Complete Care At Severna Park LLC

Based on observation and interview, it was determined that the facility failed to ensure residents' call bells were accessible to residents. This was found evident for 4 (Residents #15, #16, #17, and #20) out of 4 Residents reviewed for call bells during the complaint survey. The findings include:According to the Centers for Medicare & Medicaid Services (CMS), a call bell-also referred to as a resident call system-is a communication device that allows residents to summon staff assistance when needed.On 10/20/2025 at 11:11 AM, this surveyor observed Resident #15 in his/her room. The Resident was lying in bed, and the call bell was found inside the bedside table drawer, out of the Resident's reach.On 10/20/2025 at 11:21 AM, this surveyor observed Resident #16 in his/her room. The Resident was seated in a wheelchair next to the bed, eating breakfast. The call bell was observed on the opposite side of the bed, out of the Resident's reach.On 10/20/2025 at 11:24 AM, Resident #17's call bell was observed wrapped tightly around the bed rail on the opposite side of the bed. 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.

Based on observation and interview, it was found that the facility failed to have a functioning call bell system for residents. This was found to be evident for 7 (Resident #18, #19, #20, #22, #23, #24, and #25) out of 7 residents reviewed for call bell function during the complaint survey. The findings include:A call bell system is a communication device that enables residents to summon staff for assistance. The system activates a visual and audible signal to alert staff when a resident requests help. When staff respond and acknowledge the call, the signal is turned off, indicating that the resident's request has been addressed. The system is intended to ensure residents have reliable access to staff for timely care and assistance. TELS (Total Equipment Logging System) is the facility's computerized system used to document, track, and manage maintenance work orders and service requests.On 10/20/2025 at 11:45 AM, this surveyor conducted a dual observation with Geriatric Nursing Assistant (GNA) #8 in Resident #18's room to check the resident's call bell. When tested, the call bell…

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 investigation, record review, and interview, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 2 (Resident #6 and #8) of 11 abuse investigations reviewed during the complaint survey. The findings include: 1) The facility's investigation related to facility-reported incident #2641751 was reviewed by the surveyor on 10/24/25 at 10:32 AM. The investigation revealed that the facility substantiated the allegation based on Resident #21's statement, which indicated that agency staff Geriatric Nursing Assistant (GNA) #4 engaged in verbally abusive behavior, including yelling and using inappropriate language, specifically stating, Shut the f* up if you are able to do it yourself, why don't you? while providing care to Resident #6. During record review on 10/24/25 at 8:00 AM, it was noted that the facility conducted an interview on 10/14/25 with Resident #21's family member (roommate). The family member stated that he/she overheard GNA #4 respond to Resident #6 by saying, I'm 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 review of facility-reported incident investigation, record review and staff interviews, it was determined that the facility failed to report to the Office of Health Care Quality (OHCQ) within the required timeframe. This was evident for 2 (Resident #6 and #14) out of 2 residents reviewed for reporting abuse allegations during the complaint survey process. The findings include: 1) On 10/21/25 at 8:40 AM surveyor reviewed the facility-reported incident (FRI) #2620209 for Resident #6 revealed that on 9/16/25 at 3:30PM, Resident #6 sustained an injury of unknown origin (left hip fracture). Further review of the facility's investigation on 10/21/25 at 8:50 AM revealed that the facility submitted the initial report of the incident to the Office of Health Care Quality (OHCQ) on 9/17/25 at 3:17 PM. The final investigation report was not submitted to OHCQ until 9/25/25 at 9:19 PM. The facility is required to submit the initial report within 2 hours of the incident and the final investigation report within five working days. On 10/24/25 at 9:30 AM during an interview with the…

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

Based on review of facility-reported incident investigation, record review, and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for 1 (Resident #8) of 11 abuse investigations reviewed during the complaint survey.The findings include: On 10/20/25 at 8:51 AM, a review of Facility- Reported incident #349643 revealed that on 7/3/25, at approximately 9:35 AM, Geriatric Nurse Assistant (GNA #8) allegedly grabbed tea bags from Resident #8's hands. The facility's interview with GNA #3 revealed that while distributing breakfast trays in Unit 2, GNA #3 observed Resident #8 took three tea bags from the cart. GNA #2 then took the tea bags from Resident #8's hands in what GNA #3 described as a tugging back and forth motion. A follow-up interview was conducted by the facility with Resident #8 on 7/3/25 at 10:30 AM, Resident #8 confirmed taking 3 tea bags from the cart and described that GNA #2 grabbed and was pulling my hands multiple times back and forth trying to take the tea bags from me. GNA#2 could have pulled me out 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 record review and interview, it was determined that the facility failed to have accurate documentation for a resident. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for accurate documentation during the complaint survey. The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.Speech-language pathology services are those services necessary for the diagnosis and treatment of speech, language and cognitive communication disorders which result in communication disabilities. Speech-language pathology includes evaluation and treatment of swallowing.On 10/24/2025 at 08:17 AM, this surveyor conducted a record review of Resident #2's care plan. The care plan included interventions stating, Please ensure the resident is supervised during meals and Resident to eat only with supervision.On 10/24/2025 at 10:05 AM, this surveyor conducted a record review of the Speech-Language Pathologist (SLP) visit dated 05/16/2025. Under 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 reviews and staff interviews is was determined that the faciliy failed to ensure Care Plans were revised and Care Plan meetings were held as required. This was found to be evident for 2 (Residents #91 & #61) out of 2 Residents reveiwed for Care Plan revisions and 2 (Residents #110 and #56) out of 2 Residents reviewed for Care Plan meetings during the annual survey. The findings include: According to Centers for Medicare and Medicaid (CMS) a care plan meeting is a regularly scheduled gathering where healthcare professionals, residents (or their family representatives), and relevant staff from a facility discuss and review a resident's individual care plan, ensuring it accurately reflects their needs, preferences, and any necessary adjustments based on their current health status; these meetings are typically held quarterly and are a key part of quality care in nursing homes. 1) Surveyor review of a complaint (MD00216698) and facility reported incident (MD00216700) alleging that a facility…

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

Based on the review of facility reported incidents,staff interview, and review of facility policy, it was determined that a facility staff member failed to treat a resident with respect and free from verbal and physical abuse. This was evident during the review of 2 ( Resident #127 and #90) out of 21 Residents reviewed for allegations of abuse. The findings include: Review of the facility reported incident #MD00205993 on 5/9/25 at 8:15 AM revealed that on 5/24/24 there was a witnessed verbal altercation between Resident #127 and staff GNA #32. According to witness statements in the facility investigation packet GNA #32 overheard yelling and cursing at Resident #127 when the supervisor, staff RN #4 separated the 2 individuals and told GNA #32 that she needed to leave the facility immediately. According to a statement from Resident #127, s/he stated that GNA #32 was yelling at him/her because s/he didn't want to see the pictures on his/her phone about the previous staff. Resident #127 just wanted him/her to leave him/her alone and leave his/her room and s/she wouldn't until 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 interview, it was determined that the facility staff failed to thoroughly investigate a complaint of abuse. This was evident for 1 (Resident #124) out of 64 residents reviewed during a complaint/annual survey. Findings include: Review of resident #124's facility reported incident (MD 00182893) on 5/13/25 at 8:30am revealed the resident made an allegation of abuse after the resident reported to the facility that a nursing staff member pushed and choked him/her on 8/29/2022. The surveyor review of the facility investigation on 5/13/25 at 1:10pm revealed that the facility failed to thoroughly investigate the events surrounding the allegation of abuse. The facility investigation did not contain other resident interviews disproving widespread abuse from staff. Interview with the Administrator on 5/13/25 at 1:35pm confirmed the facility investigation of resident #124's allegations did not contain resident interviews disproving widespread abuse from staff.

Based on observation, facility staff and Resident interviews and surveyor record review it was determined that the facility staff failed to document the delivery of daily wound care for Residents with pressure ulcers. This was found to be evident in 2 (Residents #36 and #114) out of 2 Residents reviewed for treatment and services of pressure ulcers. The findings include: During the initial tour of the facility at 08:45AM on 05/05/2025 the surveyor observed Resident #36 sitting in the wheelchair with specialized heel protectors (Prevalon boots) on his/her lower extremities. Resident #36 stated that the heel protectors was for the wound that he/she had on the heel. The Medication and Treatment Administration Record (MAR/TAR) is a record used to keep track of every dose of medication or treatment that a Resident is administered. The MAR and TAR includes key information about the Resident's medication and treatment including the name, dose taken, special instructions and date and time. The surveyor conducted a record review of Resident #36's medical record on 05/09/2025 at 08:55 AM. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility staff interviews and record reviews it was determined that the facility failed to ensure residents were free from accidents. This was found to be evident in 2 (Residents #70 and #91) out of 2 Residents reviewed for accident hazards during the recertification survey. The findings include: 1) The surveyor observed Resident #70 sitting in the wheelchair in the lobby at the front entrance to the facility on [DATE] at 01:15 PM. On 05/12/2025 at 12:35 PM the surveyor conducted a record review of Resident #70's medical record. Review of the medical record revealed that Resident #70 was found on the floor in his/her room on 05/12/2024 at 18:12 PM which was documented in the progress notes of the medical record. Additionally, it was documented that Resident #70's bed had flipped over on the side, but not on the Resident. The surveyor requested from the Licensed Nursing Home Administrator (LNHA) at 06:30 AM on 05/13/2025 the facility's incident report for Resident #70's fall and incident 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 with facility staff it was determined that the facility failed to have an order to address and medicate different pain levels in a resident. This was evident during the review of a complaint for Resident #132 and the review of 1 of 6 residents' medication orders. (#132). The findings include: Review of the medical record for Resident #132 on 5/5/25 at 11:12 AM revealed admission to the facility post fall with multiple fractures requiring healing and physical therapy. Further review of the medical record for Resident #132 revealed physician orders on admission for Oxycodone 5 milligrams (mg) 2 tablets every 4 hours as needed for severe pain, a documented score of 7-10. However, a review at this time failed to reveal an order for pain medication for pain scores below '7.' A review of the medication administration record (MAR) for December 2024 noted that the Oxycodone was administered 64 times, 19 for pain scores of 0-6, in addition to 45 times for the score of 7-10. This concern was reviewed with the facility DON on 5/5/25 and again at…

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

Based on medical record review and interview, the facility failed to provide trauma-informed care after a resident expressed past traumas to a facility staff member. This was evident for 1 (resident #24) of 64 residents reviewed during a complaint/annual survey. Findings include: Review of resident #24's medical record on 5/12/25 at 7:40am an admission document dated 9/19/24, the date of the resident's admission. The document described the resident's past trauma with his/her family which caused him/her to run away from home at a young age. Further review of resident #24's medical record on 5/12/25 at 8:10am revealed no evidence that the resident's care plan was created with interventions for the resident's past trauma. On 5/12/25 at 11:30am, the surveyor interviewed the Director of Nursing (DON) regarding the trauma informed care policy. The DON confirmed resident trauma informed assessments should be done at admission and after a change in condition. The surveyor pointed out that resident #24 alleged that he/she had family trauma at a young age that caused he/she to run away from…

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

Based on the review of a facility reported incident (FRI) #MD00205993 related to an allegation of abuse, a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 1 out of 3 employee files reviewed for competencies and skill sets. The findings include: Review of the FRI #MD00205993 on 5/9/25 at 8:15 AM revealed a substantiated allegation of verbal abuse occurring between Resident #127 and GNA #32. A review of the facility investigation and concurrent review of the employee file for GNA #127 revealed that upon hire the month prior, there was no competency skills evaluations or check off sheets completed and available in her record for review. The DON was interviewed on 5/9/25 at 10:46 AM. This concern was brought to her attention as she was present and had completed this investigation and investigation packet. She was not aware of the blank competency check list. She was asked at this time for anything further or any education or training…

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 staff interviews, it was determined that the facility failed to: 1) monitor the behaviors of a resident on antipsychotic medications. 2) ensure residents were free from unnecessary medications. This was evident by 2 (Residents #61 and #111) out of 6 residents reviewed for unnecessary medication during the recertification and compliant survey. The findings include: 1) Resident #61 diagnoses included Bipolar Disorder, Psychosis, Major Depressive Disorder and Schizoaffective Disorder. 05/06/25 at 11:38 AM a review of Resident #61's medical record revealed that the resident was receiving antipsychotic medications Fluphenazine daily for Bipolar Disorder and Olanzapine at bedtime for Schizoaffective Disorder. The resident's psychiatry notes dated 2/16/25, 2/16/25, 4/4/25 and 4/16/25, revealed an increase in hallucinations and other behaviors. Further review of Resident #61's medical record revealed that a Care Plan was initated on 11/17/23 for visual/auditory hallucinations, increased anxiousness and agitation. However, the medical record failed to…

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

Based on observation, staff interviews, and review of medical record documentation it was determined that the facility failed to maintain a safe and effective system for securing medication in their designated carts on nursing units with residents with documented cognitive deficits and wandering behaviors. This practice was noted on 2 separate random observations on 2 of 2 units. The findings include: 1. During a tour of the secure dementia unit on 5/6/25 at 9:06 AM a medicine cup with a clear liquid in it was identified on an unoccupied medicine cart. There were 2 residents identified in the immediate area. Resident #80's room was immediately to the right of the medication cart where the medication was located. Resident #80 was observed walking around in his/her room and coming in and out of the room looking around and talking to the surveyor. Additionally, another resident identified as #125 was also observed in the hallway walking up and down to the cart and the door to the exit. During this time there were no staff observed in the area. At 9:12 AM staff RN #2 appeared. This…

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

Based on medical record review and staff interview, it was determined that the facility failed to maintain complete and accurate resident records. This was found to be evident for 2 (Resident #111, #119) out of 2 residents reviewed for documentation accuracy during the survey during the survey process. The findings include: Neurological checks (neuro-checks) are a series of assessments conducted at regular intervals after a fall, especially when a head injury is suspected or cannot be excluded. Their purpose is to monitor changes in neurological status that may indicate complications such as concussion, intracranial bleeding, or increased intracranial pressure. These assessments typically include evaluation of level of consciousness and orientation, pupil size and reactivity, motor strength and movement, speech and behavior, as well as vital signs. Frequency and duration of neuro checks are guided by facility protocol, physician orders, and the resident ' s condition, often beginning with frequent intervals (e.g., every 15-30 minutes) and tapering as the resident remains stable. 1)…

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 a facility reported incident and a complaint it was determined that the facility failed to appropriately document in a resident's medical record (resident #32 and #33) timely documentation of acute changes in condition, activities of daily living (adl) care, and resident information on the transfer record This was evident during the review of 2 of 52 residents reviewed during a complaint survey. The findings include: 1. Review of the medical record for Resident # 32 on 10/31/23 at 10:25 AM revealed Resident #32 had multiple co-morbidities including epilepsy, dysphagia, bipolar, chronic pain syndrome and hydronephrosis with renal and urethral calculous obstruction. On 4/23/23 Resident #32 was transferred to the hospital secondary to abdominal distention. A continued review of the nursing progress notes and change in condition reports noted that they were initiated on the day of the event, however, they were not completed until days later. The e-interact form completed for the change in…

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, interview with facility staff and policies it was determined that the facility staff failed to immediately report an allegation of abuse to Administration. This was evident during the review of 1 of 47 facility reported incidents. The findings include: Review of the facility reported incident (FRI) on 10/31/23 reported to the Office of Health Care Quality on 6/30/2023 revealed that the incident had occurred on 6/27/23 and staff did not intervene and report the incident until the following day. According to the facility investigation, on 6/28/23, 2 staff members approached the Director of Nursing reporting inappropriate behavior displayed by another employee towards not only staff but towards residents. This included aggression and loud communication. Again on 6/29 and 6/30 other employees including the house supervisor reported allegedly hearing GNA #34 using profanity towards Resident #38. On 6/30/23 Resident #38 was interviewed about the alleged verbal abuse from GNA #34. Resident #38, according to the FRI, was assessed as having a brief interview…

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 resident medical records and interview with facility staff, it was determined that the facility failed to throughly investigate a allegation of neglect as a result of facility nursing staff failing to obtain an accurate inventory of a resident's narcotic medication (Resident #9). This deficient practice affected 1 of 52 residents reviewed during a complaint survey. The findings include: A Medication Administration Record (MAR) - a document that records when and how much medication a resident is administered. For as-needed pain medication, it also documents what pain score a resident is reporting and whether the pain medication was effective at easing that pain. Failure to maintain an accurate MARs prevents members of the healthcare team from knowing when and why medication has been given. This can result in medication mistakes, overdose, or denying practitioners information on how much medication a resident receives. On 7/29/22, the state of Maryland's Office of Health Care Quality received a facility reported incident report which reported RN #35 miscounted…

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 medical record and interview, the facility failed to add soft offloading boots to a resident's heels as an intervention in the care plan (resident #22). This was evident for 1 out of 52 resident reviewed during a compliant survey. Findings include: Resident was admitted to facility on 11/17/22 with a fracture of left hip and left elbow and a wound on the left heel. A medical record review was conducted on 11/16/23 at 12 noon revealed the faclity wound care team assessed the resident #22's left heel wound and ordered a soft offloading boot for heel protection on 11/10/23. Additional review of the medical record revealed the order for soft offloading boots for the resident's left heel weren't given to the Doctor to approve. Additional review of the resident's care plan revealed no interventions for alteration in skin integrity related to left heel pressure ulcer. A interview with Staff # 32, Regional Clinical Services and staff # 33 Corp. [NAME] President of Operations revealed the facility failed to have a care plan for resident #22's Left heel pressure ulcer.

Based on medical record review and interview with facility staff, it was determined that the facility failed to follow up with physician recommendations orders. This was evident during the review of a complaint. The findings include: Review of the medical record for Resident # 32 on 10/31/23 at 10:25 AM revealed Resident #32 had multiple co-morbidities including epilepsy, dysphagia, bipolar, chronic pain syndrome and hydronephrosis with renal and urethral calculous obstruction. In addition with a history of bowel and fecal obstruction. On 4/23/23 Resident #32 was transferred to the hospital secondary to abdominal distention at the request of a family member. Further review of the medical record for Resident #32 revealed that on 4/22/23 Resident #32 was observed with abdominal distention. According to his/her medical record and hospitalizations, this was not the first time. The physician ordered an abdominal scan with 2 views and lab work according to a nurses 'late entry' progress note. This was all to be completed stat (immediately). Interview with the facility Administrator 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 resident complaint # MD00181865, and review of medical records (GNA [NAME]) the facility failed to change resident # 4 that cannot due by self. This was evident for 1 out of 1 resident. Findings include: A GNA (Geriatric Nursing assistant) GNA [NAME] is a record of what care is provided to residents on a daily basis. On 11/2/23 a medical record review was conducted for resident # 4. Family complained of resident being left wet and not changed on a regular basis for the month of August 2022. The GNA [NAME] was obtained by the Administrator. The record indicated the resident was not given care for toileting and hygiene. Resident was not given personal hygiene on the following dates: Aug. 2022 Day shift: 8/3/22 8/6/22 8/8, 9, 10, 8/22, 23 Evening shift 8/12/22 Night shift 8/7, 19, 22, 27 Toileting Aug. 2022 Day shift 8/3, 6, 8,9,10, 22, 23, 28 Eve shift 8/12/22 Night shift 8/7, 19, 22, 27. Administrator was made aware and stated that during that time period, agency was in the building due to Covid 19.

Based on a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident during the complaint survey for Resident #30. The findings include: 1. A review of Resident #30's clinical record revealed that the resident's primary physician ordered oxycodone 5 mg every 4 hours as needed for pain. Oxycodone is a strong narcotic pain-reliever. A review of the April Control Medication Utilization Record revealed oxycodone 5 mg on the following days and times was removed from the controlled lock box on 4/13/23 at 11PM, 4/14 at 3:30AM, 4/16 at 1AM, 4/17 at 2AM, 4pm and 10PM, 4/18 at 2:30AM, 3PM, 4PM, 8PM, and 4/19 at 12MN, 3AM, and 4PM. Further review of the resident's clinical records revealed that the resident April Medication Administration Record (MAR) revealed that the…

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

Based on review of resident medical records and interview with facility staff, it was determined that facility nursing staff failed to have an accurate inventory of a resident's narcotic medication (Resident #9). This deficient practice affected 1 of 52 residents reviewed during a complaint survey. The findings include: A Medication Administration Record (MAR) - a document that records when and how much medication a resident is administered. For as-needed pain medication, it also documents what pain score a resident is reporting and whether the pain medication was effective at easing that pain. Failure to maintain an accurate MARs prevents members of the healthcare team from knowing when and why medication has been given. This can result in medication mistakes, overdose, or denying practitioners information on how much medication a resident receives. On 7/29/22, the state of Maryland's Office of Health Care Quality received a facility reported incident report which reported RN #35 miscounted resident #9's Xanax medication on 7/21/22 which resulted in 2 Xanax tablets being missing…

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 records and interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility assessment was requested at the initiation of the survey on 7/12/21. Review of the Facility assessment on 7/20/21, revealed the date of assessment or update was documented as 5/1/21. This date corresponded to the facility's Change of Ownership, effective on 5/1/21. The facility assessment 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 upon staff interview and a review of facility documentation it was determined that facility staff failed to develop and implement a process to ensure that the Residents electrical or electronic equipment was inspected and failed to ensure that all the mechanical lifts used to transfer residents were inspected on a routine and as-needed basis for safe and effective operation. The findings included: A review of the facility policy required that all resident electrical or electronic equipment be inspected and contain the date of inspection and the initials of the inspector before use in the resident's room. During a tour of this nursing care center on July 12, 2021, at 9 AM the following observations were made: 1. In Room A10-A, Resident #40 had a laptop and cell phone both with charging cables that was not inspected for safety. 2. In Room C08-B, Resident #65 had a laptop and cell phone both with charging cables that was not inspected for safety. On 07/19/21 at 9:19 A.M. an interview with the Maintenance Director (#15) revealed that he had not checked the resident's electric…

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, review of resident medical records, and interview with residents and facility staff, it was determined that the facility staff failed to, 1) complete a resident's inventory of personal effects at the time of a resident's admission into the facility and update the inventory of personal effects document when a resident brings any new belongings into the facility, and 2) maintain the environment in a manner that was safe, clean, comfortable, and homelike. This was evident for 4 (Residents #42, #56, #76, #77) of 50 residents reviewed during the survey, and seven (Rooms E02, E06, E10, E12, E13, F02 and F12) of 30 rooms observed during the survey. The findings include: An Inventory of Personal Effects is a document that lists common articles of clothing, assistive devices, jewelry, appliances, and small furniture that a resident may bring into the facility. The document has space for staff to document and describe other items. A copy of this document is given to the patient or patient…

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

Based on observations, record reviews and interviews, it was determined that the facility staff failed to ensure that opened medications were documented with the date opened and included an expiration date for the medication. This was found to be evident in 2 out of 3 medication carts, 1 out of 2 treatment carts, and 1 of 2 medication storage rooms observed in the facility. The documentation of the medication refrigerator temperature in the medication storage was not compliant with the policies of the facility. This deficient practice had the potential to affect all residents. The findings include: On 07/16/21 at 1:05 PM. There were three medication treatment carts, two medication storage rooms, and six medication carts within the facility. The surveyor performed the observation of three medication carts, one treatment cart, and one medication storage room during the annual survey. An observation of the Medication Storage Room located on Unit E was conducted on July 19, 2021, at 11:48 A.M.: On 07.19.2021 at 1148, the surveyor reviewed the medication refrigerator sign off checklist…

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 the facility failed to ensure the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 of (#53) of 1 resident reviewed for hospitalization. The findings include: Review of Resident #53's electronic and paper medical record on 7/20/21 at 8:30 AM revealed on 5/3/21 at 11:30 PM Resident #53 was transferred to the hospital for a change in medical condition. Further review of Resident #53's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer. An interview was conducted with the Unit Manager (staff #19) on 7/20/21 at 11:00 AM. She indicated that there would be a form related to the bed hold and/or the written notification. The Unit Manager proceeded to review the paper chart and confirmed that a hospital transfer form notification for the resident or 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.

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was evident for 1 (#53) of 1 resident reviewed for hospitalization during the annual survey. The findings include. Review of Resident #53's electronic and paper medical record on 7/20/21 at 8:30 AM revealed on 5/3/21 at 11:30 PM Resident #53 was transferred to the hospital for a change in medical condition. Review of a note timestamped for 5/4/21 at 00.08 revealed that Resident #53 was found on the floor with an eyebrow laceration and complained of hip pain. A Nurse Practitioner was notified at 11:14 PM and an order was received to send Resident #53 out via 911 to the emergency room for further evaluation. There was no written documentation found in the medical record that Resident #53 was oriented and prepared for the transfer in a manner that the resident could understand and there was no documentation of the resident's understanding of the transfer in the medical record. An interview 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 interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#53) of 1 resident reviewed for hospitalization during the annual survey. The findings include: Review of Resident #53's electronic and paper medical record on 7/20/21 at 8:30 AM revealed on 5/3/21 at 11:30 PM that Resident #53 was transferred to the hospital for a change in medical condition. Further review of Resident #53's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy. An interview was conducted with the Unit Manager (staff #19) on 7/20/21 at 11:00 AM. She indicated that there would be a form related to the bed hold and/or the written notification in the medical chart. The Unit Manager had proceeded to review the paper chart and confirmed that a Bed Hold Policy Notice form for 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 review of resident medical record and interview with residents and facility staff, it was determined that the facility failed to ensure that resident Minimum Data Set (MDS) assessments accurately assessed the state of a resident's vision. This was evident for 1 (Resident #42) of 50 residents reviewed during the survey. The findings include: 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. The surveyor interviewed Resident #42 on 7/12/21 at 12:00 PM. During the interview, the resident stated that his/her glasses had gone missing. The resident stated that s/he had told so many people but none of them found his/her glasses or supplied him/her with new ones. The resident stated that s/he cannot read without glasses, which s/he stated was his/her primary form of entertainment. The surveyor reviewed Resident #42's medical record on 7/19/21…

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 review of resident medical record and interview with facility staff, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and the resident or their representative at least quarterly. This was evident for 2 (Residents #23 and #42) of 50 residents reviewed during the survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). #1) The surveyor reviewed Resident #23's medical record on 7/21/21 at 11:30 AM. The review revealed that Resident #23 had received a care plan meeting…

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, review of resident medical record, and interview with residents and facility staff, it was determined that the facility failed to ensure that residents were provided with an activity program that, based on residents' care plans, was designed to meet all residents' expressed interests and support their physical, mental, and psychosocial well-being, as evidenced by Resident #42 being denied the opportunity to participate in group activities or go outside, in part because the resident was unnecessarily kept in bed. This was evident for 2 (Resident #42 and Resident #67) of 6 residents reviewed for activities. The findings include: The surveyor interviewed Resident #42 on 7/12/21 at 12:08 PM. During the interview, the resident stated that s/he hasn't gotten out of bed for about two weeks. The resident also expressed interest in going outside and participating in group activities. The resident was in bed at the time of the interview. The surveyor observed Resident #42 in bed on 7/12/21 at 2:04 PM, on 7/13/21 at 11:10 AM, on 7/14/21 at 1:19 PM, on 7/15/21 at 1:10 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 review of resident medical record, observation, and interview with residents and facility staff, it was determined that the facility failed to determine if Resident #42 had glasses or required glasses for reading. This was evident for 1 (Resident #42) of 2 residents reviewed for communication and sensory needs. The findings include: The surveyor interviewed Resident #42 on 7/12/21 at 12:00 PM. During the interview, the resident stated that his/her glasses had gone missing. The resident stated that s/he had told so many people but none of them found his/her glasses or supplied him/her with new ones. The resident stated that s/he cannot read without glasses, which s/he stated was his/her primary form of entertainment. The surveyor observed Resident #42's room and could not locate any glasses or other forms of corrective lenses in the room. The surveyor reviewed Resident #42's medical record on 7/19/21 at 8:30 AM. The review revealed that the resident was admitted to the facility in August, 2020, with a diagnosis of Alzheimer's dementia, and that the resident's most recent…

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, observation, and interviews the facility failed to apply a resident's resting hand splint as ordered. This was evident in 1 (Resident #77) of 2 resident charts reviewed for assistive devices. The findings are: Observation of Resident #77 on 7/13/21 at 1:30 PM revealed the resident was not wearing the resting hand splint. Review of Resident #77's medical record on 07/15/21 revealed a physician order written and dated 06/30/21: Resident to wear left resting hand splint; on during AM care off at bedtime. Check skin pre/post application every morning and at bedtime. Observation on 07/15/21 at 12:10 PM revealed Physical Therapist #30 was providing therapy to the resident. Resident #77 was not wearing his/her resting hand splint. In an interview with the Rehabilitation Director, #20, on 7/16/21 at 9:52 AM revealed that Physical Therapist #30 was working with Resident #77 for pain management and range of motion (ROM) for the left knee. When a device is recommended by rehab and in-service is done with the staff, and we keep a copy. Nursing is responsible to make sure…

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 staff failed to thoroughly assess the need for pain medication for Resident (#12). This was evident for 1 of 2 residents selected for pain assessment and 1 of 50 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. This pain scale is most used. A person rates their pain on a scale of 0 to 10. Zero means no pain, and 10 means the worst possible pain. On 7/15/21 a medical record review for Resident #12 on 1/27/21…

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 medical record review and staff interview it was determined the facility staff failed to have a process to ensure that pharmacy recommendations were timely acted upon. This was evident for 1 (#50) of 5 residents reviewed for unnecessary medications. The findings include: Resident #50's medical record was reviewed on 7/20/21. Review of the monthly Medication Regimen Review in the electronic health record (EHR) revealed that the pharmacist had made a recommendation on 5/29/21. Further review of the EHR and the paper chart did not reveal documentation related to the consultant pharmacist's recommendation of 5/29/21. Upon request on 7/20/21 at 2:50 PM, the Unit Manager/Director (staff #19) reviewed Resident #50's medical record and she did not find the consultant pharmacist recommendation from 5/29/21. A follow-up interview was conducted with staff #19 at 8:51 AM on 7/21/21. The Unit Manager revealed that she had to contact the pharmacy to get the report and had responded to the Pharmacist recommendations of 5/29/21. Resident #50 was receiving the antipsychotic 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 with facility staff, it was determined that the facility failed to ensure that food was prepared and stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. The findings include: The surveyor conducted an initial brief tour of the kitchen on 7/12/21 at 8:30 AM. During the tour, the surveyor observed a tray of pork tenderloin that was thawing in the refrigerator on a non-drip tray. A sealed cardboard box was canted in the tray and the cardboard box was in the juice of the thawing meat. At about 8:45 AM, the surveyor observed a cart full of trays of chocolate desserts that was positioned next to the handwashing sink. The cart was close enough that the cart was touching the sink. The desserts on the cart were uncovered. Dietary Assistant #36 was observed to rotate the cart so that he could reach the faucet of the sink, however, the cart remained very close to the sink. Dietary Assistant #36 washed his hands with the exposed desserts close enough that they were at risk 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 medical record review, observation, and interviews the facility failed to ensure that infection control practices were followed while providing wound care. This is evident in 1 (Resident #9) of 2 records reviewed for wounds. The findings include: On 07/21/21 at 10:37 AM a review of Resident #9's wound care order dated 07/01/21 revealed; Clean sacrum (bottom of the spine) with NSS (normal salt saline), pat dry and apply small amount of Medi-Honey (treatment for removal of dead cells or tissue), followed by CA Alginate (absorbent dressing), cover with Optifoam (absorbent outer foam dressing) dressing every 24 hours PRN (as needed). On 07/21/21 at 11:20 AM, surveyor observed Registered Nurse (RN) #28 perform the ordered dressing change for Resident #9. The nurse did not wash her hands or sanitize the table used to create the dressing field. The dressing supplies were not placed on a sanitized surface. RN# 28 failed to wear gloves before picking up the 4x4 gauze that were used after cleansing the wound. The nurse removed scissors from her pocket and without sanitizing them,…

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 staff failed to ensure that hand rails were secured firmly to the wall. This was evident for 2 resident areas observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. The findings include: On 7/16/2021 at 10:17 AM during a tour of the facility, the handrail outside Room A9 was observed to be loose and not securely affixed to the walls. It was also observed at this time that the handrails were missing from outside Room E5 adjacent to the fire doors. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 7/26/2021.

Based on medication cart observations and staff interviews it was determined the facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out of 3 medication carts. The findings include: On 8/21/18 at 10:40 A.M. on the A-wing Long Term Care Unit, the surveyor observed on top of a standing unattended medication cart ( #2) a single piece of paper that was visable for public viewing. On the paper was written the full vital signs data for the residents who resided in Rooms A-6, A-7 and Room A-7B. The document was not kept in a confidential manner. The Surveyor stood at this unattended medication cart #2 for ten minutes without nursing staff returning. On the same day 8/21/18 at 10:55 A.M., Nurse staff member #5, who was observed at the nursing station charting was interviewed by the Surveyor. Staff Member #5 replied, I didn't realize I left the paper on the cart. During the same interview Nurse staff member #5 informed the surveyor that, all medical information is to be kept in a confidential manner and out of public viewing. 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 medical record review and staff interview it was determined the facility failed to ensure that: 1) Resident #94 did not receive an unnecessary blood draw; and 2) blood pressure medication was held according to the physician's orders for Resident #57. This was evident for 2 of 49 residents reviewed during the survey. The findings include: 1) The Hemoglobin A1C (glycated hemoglobin) blood test is used to identify the average blood glucose (blood sugar) over a three-month period. Beginning on 8/15/18 at 9:45 AM during a review of the medical record for Resident #94, the following physician order was found: A1C every 3 months-follow/up for DM (diabetes mellitus) one time a day every 3 months starting on the 10th for 28 days. It is standard practice for physician treatment orders such as this one to be transferred to a Treatment Administration Record (TAR) for the nurses to sign after administering the treatments. A review of the TAR from 8/1/18 through 8/21/18 revealed that some nurses were signing as though the orders were being completed daily and some were not. Days 10-15…

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 during an environmental tour, it was determined that the facility staff failed to provide housekeeping services, necessary to maintain the residents sit to stand lift devices in a sanitary and clean manner. This is evident for 4 out of 10 medical transfer equipment devices during the survey process. Facilities use various medical equipment to assist residents at patient transfers. The stand-up lift is a product that ensures the caregiver's security and aids in standing residents that need it. The findings include: On 8/17/18 at 2:05 P.M. the surveyor observed on the E-wing hallway, at room E-4, an Invacare lift to stand. The device was observed to be dirty with dried white and red old fluid stains located on the knee leg brace. The foot plate was, also, observed dirty with old food debris not cleaned or sanitized with white dripping stains visible on the foot plate. On 8/17/18 at 2:08 P.M. the surveyor observed in the E/F-wing shared residents shower room, a dirty sit to stand lift by Invacare which was dirty with dried fluid stains,…

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 staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writing that they are being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 1 out of 4 resident's involving Resident #74 (R#74) reviewed during the investigative portion of the survey process. The findings include: On 8/23/18 Resident #74's medical records were reviewed. This review revealed that a nurse's transfer to hospital note was written on 2/18/18 which revealed that Resident #74 had an unplanned change in condition which the resident was transferred to the acute hospital for medical evaluation. Review of the nurse's transfer note revealed that the resident's responsible person (RP) was called and given an update on the resident's status and that the resident was being transferred out to the emergency room. Further review of the medical records failed to reveal any documentation 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 medical record review and staff interview it was determined facility staff failed to: 1) clarify an unclear physician order for Resident #94 and accurately document the treatment administration; and 2) document the status and resolution of a skin condition for Resident #371. This was evident for 2 of 49 residents reviewed during the survey. The findings include: 1) The Hemoglobin A1C (glycated hemoglobin) blood test is used to identify the average blood glucose (blood sugar) over a three-month period. Beginning on 8/15/18 at 9:45 AM during a review of the medical record for Resident #94, the following physician order was found: A1C every 3 months-follow/up for DM (diabetes mellitus) one time a day every 3 months starting on the 10th for 28 days. This order is confusing as evidenced by nursing documentation on the Treatment Administration Record (TAR). The TAR for this facility is an electronic document where physician ordered treatments are listed and is used by nursing staff to sign after administering the treatments. A review of the TAR from 8/1/18 through 8/21/18…

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 staff interview it was determined the facility failed to ensure that personal hygiene equipment was properly stored to avoid possible cross-contamination. Residents #49 and #94 had the potential to have been affected by this. This was evident in the shared bathroom for 2 of 49 residents reviewed during the survey. The findings include: On 8/14/18 at 11:15 AM it was noted that bath basins labeled with the names of Residents #49 and #94 were stacked one inside of the other and sitting on the shared bathroom floor. As infectious organisms may be transmitted through indirect contact via inanimate objects, it is a minimal standard of nursing practice to store items separately that are designated for personal hygiene use. Geriatric Nursing Assistant (GNA) #1 was shown the findings and the Assistant Director of Nursing for this unit was made aware, as well.

Based on observation and interview, it was determined that the facility staff failed to ensure that personal privacy and confidentiality was maintained for 6 residents (#2, #16, #189, #223, #289, and #300) of 44 residents selected for review in the Stage 2 sample. This practice created the potential for individuals other than those providing care for the residents to read specific confidential medical information that pertained to these residents. The findings include: HIPAA, the Health Insurance Portability and Accountability Act, is a Federal law that gives patients/residents rights over their health information and sets rules and limits over who can look at and receive residents' protected health information (PHI). The Privacy Rules applies to all forms of residents' protected health information, whether electronic, written, or oral. An observation conducted on 05/18/2017 on the D/E Unit at 9:00 AM revealed that resident order sheets had been pushed under the Assistant Director of Nursing's (ADON) closed and locked door. The orders were clearly visible from the hallway and were…

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

Based on observation and interviews, it was determined the facility staff failed to ensure that: 1) a resident's catheter drainage bag was covered, 2) that the environment was kept in a manner that enhanced the dignity of a resident, and 3) that an unwanted visitor was prevented from entering a resident's room without being invited. This practice affected 3 residents (#292, #6, and #25) of the 44 residents selected for review in the Stage 2 sample. The findings include: 1) At 11:30 AM on May 18, 2017, the surveyor observed Resident # 292 being transported in a wheel chair by an Occupational Therapist (Employee # 1) The resident was wearing shorts, with a catheter drainage bag clearly visible with no dignity cover. Catheter drainage bags should be covered to protect the dignity of residents using them. 2) Resident #6 is a cognitively intact resident currently residing at the facility without a roommate. An observation conducted on 05/17/2017 at 11:00 AM revealed a strong urine smell emanating from Resident #6's room that was detectable from the hallway. Observations were made on…

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

Based on observation while conducting the initial facility tour and confirmed while conducting environmental rounds with facility staff, the facility failed to ensure that resident areas were kept clean and in good repair. The findings include: On May 17, 2017, beginning at 10:20 AM, the surveyor, accompanied by the Director of Maintenance, the Corporate Environmental Services Director and the Nurse Practice Educator conducted environmental rounds. Random rooms were selected for inspection, based on availability. The following items were observed: 1) The thresholds between the resident bedrooms and adjoining toilet rooms was missing, leaving an unfinished surface that is unable to be cleaned in rooms E 8, E11, E12 and E13. 2) Floors were unclean in the E wing dining room, room E7, the Station 2 shower room, the E wing pantry, the Homestead carpeted hallway, the Homestead dining room, rooms F5, rooms D5, D7, and the central supply closet. In room D5, trash and a used glove were observed on the floor. 3) Raised toilet seats were rusty in rooms F3 and E 9, not allowing for cleaning and…

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

Based on observation while conducting the initial facility tour and confirmed while conducting environmental rounds with facility staff, the facility failed to ensure that resident care items and toiletries were stored in a manner that reduces the risk of infection. The findings include: On May 17, 2017, beginning at 10:20 AM, the surveyor, accompanied by the Director of Maintenance, the Corporate Environmental Services Director and the Nurse Practice Educator conducted environmental rounds. Random rooms were selected for inspection, based on availability. The following items were observed: 1) An unlabeled urinal was hanging on the grab bar in the E 12 toilet room. 2) A pad for a wheelchair foot rest was on the floor in room E 11. 3) In the Station 1 shared shower, pillows were stored on a shower chair. A soiled dining chair. 4) In the A hall private shower, two bottles of body wash, a can of shaving cream, all unlabeled, were stored on the counter. 5) In room A4, a shared toilet room an unlabeled bottle of body wash was observed on the sink. 6) In room F3, bathroom tissue 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, medical records, staff interviews, and a family member, It was determined that the facility staff failed to notify the physician that Resident #256 refused a medication that was obtained as an emergency because the resident had become agitated and restless. This was evident for 1 out of 44 residents surveyed during Stage II of the survey process. The findings include: On 1/27/17, Staff #5 documented that Resident #256 was asleep in bed at the end of the evening shift. At around 1:00 AM the resident's bed alarm was heard beeping. When Staff #5 attended to the resident it was noted that the resident was agitated and restless, and refused vital signs. Staff #5 notified the physician and received an order for Seroquel 25 mg for agitation, a one-time only dose. Staff 5 documented that the resident refused the medication, therefore, the medication was not administered. The nurse failed to notify the physician about the resident's refusal to take the medication, or for further instructions as to whether to give the resident an intramuscular injection, or how to…

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

Based on review of documentation and interviews it was determined that the facility failed to act on the residents request during their monthly meetings. This was evident in 2 consistent months of resident council meeting minute notes of complaints of dirty hallways and cold food being delivered. The findings include: The Resident Council President was interviewed on 5/18/2017 at 10:00 AM, and confirmed that the main complaints at the last 2 monthly meetings were that the hallways were dirty and the food was being served cold. Review of the resident council meeting minute notes from 3/9/2017 and 4/13/2017 supported the complaint that the facility staff was not acting on the resident's grievances. During an interview with the Activities Manager on 5/18/2017 at 11:00 AM it was confirmed that the resident council meeting minute notes were accurate.

Based on interview and medical record review, it was determined that the facility staff failed to initiate a nutrition care plan with the appropriate goals and interventions for 1 resident (#232) of the 44 residents selected for review in the Stage 2 sample. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and outcomes. A medical record review conducted on 05/17/2017 for Resident #232 revealed that the resident was admitted to the facility with diagnoses that included, but was not limited to, low body mass index (BMI)-a measure of body fat. It was identified on the 12/02/2016 comprehensive assessment that the resident had a low BMI and it was decided that a nutrition care plan would be initiated. On 05/17/2017 at 1:30 PM when inquiring about Resident #232's nutrition care plan, the Nursing Home Administrator stated that a care plan was never initiated for nutrition…

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's family & facility interviews it is determined that the facility staff failed to maintain appropriate oral hygiene care for Resident # 95. This was evident for 1 out of 44 residents surveyed during Stage II of the survey process. The findings include: On May 11, 2017 during the Stage I interview process, Resident #95's family member complained that the resident was not receiving the appropriate oral care based on the resident's teeth appearing brown with a lot of plaque. On May 17, 2017 at 2:24 PM. the resident's teeth were assessed by this writer and the resident's teeth appeared dirty, thick with saliva and had visible plaque across the bottom teeth. It is the facility's responsibility to make sure that the resident receives services for maintenance of personal hygiene, when the resident is unable to perform such services independently.