15/23 Resident #7 was assessed and sent to the emergency room for left shoulder dislocation. The Surveyor asked the Director of Nursing (DON) on 2/27/24 at 8:55 AM for the investigation of the incident. At that time the DON stated she has not been able to find the investigation and has no statements from the facility staff that worked with the Resident during the time of the injury. Interview with the DON on 2/27/24 at 11:10 AM confirmed the facility does not have the investigation of Resident #7's injury on 11/15/23. 2. On 2/15/24 a review of facility reported incident MD00184931 was conducted 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 medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (Resident #12, #15, #20, #35, #38, #41, #43 and #47). This was evident for 8 of 67 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. Review of Resident #12's medical record on 2/15/24 revealed the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to evaluate and document the condition of a resident's skin wound weekly (Resident #12). This is evident for 1 of 67 residents reviewed during a complaint survey. The findings included: Review of Resident #12's medical record on 2/15/24 revealed the Resident was admitted to the facility on [DATE] with diagnosis to spinal cord injury. Further review of Resident #12's medical record revealed the Resident has a Moisture Associated Skin Damage wound to the sacrum that was in house acquired, deteriorating and 10 months old. Review of the facility documented weekly assessments for Resident #12's sacral wound revealed there was no documented skin assessment including measurements on 12/4/23 and 12/25/23. Weekly assessments of wounds allow the facility staff to determine if the treatment needs to be changed. Interview with the Director of Nursing on 2/22/24 at 9:45 AM confirmed the facility staff failed to evaluate and document the condition of…

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

Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. The Findings: on 2/21/24 at 8:00 an observation with Staff #12 a single door food cart on Unit 100 covered with dirt/food debris inside and outside of the cart. Milk sitting on top of food cart not on ice or kept cold. Milk remained on top of the food cart not chilled until 8:30 AM and uncovered. The double door food cart doors were left open as staff delivered the breakfast trays in the halls. An observation with DON on 2/21/24 at 8:28 AM of the double door food cart that has a plastic covering coming off the doors leaving the cart not to be properly clean. The DON stated that the cart was new, and the protective film was not removed prior to circulation of the cart. An observation at 8:33 AM on Unit 200 milk was noted on the top of the food cart uncovered and not kept on ice. An observation at on Unit 700 at 8:55 AM milk…

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

Based on observation, interview, and documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. This was evident during meal service, in the kitchen and infection control supplies on 4 of 8 nursing units. The findings include: 1. Observation of the kitchen on 2/21/24 at 10:00 AM with Director of Dining Services revealed the kitchen had 2 handwashing sinks for kitchen staff and both had empty soap dispensers. Interview with the Director of Dining on 2/21/24 at 10:00 AM confirmed the soap dispensers should be filled with soap and functioning for kitchen staff to wash their hands during meal preparation and kitchen clean up. 2. Observation of meal service on 2/21/24 at 8:20 AM in Resident #65's room revealed an enhanced barrier precautions sign outside the door. The sign instructs caregivers, staff and visitors to perform hand hygiene before and after patient contact, contact with environment and after removal of PPE (personal protective equipment).…

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 it was determined that the facility failed to maintain kitchen equipment and showers rooms in safe operating condition. The findings include: On 2/21/24 at 9 AM and at 1 PM during an tour of the facility's kitchen with the Director of Dinning Services and the Director of Maintenance the following observations were made: 1. The walk-in refrigerator door was observed slightly ajar and incapable of closing properly as designed. This was also observed on 2/22/24 at 8:15 AM with the Administrator. 2. The hand sink did not have hand soap available. This was also observed on 2/22/24 at 8:15 AM. 3. The hand sink by the ice machine did not have soap available. This was also observed on 2/22/24 at 8:15 AM. 4. The 3-panel light switch did not have a cover exposing the wires. 5. Review of pest control logs mention the floor and walls under the dishwasher as a problem area that is commonly soiled. 6. The water temperature to the hand sinks was 93 degrees Fahrenheit. 7. The 3 compartments sink water temperature was 94 degrees Fahrenheit. 8. The dishwasher did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews and review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning roaches and mice. The findings included: On 2/20/2024 at 10:30 AM in the Nursing conference room a roach was noted by the surveyor crawling on the wall. The DON was made aware and killed the roach. On 2/21/24 at 9 AM two Roches were noted on the kitchen wall. The facility's pest control logs were reviewed on 2/21/2024 and showed that a pest control company services the facility. On 1/31/24 the pest control company recommendation was to correct water leak and standing water by the dishwasher and to repair cracks and damage walls to prevent pest entry in the kitchen. Further, recommendations by the pest control company were made on 2/6/24 and 2/13/24 to repair cracks and damage walls to prevent pest entry into the kitchen and to fix water leaks. On 2/21/24 at 9 AM a tour of the kitchen revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, observation and interview, the facility staff failed to treat every resident with respect and dignity (Resident #10, #35, #44 and #64). This was evident for 4 of 67 residents during a complaint survey. The findings include: 1. Review of Facility Reported Incident (FRI) MD00200039 on 2/15/24 revealed on 11/29/23 former EVS (Environmental Services) Director (Staff #25) had Resident #10 mopped his/her own urine. Review of Resident #10's medical record on 2/15/24 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include intracranial injury. On 8/9/17 the Resident was certified by a physician to lack adequate decision making capacity. Further review of FRI MD00200039's facility investigation revealed Staff #25's statement on 11/29/23 at 9:32 AM included Staff #25 stated: I seen Resident #10 had urinated in his/her favorite place so I asked him/her did he/she urinate on the floor, he/she said yes. I walked to the closet and got the cart and took to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to protect residents from abuse from another resident (resident #24) and abuse from a staff member (resident #46). This was evident for 2 of 67 residents reviewed during a complaint survey. The findings include: On 7/11/23, the State of Maryland's Office of Health Care Quality received a facility reported incident (MD00194246) which reported the investigation of an alleged abuse of resident #24 by resident #23. The facility investigation substantiated physical abuse by resident #23 toward resident #24. Medical record review on 2/16/24 at 12:00pm revealed resident #24 was a long-term care resident admitted to the facility on [DATE] with diagnoses of stroke and difficulty walking. Resident #23 was admitted to the facility on [DATE] with diagnoses of Schizophrenia and mild cognitive impairment. Facility reported incident (FRI) investigation review on 2/16/24 at 12:10pm revealed GNA #45 reported the alleged abuse 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 medical record review and interview, the facility staff failed to report alleged abuse of a resident (residents # 18, #26, #37, and #39) to law enforcement. This was evident for 4 out of 67 residents reviewed during a complaint survey. Findings include: On 8/21/23, the Office of Health Care Quality received a Facility Reported Incident (FRI) report (MD00195815) which reported the alleged abuse of resident #18 by facility staff. The FRI investigation was unable to substantiate abuse of resident #18. Review of resident #18's medical record on 2/15/24 at 12:44pm revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of the FRI investigation on 2/15/24 at 12:50pm revealed resident #18 alleged 4 staff members beat him/her and the resident stated that his/her backs because of the abuse. The investigation did not reveal any evidence that the facility attempted to contact local law enforcement to report the allegation of abuse. Interview with the Director of 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 the review of facility documentation, medical record review and interview, it was determined that the facility failed to implement an effective discharge planning process for a resident (Resident #12). This was evident 1 of 34 discharged residents reviewed during a complaint survey. The findings include: During interview of Resident #12's Representative on 2/23/24 at 10:43 AM, the Representative stated the facility failed to have the durable medical equipment in place at the time of the Resident's discharge home on 2/14/24. The Representative stated he/she had a meeting with social work prior to the Resident's discharge and was told a wheelchair would be at the facility for the Resident to go home in and there would be a hospital bed and hoyer lift delivered to the Resident's home prior to his/her arrival. The Representative stated at the time of discharge the wheelchair was not at the facility and the equipment was not delivered until 8:30 PM after the Resident arrived home. The Representative then…

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 failed to place a discharge summary on a resident's (resident #21 and #34) medical record after discharge. This was evident for 2 of 67 residents reviewed in a complaint survey. The findings include: Review of resident #21's medical record on 2/22/24 at 12:36pm revealed no evidence of a discharge summary after the resident discharged from the facility on 5/31/23. Interview with the Director of Nursing (DON) on 2/22/24 at 1:36pm revealed the resident discharged from the facility when local law enforcement placed the resident under arrest for violation of his/her probation. The surveyor pointed out that the progress notes on the resident's medical record provide no evidence that the resident discharged from the facility on 5/31/23. The DON reviewed the progress notes and agreed that the facility failed to place a discharge summary on the resident's medical record. 2. Review of resident #34's medical record on 2/23/24 at 10:00am revealed no evidence of a discharge summary after the resident from the facility 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 the medical record review and resident interviews it was determined the facility staff failed to ensure that dependent resident (resident #67) personal hygiene needs were adequately met by not providing hot water showers and baths as scheduled. This was evident for 1 of 67 residents reviewed during the complaint survey process. The findings include: In an interview with Resident #67 on 2/21/24 at 09:48 AM, revealed that Resident #67 stated I don't take showers or baths. I would like a shower because I'm young and still get my menstrual. The water temperature is too cold. A review of Resident's #67's Treatment Administration Records (TARs) revealed that the resident is scheduled to receive showers on Tuesday and Friday and daily bath. For the month of February 2024, the resident received no showers and only 3 baths for the month. On 2/22/24 at 12:30 PM the Director of Nursing (DON) stated that it's not unusual for the Resident to refuse care and then handed the surveyor a care plan for refusal of care with ADL's . The DON was unaware that the shower water temperature 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 assess and document a resident's need for pain medication (Resident #14). This was evident for 1 of 67 residents reviewed during a complaint survey. The findings include: Review of Resident #14's medical record on 2/15/14 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation services. Review of Resident #14's August 2023 Medication Administration Record revealed the Resident was administered Acetaminophen 650 mg on 8/1/23, 8/2/23, 8/3/23, 8/5/23, 8/6/23, twice on 8/7/23 and 8/9/23. Acetaminophen is a medication used to treat pain and fever. The Resident was transferred to the hospital on 8/9/23 and did not return to the facility. Further review of Resident #14's medical record revealed no assessment or documentation of why the Resident was receiving Acetaminophen. Interview with the Director of Nursing on 2/22/24 at 11:00 AM confirmed the facility staff failed to assess and document Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #15) This was evident for 1 of 67 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #15's medical record on 2/15/24 revealed the Resident was admitted to the facility on [DATE] and discharged to the hospital on 9/27/23. Further review of the Resident's medical record revealed after the Resident was discharged on 9/27/23, the facility staff documented on 9/28/23 they administered medications, a hour of sleep snack and documented a blood pressure of 112/70. Review of the Resident's September 2023…

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 interview with facility staff, it was determined that the facility failed to have a full time CDM (Certified Dietary Manager) or certified licensed Dietician on staff and in the kitchen on a full time basis. This practice had the potential to affect all residents. The findings include: The Dietary Manager (Staff #7) was interviewed on 10/8/19 at 8:15 AM. The Dietary Manager stated that he was currently in school to get his CDM (Certified Dietary Manager) License. Dietician #14 stated she/he does not routinely remain in the kitchen to observe the tray line and only works two to four days per week. There were two other Dieticians on staff but they were not Registered Dieticians. After speaking with staff # 14, she/he was in the kitchen on 10/11/19 to watch the tray line and take temperatures and monitor staff. The Administrator was made aware.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, the facility failed to send the comprehensive care plan goals with the residents who were sent to the hospital. This was evident for 4 (Residents #81, #98, #124, and #179) out of 4 residents reviewed for hospitalization. The findings include: 1. Resident #81 was sent to the hospital on 1/31/19 due to a fall from mild orthostatic hypotension and a drop in blood pressure. A written notice of transfer to the hospital was sent to his/her responsible party and a bed hold policy was given to the resident. There was no evidence that the care plan goals were sent with the resident to the hospital. The Director of Nursing was made aware of these findings and acknowledged that the care plan goals were not sent to the hospital with the resident. 2. Resident #98's medical record was reviewed on 7/18/19. The review revealed that Resident # 98 was admitted to the hospital with urinary tract infection, sepsis, acute renal failure and elevated troponin. There 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 observation of the kitchen, it was determined that the kitchen staff: 1) failed to label and date food that was cooked and put away in the refrigerator; 2) failed to date food placed in the dry storage room; and, 3) failed to monitor staff for hair net use in the kitchen. The findings include: 1) On 10/07/19 at 06:22 PM, the Kitchen was observed. Staff #3 was the supervisor on duty. During this time the kitchen staff was in the process of putting food on the plates to distribute to units. During observation in the dry storage room, there were plastic containers filled with 4 types of cereal, Cheerios, Corn Flakes, Raisin Bran and [NAME] Crispy's. None of the containers were dated. There were, also, 3 trays of cereal in bowls (approx. 120 bowls) that were covered but not dated. On 10/8/19 at approx. 8:30 AM this surveyor met with the Director of Dietary Services and again the dry storage room was observed and an additional 39 Bowls of cereal not dated (counted by manager) an open loaf of Texas Toast was…

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

Based on medical record review and staff and resident interview, it was determined the facility failed to ensure that staff documented a physician's order for a suprapubic catheter for Resident #474. This was evident for 1 (Resident #474) of 44 residents reviewed during the survey. The findings include: On 10/8/19 at 9:42 AM during an interview, Resident #474 stated s/he had a suprapubic catheter. According to https://medlineplus.gov/ency/patientinstructions/000145.htm: A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. On 10/11/19 at 11:39 AM during a review of the medical record for Resident #474, it was noted there was no documented physician order for a suprapubic catheter. During an interview with Unit Manager (UM) #15, she stated that she, also, was unable to find a physician order for the suprapubic catheter.

Based on observation and interview with the Director of Dietary and Supervisor of Maintenance, the facility failed to have the freezer in safe working conditions. This practice has the potential to impact all residents receiving nutrition from the facility's dietary services. The findings include: On 10/7/19 at 6:41 PM an inspection of the kitchen was conducted. The temperature on the freezer door was - 20 degrees. To the right of the freezer door was metal shelves covered in thick frost. Fans in the freezer, also, contained thick frost. On one of the shelves to the right of freezer door, were ice cream cups stuck to the freezer shelf. Two other shelves contained trays of frozen food that were, also, stuck in the ice build up. On 10/8/19 at 8:45 AM, the Director of Dietary (# 7) was shown the freezer and removed 17 trays of food due to frost -10 degrees and discarded food. The Maintenance Supervisor (staff #16) came into to kitchen to look at the freezer door. He/she stated that the door is not even with the floor causing heat of kitchen to go under the freezer door. 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 observation, medical record and staff interview, the facility staff failed to develop a treatment plan for Resident #33 eyes that were watery and bright red along the bottom of both eyelids. This was evident for 1 out of 67 residents investigated during the survey process. The findings Include: On October 7, 2019 during a late entrance tour of the facility around 6:30 PM, Resident #33's eyes were observed to be bright red along the base of both eyelids. The resident was not able to explain the redness to the eyes. On October 9, 2019 around 10:29 AM, Resident #33's eyes remained bright red around the bottom of each lid. On October 11, 2019 around 10:39 AM while reviewing the residents medical record, it was noted that there was no treatment ordered for the resident's eyes. The resident was observed in the bedroom again this day with eye lids appearing the same, way watery and red. The Writer interviewed the Assistant Directorof Nursing (ADON) about the resident's condition. With surveyor intervention the ADON informed this writer that the ADON will have the Nurse…

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

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure that orders for as-needed psychiatric medication were limited to 14 days. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medication. The findings include: Resident #7's medical record was reviewed on 10/11/19 at 9:43 AM. During the review, it was found that the resident was prescribed an as-needed benzodiazepine antianxiety medication with the following instructions: Give 1 tablet by mouth every 12 hours as needed for anxiety. The order date was 9/25/19, 16 days prior to the review date. Review of the physician notes did not reveal a rationale by the prescribing practitioner for why the medication should be extended beyond 14 days of use, nor did it reveal the intended duration of the therapy. Regulation requires that as-needed orders for psychotropic drugs be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the as-needed order to be extended beyond 14 days, he or she…

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

Based on observation, medical record review and staff interview it was determined the facility failed to ensurethat Resident #204 was not served food that would trigger a known food allergy. This was evident for 1 (Resident #204) of 12 residents identified by the facility as having food allergies. The findings include: On 10/8/19 at 10:10 AM during an initial interview, Resident #204 stated s/he sometimes gets food that s/he is allergic to or doesn't like. At 2:35 PM the resident was interviewed regarding that day's lunch. S/he stated s/he didn't like the food served and had asked for a salad substitute. The resident went on to say that the salad had tomatoes on it and s/he was allergic to tomatoes. A salad with tomatoes on it was observed in the room. An examination of the lunch ticket on the resident's food tray confirmed that dietary staff knew that the resident was allergic to tomatoes as it was clearly written on the ticket. When the surveyor went to speak to a nurse, Staff Nurse #2 was overheard telling a Dietary Aide that the food substitute that was served had tomatoes on it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, it was determined the facility failed to 1) ensure equipment used for personal hygiene was not left directly on the bathroom floor for Residents #199 and #475; and 2) ensure that a visitor of Resident #475 received education regarding why a gown and gloves needed to be worn when visiting the resident. This was evident for 2 (Residents #199 and #475) of 44 residents reviewed during the survey. The findings include: 1) On 10/8/19 at 9:57 AM during an inspection of the bathroom of Resident #199, a bedpan was observed lying on the floor of the bathroom. The bedpan was not in a plastic bag and was not labeled with a resident room number or name. Resident #199 was out of the room at the time. It is a standard of nursing practice to not store items used for personal hygiene directly on the floor. Geriatric Nursing Assistant (GNA) #1 was brought to the room and asked why the bedpan was on the floor. She stated she did not know and added that the resident 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 medical record review and interview, it was determined that the nursing staff failed to notify the physician that a resident (#133) was consistently refusing or not available for ordered insulin injections. This was evident for 1 of 37 residents sampled for investigations. The findings included: Resident #133 was admitted to the facility for care that included insulin injections to control diabetes. The physician ordered 10 units of Humalog insulin to be injected daily at 6:30 AM, 11:30 AM, and 4:30 PM. The physician also ordered a sliding scale insulin to be given at 6:30 AM, 11:30 AM, and 4:30 AM. Sliding scale insulin doses are dependent on the level of blood sugar at the time. For sliding scale the nurse first takes the blood sugar reading and then the dosage of insulin is made dependent on the blood sugar level. Resident #133 did not receive Humalog 10 units of insulin nor the sliding scale insulin due to refusal or for not being on the nursing unit for the 11:30 AM dose 11 times from May 1, 2018 through June 10, 2018. The 4:30 PM medications were not received 11 times…

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

Based on medical record review and interview, it was determined that the facility failed to notify the responsible party in writing of a Resident's (#124) transfer to the hospital. This was evident for 1 of 37 residents sampled for investigations. The findings include: On 4-25-18 Resident #142 was transferred to the hospital for seizure activity. The facility notified the responsible party verbally but did not send a written notice. This finding was confirmed by the Center Executive Nurse on 6-18-18 at 10:30 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with facility staff and review of resident medical records, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the residents' status. This was true for 1 of 7 residents (Resident #48) reviewed for hospitalizations during the annual survey. The findings include: Resident #48's pneumonia status was incorrectly coded on the most recent MDS assessment. The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. Resident #48's medical record was reviewed on 6/15/18 at 11:53 A.M. During the review, it was revealed that Resident #48 had returned from a recent hospitalization due to pneumonia as evidenced by the hospital's Discharge summary dated [DATE] (the date of readmission) and corroborated by 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 staff failed to revise and update a resident's (#133) care plan based on changing resident needs after the 5-12-18 quarterly assessment. This was evident for 1 of 37 residents selected for investigative review. A comprehensive care plan is used to identify care area concerns that are specific to the resident and are used to improve and maintain a resident's status. A care plan includes a measurable objective and a time frame to evaluate its effectiveness. The findings include: Resident #133 had their required quarterly assessment completed on 5-12-18. The diabetes - insulin dependent care plan was not revised to include Resident #133's refusal to take the ordered insulin injections at times and and for leaving the nursing unit and not returning for the ordered insulin doses. On 6-15-18 at 12:30 PM the Center Nurse Executive confirmed the nursing staff failed to update the care plan to include Resident #133's refusal and leaving the nursing unit so as to not receive the ordered insulin. On 6-15-18,…

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

Based on observation and interviews, it was determined the nursing staff failed to provide showers to a dependent resident (#121). This was evident for 1 of 1 residents selected for review during the survey process. A resident who is unable to carry out Activities of Daily Living requires the necessary services to maintain good nutrition, grooming, personal and oral hygiene. The findings include: On 6/18/18 a review of the resident's medical record was initiated. The concern exists that the resident is not receiving showers. The record reveals the shower days are Tuesdays and Fridays, on the 7/3 shift. On 6/15/18 at 2 PM, an interview with the Unit Manager, indicated the showers for this resident are not being documented. The only documented shower in the TASK section was on June 4, 2018. The resident is receiving bed baths on her shower days. In an observation of the resident on 6/15/18 at 2:00 PM, the resident's hair did not appear clean, and when asked, she stated her hair was dirty. The concern exists that the resident is not receiving her showers twice a week. The Administrator…

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

Based on medical record review and interviews with facility staff, it was determined that the facility staff failed to follow a written physician order (Resident #333). This was evident for 1 of 37 resident's selected for investigative review. The findings include: Resident #333 has a history of gastrointestinal bleeding (GI bleed) but does not want to be sent to the hospital and prefers to be treated at the facility. On 6-10-18 Resident #333 developed symptoms of a GI bleed. At 6:10 AM the physician ordered the resident to receive an intravenous (IV) medication to prevent further bleeding and an IV of normal saline fluids to be given at 50cc an hour. On the medication administration record the IV of normal saline was not started until 6-11-18, at an unknown time. The IV medication was never received by the facility. A Nurse Practitioner assessed Resident #333 on 6-10-18 at 12:12 PM and noted the facility was unable to get the IV medication but took no action and failed to followup as to why the IV wasn't started. Resident #333 was sent to the hospital on 6-11-18 at 10:00 AM for…

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

Based on medical record review and interview, it was determined that the nursing staff failed to implement ordered preventative measures to prevent heel pressure ulcers (#176) for 1 of 37 residents selected for investigative review. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). The findings included: On 2-1-18 Resident #176 was ordered Prevalon Boots to be put on both feet when in bed to prevent skin breakdown. A Prevalon Boot prevents pressure on the heels which leads to skin breakdown. On 6-12-18 at 9:00 AM Resident #176 was in bed but without the ordered boots. On 6-12-18 at 12:50 PM Resident #176…

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

Based on observation and staff interview it was determined the nursing staff failed to properly secure medications left unattended on a resident's bedside tray (Resident #42) and failed to apply ordered fall mats (#176). This was evident for 2 of 37 residents selected for investigative review. The findings included: 1. On 6-11-18 at 9:15 AM while attempting to interview Resident #42 in their room it was noted, Resident #42 was asleep in the bed and on the bedside table was a medication cup with 4 pills left unattended. At 9:16 AM Nurse #1 confirmed the unattended pills were left on the bedside table and not administered to Resident #42. The medications were identified as T81 low dose aspirin 81 mg, A102 bupropion 300 mg, MP 542 spironolactone 50 mg, and GG296 loratadine 10 mg. The medications were the scheduled 8:00 AM doses. The medication administration nurse was questioned and had no idea how long the pills were left on the bedside table. Both the 6-10-18 and 6-11-18 8:00 AM medications were signed off on the medication adminitration record as given. On 6-13-18 at 9:30 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.

Based on medical record review and staff interviews, it was determined the facilty failed to acquire current pharmacy monthly orders in the medical record for Resident (#170). This was true for 1 of 1 resident selected for review during the survey process. The findings include: The facility must provide and establish a system from Pharmacy Services in acquiring records, receipts and disposition of medications to meet the needs of a resident. On 06/13/18 11:00 AM a review of Resident #170's medical record was initiated. The concern exists that the facility has not received the June Physician orders from the pharmacy. In an observation of the record, it was revealed that no June physician orders are on the chart. The resident was admitted to the facility 5/11/18 from an acute care facility. Diagnosis includes Alcoholism, asthma, depression, Syncope, and mastitis of the left breast. Medications on admission include Bupropion XL 300mgm for anxiety, Lamotrigine 100mgm for anxiety and a list of 16 other medications. In an interview with the Unit Manager(UM) on Station 5, on 6/13/18 it 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 and interviews, it was determined the facility staff failed to safely dispose of expired items in the refrigerator. The findings include: Effective food safety involves identifying hazards which could result in food safety concerns as storage and disposition of expired items in the kitchen. On 06/11/18 at 7:58 AM a review and observation of the kitchen found a large tray of egg salad in the refrigerator to have an expiration date, 5/29/18. The egg salad was covered with a torn piece of plastic wrap exposing the egg salad to the air. Upon surveyor intervention the egg salad was removed. The Administrator and Director of Nursing were made aware at the exit conference.

Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for residents (#133 and #42). This was evident for 2 of 37 residents selected for investigative review. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Resident #133's medication administration record (MAR) was incomplete. On May 23 and 28, 2018 the nurse failed to document the required blood pressure and pulse before administering the ordered blood pressure medication Norvasc. On May 21, 24, 25, and 26, 2018 the nurse failed to document the required pulse before administering the ordered Norvasc. On June 8, 2018 the nurse failed to documnent on the MAR the amount of insulin given and the injection site used for the 6:30 AM sliding scale insulin. On May 1 and 2, 2018 the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to maintain a sanitary and comfortable environment for residents. This was true for 3 of 60 rooms (room [ROOM NUMBER], 106, and 209) reviewed during the annual survey. The findings include: The facility failed to maintain a sanitary and comfortable environment in resident rooms [ROOM NUMBER]. During an observation that took place on 6/12/2018 at 9:14 A.M., room [ROOM NUMBER] was found to have sticky tan-colored fluid underneath the resident's tube feeding machine and brown crumbling material that resembled dirt on the floor beneath a potted plant. The resident's bedside table and over-the-bed table were both sticky to the touch. Flies were present in the room around the sticky material. During a repeat observation that took place on 6/18/2018 at 9:30 A.M., room [ROOM NUMBER] was found to have more brown sticky matter below the tube feeding machine and flies were still present. The Director of Nursing 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.