Brooke Grove Rehab. & Nsg Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to ensure the physician supervised the medical care of a resident with a known functional and cognitive decline. This deficient practice was evident for 1 (#186) residents reviewed for physician services during the survey. The findings include: On 03/31/2025 at 10:53 AM, a review of complaint MD00188081, revealed that the family of Resident #186 had concerns during a visit on 01/18/23. The family observed the resident inability to walk, chew food, follow commands, and expressive aphasia (difficulty speaking). The family reported concerns that the resident change in condition was not adequately addressed. A review of nursing notes dated 12/4/22 at 9:06 PM, indicated that Resident #186 had not resumed usual mobility since returning from the emergency department (ED) on 12/3/22. A review of the physician's note dated 12/5/22 at 1:09 PM indicated that Resident #186 was sent to the ED due to a change in mental status. The resident 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 observations, record review, and interview with staff, it was determined that the facility failed to obtain a psychiatric consult as ordered by the physician. This was evident for 1 (Resident #151) reviewed for behavioral-emotional care during the survey. The findings include: On 3/26/2025 at 11:58AM, during a tour of the 2nd floor rehab unit, the Surveyor observed Resident #151 in his/her bed facing the window opposite the doorway. The Surveyor knocked and introduced themselves. The resident stated, I want you to leave. I just want to sleep. The resident appeared upset and short tempered. The Surveyor apologized for bothering the resident and continued touring the unit. On 3/27/2025 at 2:00PM, the Surveyor observed Resident #151 cuddled in bed sleeping. An interview with Registered Nurse #41 revealed that the resident sleeps a lot and usually would wake up and open up more when their daughter comes to visit. The resident does not want to be bothered most of the time. On 3/28/2025 at 10:30AM, the…

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

Based on observation and interview, it was determined that the facility failed to ensure that a staff prepared a meal tray based on a meal ticket. This was evident for 1 tray identified during a random tray line observation. The findings include: On 03/27/25 at 11:53 AM, the surveyor observed the lunch tray line in the kitchen where staff prepare the resident trays that get delivered to the prospective units. On 03/27/25 at 12:03 PM, the surveyor observed Dietary Aide (Staff #31) prepare a meal tray . The meal ticket on the meal tray indicated chicken noodle soup as one of the food items listed. On 03/27/25 at 12:04 PM, the surveyor observed Staff #31, prepare and place the meal tray on the tray cart without chicken noodle soup. At the same time, the surveyor asked Staff #31, if soup was served on the units, she indicated no, and that the kitchen would prepare it. The surveyor requested Staff #31 to take off the meal tray that had just been placed on the tray cart and compare the meal tray to the meal ticket. On 03/27/25 at 12:05 PM, the surveyor asked why Staff #31 did not place…

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 the facility failed to provide food at an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray. The findings include: On 03/27/25 at 11:53 AM, the surveyor observed the kitchen prepare the lunch tray line. On 03/27/25 at 01:11 PM, the surveyor observed the last tray cart of the lunch tray line get delivered onto the unit. On 03/27/25 at 01:50 PM, the surveyor observed the last resident meal tray taken from the same cart and delivered to the prospective resident. The surveyor then requested Executive Chef (Staff #36), who was present at the time, to remove the test tray from the cart and obtain temperatures of the food items. On 03/27/25 at 01:50 PM, the surveyor observed Staff #36 obtain the temperature of the meatloaf which was 114.2 degrees fahrenheit, cod (a type of fish) which was 105.8 degrees fahrenheit, mashed potatoes which were 115.5 degrees fahrenheit, and vegetables (asparagus with garlic and red pepper) which was 107.0 degrees fahrenheit. On 03/27/25 at 01:51 PM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to ensure that documentation was completed for physician orders. This was evident for 1 (Resident #167, #179) of 49 residents' records reviewed during an annual survey. The findings include: 1. On 03/28/25 at 01:58 PM, review of Resident #167's medical record revealed the resident had an order for continuous oxygen at 2 liters per minute with a start date of 12/20/23 and an end date of 1/24/25. (Liters per minute refers to the amount of oxygen delivered to a patient per minute.) On 03/31/25 at 08:51 AM, review of the documentation for the order mentioned above in the resident's record for the month of September 2024, revealed 5 shifts (9/1/24 night, 9/7/24 day, 9/12/24 night, 9/23/24 day, and 9/26/24 day) which the order was not documented on. On 03/31/25 at 09:45 AM, an interview with the Director of Nursing (Staff #2) revealed that the expectation was for staff to document based on orders every shift. She further indicated…

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

Based on interviews and a review of pertinent facility documentation it was determined that the facility failed to maintain signature sheets of committee members who attended Quality Assurance and Improvement Program (QAPI) meetings. This was found to be evident during review of QAPI documentation during the survey. Findings include: An interview was conducted with the Administrator on 4/1/25 at 11:08 AM and he was asked to provide the survey team with copies of attendance sheets for QAPI meetings from December 2023 to March 2025. The Administrator stated that the facility has a new QAPI Coordinator (#32) that started when he came on board. He offered that he would look for the attendance sheets but is unsure if he would be able to provide the attendance sheets prior to this time. An interview was conducted with the QAPI Coordinator (#32) on 4/1/25 at 11:25 AM and she stated that she became the QAPI Coordinator in December 2024. She stated that the previous Administrator conducted meetings (virtual) until she came into the position. She provided paper copies of attendance sheets 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 observation and staff interview, it was determined that the facility failed to maintain a sanitary environment. This was evident for 1 (Unit 2) out of 1 clean utility rooms observed during the survey. The findings include: On 03/26/25 at 09:25 AM, the surveyor observed an equipment pole in the clean utility room which had a sticker that indicated it was used for a resident. On 03/26/25 at 09:25 AM, an interview with Licensed Practical Nurse (Staff #37) revealed that housekeeping would clean the equipment pole and when it was clean it would be placed in the clean utility room. On 03/31/25 at 11:34 AM, an interview with the Director of Housekeeping/Environment Services revealed that when equipment poles are clean, the facility staff would place a blue tag at the base. When the surveyor described the state of the equipment pole observed on Unit 2, he indicated that he would not have considered it to be cleaned, and agreed with the surveyor's concern.

Based on record reviews and interviews, it was determined that facility staff failed to ensure all actively employed geriatric nursing assistant (GNA) completed annual dementia education. This deficient practice was evident for 6 out of 6 (#46, #47, #48, #49, #50, #52) GNA's training reviewed during the survey. The findings include: On 03/27/25 at 10:09 AM, during an interview with the Assistant Director of Nursing (ADON) #3, he stated that annual nursing assistant competencies are conducted throughout the year and on designated dates to ensure all required in-service are completed before the end of the year. The surveyor requested to review the competency records of current staff and agency GNA's. On 03/27/25 at 11:41 AM, during an interview with nurse scheduler #51, she explained that the facility's educator is responsible for ensuring that agency GNA's receive the required GNA education prior to working at the facility and the director of nursing generally reviews the GNA annual competencies during the employees annual performance review. The nurse scheduler #51 and the surveyor…

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

Based on surveyor review of clinical records and staff interviews, it was determined that the facility's staff failed to implement residents' wishes stated in their advance directive and failed to verify the authority of a medical decision maker on the MOLST (Maryland Medical Orders for Life-Sustaining Treatment) form. This was evident for 2 of 7 residents reviewed for advance directive care area (Residents #83 and #136). The findings include: A MOLST is the portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments used in Maryland. An Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. 1. On 02-28-2020, surveyor review of Resident #83's clinical record revealed that the resident had an advance directive signed in December 2000 which stated that Resident #83 was required to be certified…

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

Based on surveyor review of resident council minutes, and staff interview (s) it was determined that facility staff failed to report an allegation of abusive behavior during mealtime. This finding was evident upon review of resident council minutes as part of the resident council facility task during survey. The findings include: On 02-28-2020 at12:10 PM, a review of resident council minutes, dated 01-13-20, revealed Resident #92 reported observing residents who require assistance with meals being subjected to abusive behavior by staff at mealtime. Resident #92 stated it was nerve-wracking watching them. On 02-28-2020 at 12:20 PM, interview with the Administrator and the Administrator in Training (AIT) revealed that both employees review the resident councils' minutes each month, however, neither were aware of Resident #92's allegation of abuse during the 01-13-2020 meeting. Upon listening to a recording of the meeting, the administrator confirmed that the minutes accurately reflected Resident #92's allegation made during the meeting. Upon further investigation, it was determined…

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

Based on surveyor clinical record reviews and interviews with the facility staff, it was determined that the facility staff failed to review and revise residents' care plans. This was evident for 2 of 36 residents selected for this survey (Residents #101 and #132). MDS (Minimum Data Set) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Quarterly review assessment is an assessment due no less frequently than every 92 days. The findings include: 1. On 02-26-2020 surveyor review of Resident #101's clinical record revealed the resident was admitted to the facility with a diagnosis of major depressive disorder. In addition, Resident #101 had a physician order for a psychotropic medication. A psychotropic medication is any drug that affects brain activities associated with mental processes and behaviors. Psychotropic drugs include but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. Further review of Resident #101's clinical record revealed a…

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

Based on surveyor review of the clinical record, it was determined the facility staff failed to monitor psychotropic medications for efficacy and adverse consequences. This finding was evident for 1 of 5 (Resident #101) residents selected for review of unnecessary medications during the survey. A psychotropic medication is any drug that affects brain activities associated with mental processes and behaviors. Psychotropic drugs include but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. The findings include: On 02-26-2020, surveyor review of Resident #101's clinical record revealed the resident had a physician order for two psychotropic medications administered to be administered daily for treatment of psychosis and depression. However, further review of Resident #101's clinical record revealed no evidence of the facility's staff monitoring for the efficacy and adverse consequences of the psychotropic medications. On 02-27-2020 at 2:30 PM, surveyor interview with the director of nursing revealed no additional information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and facility staff interview, it was determined that the facility staff failed to label drugs and biologicals in accordance with accepted professional standards. This finding was evident for 1 of 14 medication storage carts selected for inspection during the survey (Cart #10). The findings include: On 02-27-2020 at 11:47 AM, surveyor inspection of [NAME] wing Cart #10 on the second floor rehab unit revealed a bottle of Colace (stool softener) liquid with an expiration date of [DATE]. Further observations revealed a Humalog KwikPen (disposable single-patient-use prefilled pen) with an open date marked as 01-23-20. It should have been discarded 28 days after opening. In addition, there were three (3) yellow top, two (2) purple top, four (4) red top, one (1) blue top, and one (1) green top phlebotomy tubes (tubes used to draw blood for lab testing) that expired in 2019 stored in the medication Cart #10. On 02-27-2020 at 12:30 PM, interview with the Director of Nursing revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor interview of residents and facility staff, and observation of tray line and meal service, it was determined that the facility staff failed to have an effective system to ensure that residents received the food items of their preference. This finding was evident during the dining observation for one of six dining rooms (Foxtrot). The finding includes: On 02-24-2020 at 8:50 AM, initial screening of Resident #08 revealed a complaint that he/she often got meals the consisted of food items not selected. On 02-24-2020 at 12:40 PM observation of Resident #08's lunch meal revealed the tray ticket and tray items were identical, however, the resident stated the items were not self-selected and were not what he/she would have chosen for that meal. On 02-24-2020 at 1:00 PM, observation of the [NAME] Trot dining room revealed meal tickets on trays that were inconsistent with items served on the tray. On 02-24-20 at 1:30 PM, a random observation of the ordered items for one lunch meal ticket indicated the…

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

Based on surveyor observation and staff interview, it was determined that the facility staff failed to store and serve food in accordance with professional standards for food service safety. This finding was evident for 1 of 5 dining areas observed in the facility. The findings include: On 02-24-2020 at 5:15 PM surveyor observed Resident #145 in dining area located in second floor rehab unit. The resident had a Supplemental nutrition drink named Vital. According to the label on the Vital, the use by date is 03-01-2018. An inspection of the refrigerator outside of the pantry revealed six (6) 8oz individual supplemental nutrition drinks that expired in March 2019. On 02-25-2020 at 12:00 PM, interview with the Director of Nursing revealed no additional information.

Based on surveyor review of clinical records and interview of the facility staff and the legal representative, it was determined that the facility staff failed to inform an individual's legal representative when a treatment was changed. This finding was evident for 3 of 3 residents selected for notification of change review (#39, #75, and #87). The findings include: 1. On 02-11-19 at 12:30 PM, resident #39 was observed eating lunch at the dining table. The resident was alert, but oriented to name only. On 02-14-19, review of the clinical record revealed that resident #39 was admitted to the facility in February 2019 following a hospitalization. Resident #39's adult child was the power of attorney (POA) for health care decisions. Further review revealed that a nurse practitioner made a gradual dose reduction (GDR) of an anti-psychiatric medication, Seroquel, on 01-24-19. However, there was no evidence that the resident's POA was informed about this GDR. On 02-14-19 at 2 PM, interview of the Director of Nursing revealed the nurse practitioner should discuss the risks and benefits of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, interviews with facility staff, and review of residents' clinical records, it was determined that the facility failed to revise residents' care plans in a timely and accurate manner to reflect the residents' current clinical status. This was evident for 3 of 38 residents selected for this survey (#107, #39, and #75). The findings include: 1. On 02-12-19 at 11:42 AM, 02-13-19 at 12:22 PM, and 02-13-19 at 02:04 PM, surveyor observation revealed resident #107 seated in their wheelchair with a left arm tray attached. A wheelchair arm tray is an adaptive device attached to a wheelchair used to provide support for a patient's arm. Review of resident #107's clinical record revealed an occupational therapy recommendation on 05-22-18 for the use of a wheelchair left arm rest. Further review of resident #107's clinical record revealed no evidence of a care plan addressing the use or indication of the wheelchair left arm tray. On 02-14-19 at 07:22 AM, 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 surveyor observation, review of the clinical records and interview of the facility staff, it was determined that the facility staff failed to ensure the quality of care based on professional standards of practice involving physician's orders. The findings were evident for 3 of 39 residents selected for review during the survey (#39, #87 and #86). The findings include: 1. On 02-14-19 at 9:30 AM, observation of resident #39's morning care in presence of staff #4 and 2nd floor nursing unit manager revealed that a dressing was on the resident's left lateral knee. The dressing was dated as done on 02-11-19 evening shift. Review of Treatment Administration Record (TAR) revealed that the nursing staff signed off that the dressing on resident #39's left lateral knee was done twice a day on 02-12-19 and 02-13-19. However, the documentation on TAR was inconsistent with surveyor observation on 02-14-19. On 02-14-19 at 2:30 PM, interview of the Director of Nursing (DON) revealed no additional information. 2. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews with staff, and residents' family members, it was determined that the facility staff failed to consult with the resident's health care agent as per the resident's advanced directive to make end of life decisions for the resident. This finding was evident for 1 out of 6 residents selected for review of this care area. (#111) The findings include: 1. On 02-12-19, review of the clinical record for resident #111 revealed a Maryland Advance Directive dated 07-12-14 which designated an agent to make health care decisions. Further review of the clinical record revealed that Maryland Medical Orders for Life Sustaining Treatment (MOLST) were completed prior to resident #111's admission to the facility on [DATE], and were dated 07-10-18. This MOLST documented certification for the basis of the order was made as a result of a discussion with and the informed consent of the patient. Resident #111 selected palliative and supportive care, with instructions not to provide…

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

Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to report and investigate an injury of unknown origin for resident #75. This finding was identified during an investigation of MD00135150. The findins was evident for 1 of 38 residents reviewed during the survey. The findings include: On 02-11-19 at 9 AM, observation of resident #75 revealed that the resident was non-verbal and cognitively impaired due to dementia. The resident could ambulate without a device, but required staff supervision and guidance. On 02-14-19, review of resident #75's clinical record revealed that a purple discoloration of 7 cm x 7 cm was noted on the resident's right hip on the evening on 01-13-19. The attending physician and the resident's responsible party were notified on the same evening. Further review of the progress notes between 01-01-19 and 01-13-19 revealed that no fall or other incident was reported. The nursing staff signed off on the January 2019 Treatment Administration Record (TAR) that resident #75…

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

Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan to meet the resident's medical condition. This finding was evident in 1 of 38 residents selected for review during the survey. (#100). The findings include: On 02-11-19 at 08:15 AM, surveyor observation during initial tour of the facility revealed an isolation cart set up in resident #100's room. On 02-13-19 at 11:10 AM, surveyor review of the clinical records revealed that resident #100 was re-admitted to the facility's rehabilitation unit after a brief hospital stay. Further record review revealed that resident #100 was on isolation precautions due to clostridium difficile, a persistent watery diarrhea which is caused by a life-threatening germ or bacteria that affects the colon of patients following antibiotic treatment. However, there was no evidence that the facility developed a resident centered plan of care to address resident #100's identified medical condition (clostridium difficile/ C-diff)…

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

Based on surveyor review of the clinical records and surveyor staff interviews, it was determined that the facility failed to meet professional standards of practice. This finding was evident for 2 of 38 residents reviewed during the survey. (#67 and #114). The findings include: 1. On 02-12-19, surveyor review of the clinical record for resident #67 revealed an Advanced Healthcare Directive, dated 08-11-17, that was received by the facility on 11-09-18. An Advanced Healthcare Directive is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. Surveyor review of the physician progress notes revealed a History and Physical, dated 11-12-18, which documented the physician discussed healthcare decisions for resident #67 with the Power of Attorney (POA). The Power of Attorney is the individual named in the Advanced Healthcare Directive to make healthcare decisions. There was no evidence that the physician reviewed resident #67's Advanced Healthcare Directive.…

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

Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to stand or transfer resident #39 by using a standing lift as ordered. This finding was evident for 1 of 8 residents selected for accidents/hazards review. The findings include: On 02-14-19, review of resident #39's clinical record revealed that a physician's order was written in February 2018 to use a standing lift to stand or transfer the resident. Further review of resident #39's clinical record revealed that the resident sustained a skin tear on the left lateral knee during a transfer from the bed to the wheelchair, in the morning on 01-30-19. On 02-14-19 at 9:20 AM, observation of morning care in presence of staff #4, #8 and #9 revealed that the resident was transferred from the bed to the standing position by 2 person assistance. No standing lift was used. On 02-14-19 at 2:45 PM, interview of staff #8 and review of the incident report revealed that a day nursing assistant, who was assigned to resident #39, informed staff #8 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 record review and interviews with facility staff, it was determined that the facility failed to act upon monthly pharmacist medication irregularity reviews. This was evident for 1 of 7 residents (#62) selected for the unnecessary medication review during this survey. The findings include: On 02-14-19 at 07:35 AM, surveyor review of resident #62's clinical record revealed that a pharmacy review was conducted on 10-02-18 which identified medication regimen irregularities that required a physician's response. Additionally, there was a pharmacy review on 02-06-19 that identified another medication regimen irregularity that required a physician response. There was no evidence in resident #62's clinical record to indicate that the physician was aware of the pharmacy recommendations made on 10-02-18 and 02-06-19. The facility policy regarding clinical drug regimen reviews revealed that two-way communication of drug review recommendations between the clinician(s) and physician must be completed by midnight of the next calendar day and all physician-prescribed/recommended actions…

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

Based on surveyor observation, resident interview, review of facility policy and procedures and interview of facility staff, it was determined that the facility staff failed to ensure infection control practices in the handling of soiled linen to prevent the spread of infections. This finding was evident for 1 of 4 residents selected for review of infections during the survey. (#191). The findings include: On 02-11-19 at 08:33 AM, surveyor tour of resident #191's room revealed a pile of dirty linen/sheets placed on resident #191's hand-washing sink. Further observation revealed that the linen was soiled with fecal matter and urine. On 02-11-19 at 08:34 AM, surveyor interview with resident and resident's daughter who was at the bedside revealed that the linen were removed from the bed and placed on the hand-washing sink when staff #5 assisted resident #191 from bed. Resident #191 stated during the interview that I can't even wash my hands for my breakfast because this dirty linen has been placed on my sink. On 02-11-19 at 11:15 AM, surveyor further observation revealed the dirty…

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.