Brooke Grove Rehab. & Nsg Ctr

Based on observations, record review, and interviews with staff it was determined that the facility failed to maintain food temperature logs and store food and drinks in a manner that maintains professional standards of food service safety. This practice has the potential to affect residents who eat the food and receive thickened drinks prepared in the facility's main kitchen and satellite kitchens located on rehab floor #1 and #2.The findings include:1.On 5/18/2026 at 8:00AM, during a tour of the main kitchen, the Surveyor observed the tray line of food being plated and trays prepared to serve residents on the long-term care unit.On 5/18/2026 at 8:25AM, an observation of the food temperature log binder failed to reveal food temperatures recorded for:-5/16/2026 breakfast and lunch-5/17/2026 breakfast and lunch-5/18/2026 breakfastOn 5/18/2026 at 8:26AM, the Surveyor's findings were confirmed by Executive Chef #14. During an interview, the Surveyor was informed that to ensure proper food temperatures before serving residents, food temperatures are taken while the food is on the food…

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

Based on observation and interview, it was determined that facility failed to maintain proper infection prevention and control practices. Specifically, the laundry service area was not maintained in a sanitary manner, failing to provide an environment free of cross-contamination. This was evident by the whole laundry service areas observed during an annual survey. The findings include:A tour of the laundry service area was conducted on 05/21/26 at 2:25 PM, the following issues were observed in the service area: - A personal iPad in a small old shopping bag was left on a side table in the washing room.- The top shelves of the dryer room were filled with staff's personal belongings, food and drinks.- A makeshift eating area was set up within the dryer room.During an Interview, on 05/21/26 at 2:35 PM, the Housekeeping Director #19 stated that all laundry staff has designated personal items lockers which he declared that there should be no personal items in the Laundry service area. He confirmed that the makeshift eating area was an oversight.During an interview on 05/21/26 at 4:39 PM,…

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 documentation review, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (Resident #7, #8) of 6 residents reviewed for facility reported incidents during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 3/27/26 at 9:50 AM a review of facility reported incident 2652256 was conducted and revealed on 10/23/25 Resident #7 was found in a seated position on the floor beside the bed. A left hip x-ray was ordered and Resident #7 was found to have a non-displaced femoral neck impaction fracture. Review of Resident #7's…

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

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #2). This was evident for 1 of 3 residents reviewed for narcotic medication administration during a complaint survey.The findings include. A medical record is the official documentation of 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 #2's medical record on 3/26/26 revealed the Resident was admitted to the facility in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of Resident #2's March 2026 Medication Administration Record revealed the Resident received Tramadol 25 mg on March 8th, 2026 at 9:23 AM. Tramadol is a narcotic pain medication used to treat moderate to severe pain. Review of Resident #2's Controlled Drug Receipt/Record/Disposition Form…

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 and medical record review and interviews with facility staff it was determined the facility staff failed to report allegations of resident abuse in a timely manner. This was found to be evident for 8 (Resident #193, #169, #191, #24, #170, # 172, #188, #194) of 8 residents reviewed for abuse during the facility's survey. Findings include, 1. Intake MD00212529 was reviewed on 3/31/25 at 10:43 AM for allegations of abuse. Review of the facility's investigation revealed that a PRN (as needed) Physical Therapist (PT) (#17) observed Resident #193 and Nurse (#18), forcefully administer medication to the resident, and continued, even after the resident began choking. Abuse was unsubstantiated. Further review of a statement by the PT (#17), she stated that she went to report her observations to the charge nurse but did not see her. A few hours later the PT #17 saw the nurse (#18) in the hallway who approached her. An interview was conducted with the Therapy Site Manager (TSM #16) on 3/31/25 at 11:01 AM and he was asked if he could provide information regarding the…

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

Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of allegations of abuse. This deficient practice was evidenced in 4 (#170, #172, #188, #194) of 4 facility reported incident investigations reviewed during the recertification survey. The findings include: 1. On 03/27/25 at 9:14 am a review of the self-report related to Resident #188 revealed the resident reported being abused by a nurse. The alleged perpetrator's statement indicated they did not work with the resident on the day of the alleged incident, nor did the statement deny or confess that the alleged incident happened. The staff who worked with the resident the day the alleged incident was reported was not interviewed. The facility staff failed to complete a thorough investigation. The Director of Nursing #2 was made aware. 2. On 03/27/25 at 2:48 pm after reviewing the facility's investigation related to the allegation of abuse concerning Resident #170, Administrator #1 and Director of Nursing (DON) #2 were made aware the investigation of the alleged…

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

Based on observations and staff interviews, it was determined that the facility staff failed to ensure food items in the kitchen and unit refrigerator were stored to maintain the integrity of the specific items and failed to ensure equipment temperature logs were maintained for monitoring. This was evidence in observations in the kitchen and west wing refrigerators. The findings include: 1a) On 03/26/25 at 07:41 AM, an initial observation of the facility kitchen vegetable fridge revealed a bag of spinach opened and unlabeled, a bag of iceberg lettuce opened and unlabeled, a carrot bag opened and unlabeled, tahini opened and unlabeled, honey mustard salad dressing opened and unlabeled, a vanilla butter cream container that was opened and unlabeled, pre-poured french dressing into single size cups unlabeled, ranch dressing in a container which indicated best by 3/17/25, a container of garlic that had a label which indicated best by 3/24/25, and a small, white colored take out container that was unlabeled. On 03/26/25 at 07:46 AM, the surveyor observed a white, salad dressing- like…

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, review of a facility reported incidents (FRI), and interviews with staff, it was determined that the facility failed to ensure a resident's request was accommodated. This was evident for 1 out of 33 facility reported incidents (FRIs) reviewed during the survey. The findings include: On 3/28/2025 at 10:30AM, the Surveyor reviewed the investigative file for a FRI MD00202881, reported by the family member of Resident #195 on 2/21/2024 at 3:51 PM. The family member stated that on 2/18/2024 at 11 PM, the resident needed to adjust the bed settings, as [he/she] had severe and painful spinal arthritis. The family member reported that Geriatric Nursing Assistant (GNA) #40 would not give the resident the bed controls because GNA#40 did not want the resident playing with the buttons. Further review of the investigative file revealed a statement from GNA #40 on 2/23/2024 at 1:58PM. GNA #40 stated that when she answered Resident #195's call light, the resident said, I'm flat on the bed I need my head up because I don't want to die here. GNA #40 responded, The head of the…

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

Based on record review and interviews 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 # 191) of 3 residents reviewed for abuse during the survey. The findings include: The facility reported incident MD00210136 was reviewed on 3/28/25 at 12:06pm. According to the facility's investigation, a housekeeper (Staff #38) made inappropriate comments to Resident #191. The resident reported the incident to the facility on 9/21/24 at approximately 10:30am. The facility interviewed Staff #38 during their investigation, at which time Staff #38 admitted to the allegation made by the resident. Staff #38 was immediately terminated and escorted off the premises. The facility conducted interviews with other residents and staff during the investigation and determined that no other residents had been affected. On 3/31/25 at 11:51am, the Director of Nursing was interviewed regarding the facility reported incident and confirmed that the abuse allegation was substantiated 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.

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 develop and implement a person-centered comprehensive care plan for residents. This was evident for 2 (Resident #67 and #119) residents reviewed for activities during the survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. A Baseline Care Plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident specific health and safety concerns to prevent a decline or injury, and would identify needs for supervision, behavioral interventions, and assist with activities of daily living, as necessary. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical,…

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

Based on record review and staff interview, it was determined that the facility failed to ensure resident care plans were revised to reflect their communication needs. This was evident for 2 (Resident #91 and #124) of 3 residents reviewed for communication. The findings include: 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 assuring the resident's needs are attended to. The care plan is to be reviewed and revised each quarter. 1. On 03/26/25 at 08:55 AM, an observation of Resident #124 revealed that the resident was speaking a native language. On 03/27/25 at 09:58 AM, review of Resident #124's care plan revealed that the resident had a language barrier, but failed to indicate what language the resident spoke. On 03/28/25 at 07:37 AM, an interview with Geriatric Nursing Assistant (Staff #30) revealed that the resident spoke a native language, but was unable to indicate…

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

Based on observations, record reviews, and interviews, it was determined that facility staff failed to: follow physician's orders for a resident receiving oxygen, including failure to document amount and method of oxygen delivery, failed to hold a resident's blood pressure medication based on the ordered parameter and failed to notify the physician and failed to continue assessments including neuro checks after a resident sustained a fall. This deficient practice was evident for 3 (#24, #81, #186) out of 3 residents' reviewed for physician's orders during the survey. The findings include: 1. During the initial tour of the long-term care unit #2 on 03/26/25 at 07:46 AM, the surveyor observed Resident #24 sitting upright in bed asleep with oxygen infusing at 2 liters (L) through a nasal cannula. A second observation was made at 9:42 AM, and the resident was awake in bed, and oxygen was infusing at 2L through a nasal cannula. On 03/27/25 at 02:20 PM, the surveyor observed Resident #24 sitting in bed awake with supplemental oxygen infusing at 3.5L through a nasal canula. Review 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.

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.