Autumn Lake Healthcare At Oakview

Based on interviews and record review, it was determined that the facility failed to accommodate resident's food preferences and intolerances. This was evident for 1 (Resident #133) of 3 residents reviewed for food choices during the recertification survey. The findings include:On 8/01/2025 at 10:00 AM During the resident council meeting, a facility task that was completed during the survey, Resident #133 reported that the facility kept serving them Lactaid milk and oatmeal even though they have communicated their dislikes and preferences to Staff #5, dietary manager, several times. Furthermore, Resident #133 stated that for breakfast on 8/01/25 they received oatmeal and Lactaid milk, 2 items that they dislike because they cause diarrhea episodes. The resident reported that they do not eat the oatmeal provided by the facility because it was cooked with milk, and that they have requested cream of wheat instead.On 8/01/2025 at 11:00 AM A review of Resident #133's medical record was conducted. The review revealed that the resident had lactose intolerance. On 8/01/2025 at 1:00 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.

Based on observations and interviews, it was determined that the facility failed to maintain a safe and sanitary environment for a resident. This was evident for 1 (Resident #126) of 8 residents reviewed for safe, sanitary and functional environment during the recertification survey.The findings include:On 7/24/2025 at 1:15 PM An observation of Resident #126's room was conducted. The surveyor noted a strong musty smell and observed black substance underneath the resident's bathroom sink. On 8/01/2025 at 10:30 AM Another room observation was conducted with 2 surveyors. Upon opening the door, both surveyors noted a strong moldy smell coming from Resident #126's room. The second-floor Unit manager, Staff #4, was asked to enter the room with the surveyors. She also acknowledged the strong moldy odor coming from the resident's room. The bathroom floor was noted to have black substances. On 8/01/2025 at 10:30 AM An interview with Staff #4 was conducted. Staff #4 reported that she became aware of the mold problem in the resident's bathroom last week. She added that at times Resident #126…

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 have a process in place to ensure that handrails were securely attached to the wall. This was evident for 1 of 1 unit observed.The findings include:An observation of the 2nd floor nursing unit on 7/24/25 at 8:15 AM revealed a loose handrail that was directly across the hallway from the elevator doors. The metal bracket that secured the handrail to the wall was pulled away with the drywall attached. The handrail to the right, when stepping out of the elevator, was loose. The metal bracket that secured the handrail to the wall was pulled away with drywall attached.During an observation of the loose handrails on the 2nd floor nursing unit on 8/5/25 at 12:34 PM with the Maintenance Director and the Nursing Home Administrator (NHA), they acknowledged the concerns. The maintenance director reported that he had instructed his maintenance workers to check the handrails periodically, however there was no documentation of this task. He stated that he was going to create something to have them sign off that they…

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

Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation and a certified Registered Dietician for nutrition management. This has the potential to affect all residents. The findings include: On 10/19/23 at 10:21 AM, an interview with the Kitchen Manager staff #51 revealed that he was not clinically qualified as per Federal and state regulations. During the interview, he reported that he had been in his position for two and a half years. He reported that he had completed his coursework, but had not yet passed the Certified Dietary Manager (CDM) exam. He stated he planned to take the exam in November 2023. On 10/23/23 at 1:14 PM, an interview with Dietician (eligible) staff # 28, revealed that she was not clinically qualified as per Federal and state regulations. During the interview, she reported that she had been in her position since June 2023. She continued that she was eligible to take the registered dietitian exam, but had not taken it…

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

Based on review of pertinent documentation, observation, and interviews with resident and staff, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated resident preferences. This was evident for 5 (Resident # 112, Resident # 49, Resident # 25, Resident #2, Resident #59) out of 6 residents on 5 of the 6 units at the facility reviewed for food during a survey. This has the potential to affect all residents. The findings include: 1. Resident #112 was admitted to the facility for rehabilitation and wound care. An observation of resident's menu ticket and tray was made on 10/16/23 at 12:16 PM. The observation revealed that the resident had milk listed on his/her menu ticket; however, there was no milk on his/her tray. On 10/18/23 at 12:38 PM, an additional observation of Resident #112's menu ticket and tray were made. This observation revealed that milk was included on the menu ticket; however, the observation failed to reveal that the resident was provided milk. On 10/19/23 at 9:44 AM, a third observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to provide a home-like environment for residents. This was evident for 2 of 2 nursing units reviewed for the environment. The findings include: On 10/11/23 at 12:16 PM, during a tour of the second-floor unit, an observation was made in room [ROOM NUMBER]B that about a third portion of the paper blinds had been ripped off from the bottom. On 10/12/23 at 1:13 PM, an observation was made of room [ROOM NUMBER], where surveyor observed stained ceiling tiles upon entry to the bathroom. One measured about 4 X4 inches to the right-hand corner of the ceiling and another, 6X6 inches to the left. Further observation was made of a missing ceiling tile, about 18x24 inches, in front of the toilet in the bathroom. A continued observation was made on the second floor on 10/12/23 at 1:16 PM. The observation revealed chipped laminate about 3x2 inches to the left and 1x1 inches to the right sides of the counter at the nurses' station. On 10/11/23 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 staff interview, it was determined the facility failed to notify residents or their representatives in writing of the reason for transfer and document that notification in the medical record. This was evident for 3 (#104, #142, #96) of 3 residents reviewed for hospitalization. The findings include: On 10/25/23 at 8:21 AM, a review of the Resident #104's medical record revealed the resident was admitted to the facility in April 2023, and following his/her admission, had been transferred to the hospital on 9/15/23, returned to the facility on 9/19/23, then transferred to the hospital on 9/25/23 and returned to the facility on 9/29/23. Continued review of the medical record failed to reveal evidence that written notification of the resident's hospital transfer had been provided to Resident #104 and the resident's representative. On 10/25/23 at 10:55 AM, during an interview, Staff # 35, RN, 3rd floor Unit Manager (UM), stated when a resident was transferred to the hospital, the nurses completed had a SNF (skilled nursing facility) to Hospital Transfer…

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

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 3 (Resident #79, #24, #7) of 47 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) On 10/23/23 at 1:33 PM, a review of Resident #79's medical record revealed the resident was admitted to the facility in November 2021 for rehabilitation following an acute hospitalization for a traumatic brain injury, and multiple fractures resulting from a motor vehicle accident, and resided in the facility for long term care. In a History of Present Illness note on 11/8/21, the physician documented Resident #79 had a past medical history which included Hepatitis C (viral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #112) of 3 residents reviewed for care planning. The findings include: Resident #112 was interviewed on 10/12/23 at 12:56 PM. During the interview, the resident stated that s/he had been admitted to the facility on [DATE]. The resident stated that a baseline care plan meeting had been held with the resident within 48 hours of admission. However, when asked if s/he had been provided with a summary of the baseline care plan or a list of his/her medications, Resident #112 stated no. On 10/31/23 at 2:04 PM, Resident #112's electronic medical record was reviewed. The review included an admission care plan note dated 8/15/23, 11 days after the resident's admission, that stated the resident was provided with a copy 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 and interview, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 3 (Resident #59, #129, #172) out of 47 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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. 1) Review of Resident #59's medical record revealed the resident was admitted in June of 2023. A care plan was initiated for the resident in June 2023. 1a) During an interview with Resident #59 on 10/12/23 at 9:14 AM, when asked about activities, the resident reported that no one gets him/her up to go and they do not bring him/her things to do. Review of the admission Minimum Data Set…

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

Based on observation, medical record review, and interviews, it was determined that the facility staff failed to evaluate and revise a resident's care plan to reflect accurate and current interventions. This was evident for 2 (#93, #7) of 47 residents reviewed during the survey. The findings include: A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 10/11/23 at 10:43 AM, an observation was made of Resident #93's room during a tour of the third-floor unit. The room was noted to have no curtains on the windows, no television in the room, no cables for the heating, ventilation, and air conditioning system, no baseboard to the walls, no nightstand, no furniture except the bed, and the bathroom door had a metal bar bolted across the upper left corner that prevented it from being opened. On 10/18/23 at 2:45 PM, a medical record review for Resident # 93 revealed a care plan focus originally initiated on 3/24/23 that stated that Resident # 93 had a tendency to demonstrate physical…

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, staff interview, and observation, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of residents. This was evident for 4 (#59, #84, #7, #422) of 5 residents reviewed for activities. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of Resident #59's medical record revealed the resident was admitted in June of 2023. During an interview with Resident #59 on 10/12/23 at 9:14 AM, when asked about activities, the resident reported that no one gets him/her up to go, and they do not bring him/her things to do. Review of the admission Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) On 10/16/23 at 9:38 AM, a medical record review for Resident # 84 noted that a monthly pharmacy review was completed on 4/23/23 with a recommendation to review an antidepressant for dose reduction. On 10/17/23 at 1:42 PM, a review of Resident #84's medical record showed that a consulting psychiatric Nurse Practitioner reviewed and signed the pharmacy recommendation on 6/6/23. The attending Physician saw resident # 84 on 4/30/23, 6/15/23, 6/16/23, 6/28/23, and 6/30/23. However, the review failed to show that the attending Physician for Resident # 84 had reviewed or responded to the pharmacy recommendation. On 10/17/23 at 2:19 PM, during an interview with the Director of Nursing (DON), she stated that the psychiatric Nurse Practitioner reviewed and signed all the pharmacy recommendations for psychotropic medication use. On 10/23 at 9:54 AM, an interview was conducted with the attending physician for Resident # 84 ( also the Medical Director). During the interview, she stated that she did not review pharmacy…

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 reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 2 (#3, #104) of 5 residents reviewed for advance directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. 1) On 10/12/23 at 1:35 PM, a review of Resident #3's EMR (electronic medical record) and paper medical record failed to reveal evidence that Resident #3 had an advanced directive in place. On 10/25/23 at 1:09 PM, review of the medical record revealed that Resident #3 resided in the facility for long term care since 2010. Resident #3's quarterly assessment with an assessment reference date (ARD) of 7/29/23, documented that Resident #3's BIMS (brief interview for mental status) summary score was 15, indicating 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, record review, and interview, it was determined that the facility staff failed to notify a resident's attending provider of a change in condition. This was evident for 1 (# 34) of 4 residents observed during medication administration and 1(#2) of 3 residents reviewed for Nutrition. The findings include: Systolic blood pressure is the top blood pressure. It refers to the pressure in the arteries during heart muscle contraction. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. 1) On 10/23/23 at 9:03 AM, during medication administration for Resident # 34, it was observed by the surveyor that two blood pressure medications were not administered by staff # 45, a licensed practical nurse (LPN) who stated the medications were held because Resident # 34's blood pressure reading was low. On 10/23/23 at 12:21 PM, 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 review of facility documents and staff interview, it was determined the facility failed to report an injury of unknow origin to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours of the allegation. This was evident for 1 (#24) of 13 residents reviewed for abuse. The findings include: On 11/2/23 at 3:49 PM, a review of the facility reported incident MD00171214 was conducted related to Resident #24 sustaining an injury of unknown origin. The facility's self-report documented that the Nursing Home Administrator was informed of the injury on 8/22/21 at approximately 6:15 PM. An email confirmation of the facility's self-report to the state agency was provided to the surveyor and reviewed. The email confirmation documented that the incident was reported to the state agency on 8/23/21 at 1:50 PM. Once the facility staff became aware of the injury of unknown origin, the facility failed to forward a first report to the state agency immediately, but not later than 2 hours. The concerns related to timely reporting an injury of unknown…

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 documents and staff interview, it was determined the facility failed to thoroughly investigate when a vulnerable resident who was assessed, and care planned as an elopement risk, left the facility grounds unattended for an unknown amount of time. This was evident for 1 (#136) of 4 residents reviewed for accidents. The findings include: 1) On 10/17/23 at 9:00 AM, a review of facility reported incident MD00175135 revealed documentation that, on 12/19/21 at approximately 2:15 PM, Resident #136 was observed by staff wheeling herself in the neighborhood around the facility. In a handwritten statement, Staff #14, Dining Services, documented that s/he observed Resident #136 at an intersection which was approximately 0.9 miles from the facility. The facility's investigation indicated Resident #136 was not identified as missing from the facility, until the resident was observed in the community by the staff person. The facility's self-report revealed documentation that Resident #136, accompanied by Staff #16, Activity Aid, was let out of the front of the building…

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 provide the resident and the resident representative written notice of the bed hold policy. This was evident for 1 (Resident #96) out of 3 residents reviewed for hospitalizations. The findings include: Resident #96 is a long-term care resident admitted in 2022. On 10/13/23 at 9:35 AM, Resident #96's medical records were reviewed and revealed that the resident was transferred to the hospital in July of 2023. On 10/18/23 at 12:03 PM, Licensed Practical Nurse (LPN staff#27) was interviewed about the process when a resident is ordered to be transferred to a community hospital for treatment. LPN staff #27 was able to name the different documents and notices that they are required to prepare to facilitate the resident's transfer. The nurse then documents these preparations in the facility's Change in condition/ Concurrent review evaluation form. On 10/19/23 at 1:20 PM, a review of the Change in condition/Concurrent review form with a reference date of 7/20/2023 signed by a registered nurse (RN staff #46)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to complete, within 14 days, a Significant Change in Status Minimum Data Set (MDS) Assessment. This was evident for 1 (#84) of 3 residents reviewed for Activities of Daily Living. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. Activities of Daily Living (ADLs) collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. A significant change means a major decline or improvement in a resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that have an impact on more than one…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that a resident with a positive Level I PASARR (Preadmission Screening and Resident Review) screen was evaluated by the designated state-authority through the Level II PASARR process, and approved for admission to the nursing facility. This was found to be evident for one (Resident #88) out of two residents reviewed for PASARR. The findings include: On 10/18/23, review of Resident #88's medical record revealed that the resident was admitted in April 2022 after an extended hospitalization on a psychiatric unit. Review of the Preadmission Screening and Resident Review (PASARR) Level I ID Screen for Mental Illness and Intellectual Disability or Related Conditions form revealed Section C Serious Mental Illness contains three screening questions used to determine if the resident has a Serious Mental Illness. These include diagnosis of a major mental disorder, level of impairment, and recent treatment. Further review of the electronic medical record revealed a PASARR screen completed 4/14/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined that the facility failed to provide services consistent with professional standards of practice to prevent the development of pressure ulcers and promote healing of existing pressure ulcers/injuries by 1) failing to follow practitioners orders by failing to accurately transcribe and implement wound treatment orders as prescribed, and 2) failing to ensure that a low air mattress was implemented when recommended. This was evident for 1 (#129) of 4 residents reviewed for pressure ulcers. The findings include: 1) A pressure ulcer also known as pressure sore, or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue and are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to prevent a vulnerable resident who was assessed, and care planned as an elopement risk, from leaving the facility grounds unattended for an unknown amount of time. This was evident for 1 (#136) of 4 residents reviewed for accidents. The findings include: Elopement occurs when residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way. 1) On 10/16/23 at 8:42 AM, a review of Resident #136's medical record revealed the resident was admitted to the facility in August 2020, with diagnoses that included schizoaffective disorder (bipolar type) and schizophrenia. Resident #136's admission assessment with an Assessment Reference Date (ARD) of 8/23/20 and quarterly assessment with an ARD of 11/23/20 documented Resident #136 had a Brief Interview of Mental Status (BIMS) score of 8, indicating the resident was mildly…

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 promptly address a resident's significant weight loss. This was evident for 1 (Resident #132) of 6 residents reviewed for nutrition. The findings include: Resident #132's medical record was reviewed on 11/1/23 at 12:37 PM. The review revealed that the resident had been admitted to the facility in July, 2021, and was discharged from the facility to the hospital in October, 2021. The resident did not return from the hospital. Review of the resident's weights revealed the following weights: - 7/2/21, 9:06 PM: 190.8 lbs - 7/3/21, 12:27 PM: 190.7 lbs - 7/9/21, 2:51 PM: 190.7 lbs - 7/16/21, 2:43 PM: 190.7 lbs - 7/30/21, 5:15 PM: 156.7 lbs - 8/3/21, 11:19 AM: 156.4 lbs - 8/5/21, 12:39 PM: 156.8 lbs - 8/6/21, 3:53 PM: 156.5 lbs - 9/9/21, 12:03 PM: 146.6 lbs - 9/10/21, 12:06 PM: 146.6 lbs - 9/22/21, 11:02 PM: 146.8 lbs - 9/23/21, 2:09 PM: 146.8 lbs - 9/29/21, 11:48 AM: 146.7 lbs - 10/6/21, 2:18 PM: 144.3 lbs These weights demonstrated that a significant weight loss (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 reviews and interviews, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feedings. This was evident for 2 (Resident #96, #80) of 2 residents reviewed for tube feeding. The findings include: 1) Resident #96 had been residing in the facility since 2022 and received g-tube feedings for increased nutrition. a) On 10/16/23 at 10:56 AM, Resident #96's medication administration record (MAR) for the month of July revealed two separate and different orders for tube feeding (TF): One time a day, Glucerna 1.5 @ 55 ml/hr x 12 hours, starts at 6 pm and ends at 6 am or until total volume is diffused. (order date 7/11/23, D/C date 7/20/23) Every evening and night shift, Glucerna 1.5 @75 ml/hr x 12 hours/day; up at 6 pm and down at 6 am or until 900 ml have infused. (order date 5/4/23, D/C date 7/20/23) From 7/11/23 - 7/20/23, the staff was documenting that the resident was receiving both these feedings. The resident was sent to the hospital on 7/20/23. On 10/17/23 at 9:43 AM, the 2nd floor unit manager (UM, Staff…

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 pertinent documentation and interviews, it was determined that the facility failed to provide documentation of peritoneal dialysis (PD) training to their nursing staff prior to the staff providing care to residents receiving PD treatment. This was evident for 2 (Resident #138 and # 130) out of 4 residents reviewed for dialysis during the survey. The findings include: 1. On 10/16/23, a review of Intake #MD00175057 revealed a concern regarding the peritoneal dialysis administration and care provided to Resident # 138. Peritoneal dialysis is a treatment for kidney failure, a condition where the kidneys are no longer able to filter blood well enough . Because peritoneal dialysis works inside the body, it's different from a more-common procedure to clean the blood, called hemodialysis. That procedure filters blood outside the body, in a machine. Peritoneal dialysis treatments can be done at a long-term care facility and at home. On 10/19/23 at 3:13 PM, the second-floor evening unit nurse manager (staff #41) was interviewed. He reported that residents were administered…

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: 1) ensure that orders for medication included an accurate route of administration, 2) ensure orders had adequate parameters to indicate when to administer as needed medicationsfor constipation, 3) ensure that residents were not given as-needed pain medication outside of a medication's parameters, and 4) ensure a resident received medication according to an attending physician's orders. This was evident for 2 (#79, #112) of 7 residents reviewed for unnecessary medications and 1 (#34) out of 4 residents observed for medication administration. The findings include: 1a) On 10/23/23 at 1:33 PM, a review of Resident #79's medical record was conducted. Review of Resident #79's October 2023 Medication Administration Record (MAR) revealed the resident had physician orders which indicated medications were to be administered enterally (delivered through a feeding tube directly into the stomach or small intestine) to the resident. There was an 11/6/21 order for Sennosides (laxative) Syrup, give…

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

Based on medical record review and staff interview, it was determined that the facility staff 1) failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days and failed to ensure a resident who received psychotropic medication was monitored for behaviors and side effects. This was evident for 1 (#) of 1 residents reviewed for hospice, and 1 (#79) of 7 residents reviewed for unnecessary medications. The findings include: 1) On 10/23/23 at 8:31 AM, a review of Resident #82's medical record revealed the resident was admitted to the facility at the end of July 2023 with diagnoses which included depression, anxiety, and Alzheimer's dementia and was receiving Hospice services. Review of Resident #82's October 2023 Medication Administration Record (MAR) revealed psychotropic medications prescribed to be administered as needed (PRN) had no discontinuation/end date, were not limited to 14 days duration, and had no documented rationale for continuing the orders beyond 14 days: a 7/29/23 physician's order for Haloperidol (Haldol) (antipsychotic) Concentrate…

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 prevent cross contamination of cookware and ensure that clean cookware was separated from dirty work areas and protected from splashes. This has the potential to affect all the residents. The findings include: On 10/19/23 at 12:40 PM, an observation of the kitchen was made. The observation revealed that the staff had washed dishes in a scullery sink that had three basins. One basin for washing, one for rinsing, and one for sanitizing. Further observation revealed that, following the sanitizing of 3 large cookie sheets and one large cutting board, all three of these items were then placed behind the faucets with about 1/3 of the cookware hanging above the washing basin and exposed to splash from the washing basin. On 10/19/23 at 12:42 PM, The Kitchen Manager, Staff #51, was asked about this practice noted in the above observation. The Kitchen Manager immediately removed the cookware from behind the faucets and placed them among the items needed to be washed. On 11/02/23 at 8:46 AM, during an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed ensure that a resident's current wishes related to life-sustaining treatment were up to date by failing to void previous MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST was created. This was evident for 1 (#104) of 5 residents reviewed for advanced directives. The findings include: Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may…

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, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior recertification survey. This was evident during the survey process and review of the Quality Assurance Program. The findings include: On 11/3/23 at 1:00 PM, the surveyor reviewed the results of the facility's last recertification survey, with a plan of correction date 10/25/19. It was determined that effective processes were not put in place regarding repeat deficiencies. The corrective actions implemented by the facility after the recertification surveys failed to effectively correct deficiencies related to the facility's failure to ensure a safe/clean/comfortable/homelike environment, notice requirements before transfer/discharge, development and implementation of care plans, and care plan timing and revision. These failures resulted in a continuation of the deficient practices as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that staff failed to store resident care equipment and supplies in a sanitary manner as evidenced by failing to store linens so as to prevent the spread of infection facility and failed to keep the door separating the clean from the soiled area of the laundry room closed to prevent cross contamination.This was evident in 22 resident rooms observed during the initial resident sample observations and evident in 2 out of 2 observations of the laundry area. .The findings include: On 10/11/23 at 9:21 AM, an observation was made of the bathroom in room [ROOM NUMBER]. In the middle of the bathroom there was a Geri-chair. On the seat of the Geri chair there was a white plastic bed pillow with multiple cracks in the plastic. On top of the pillow was a large, clear plastic bag that appeared to contain folded linen. Along with Staff #35, RN, 3rd floor Unit Manager, a second observation was made of room [ROOM NUMBER]'s bathroom on 10/11/23 at 9:37 AM. At that time, Staff…

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

Based on observations, interviews, and record review, it was determined that the facility failed to have the call device accessible to the residents while in their room. This was evident for 2 (Resident #7, #25) of 2 residents reviewed for call system functionality and accessibility. Then findings include: Resident #7 is a long-term care resident of the facility admitted in 2023. On 10/12/23 at 2:50 PM, in the initial tour of the resident's room, the surveyor observed the resident in bed, on the low position and the call device on the floor and not within reach of Resident #7. On 10/18/23 at 12:44 PM, Resident #7 was observed eating his/her lunch on the bedside table and the resident asked the surveyor to turn up the heat in the room. Resident #7's call device was observed not within his/her reach. On the same day at 12:50 PM, the surveyor asked the nurse (LPN, staff #24) to assist Resident #7 with his/her request. Staff #24 moved the call device that was hanging from the wall to the bed. The next day on 10/19/23 at 12:05 PM, the call device for Resident #7 was again observed on the…

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

Based on pertinent document review and interviews, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) working at the facility received 12 hours of continuing education annually. This was evident for 2 GNAs (GNA# 53, GNA # 54) out of 3 GNAs reviewed for staffing during a survey. The findings include: On 10/30/23 at 11:54 AM, the Director of Staff Development was interviewed. She stated that she scheduled staff competencies once a year, and the GNAs were provided with time off to complete the training. She stated that, in addition to the competencies, Human Resources (HR) enrolled each staff member in the online Healthcare Academy to complete their required annual training. On 10/30/23 at 11:54 AM, the Director of Staff Development provided the competency training packages for the 2023 competencies. A review of the training documents failed to reveal that GNA Staff #53 (hire date 2/19/15) and GNA Staff #54 (hire date 9/11/17) completed their 2023 competencies. On 10/30/23 at 12:24 PM, the Director of HR was interviewed. During 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 surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice. This finding was evident for 4 of 30 residents selected for review during the survey (#44, #51, #81, #88). The findings include: 1. On 10-23-19 at 10:30 AM, surveyor review of the clinical record for resident #51 revealed the resident was admitted to the facility's long-term care unit with multiple diagnoses including, but not limited to, unspecified pain. Further review of resident #51's medication administration record (MAR) for the months of August and September 2019, revealed that Tylenol (medication for normal ache and pain) 1000 mg was given twice a day, Gabapentin (medication for nerve pain) 200 mg three times a day for neuropathic pain, and Tramadol (an opioid analgesic) 50 mg twice a day as needed for breakthrough pain. Additional record review revealed that resident #51 was administered the Tramadol on August 8th, 9th, 21, 26, and 29,…

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 review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility staff failed to follow physician orders in medication administration for resident #88. This finding was evident for 1 of 30 residents reviewed for the survey. The findings include: On 10-23-19, surveyor review of the clinical record for resident #88 revealed that, on 10-04-19 the resident was evaluated by the optometry consultant. An assessment concluded the resident had conjunctivitis and the recommended treatment was Polytrim 4 times a day for 14 days. Further review revealed on 10-04-19 at 4:30PM the attending physician for resident #88 ordered the administration of Polytrim Solution eye drops 4 times a day in each eye for 14 days for Conjunctivitis. Conjunctivitis is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. Review of the October 2019 MAR (Medication Administration Record) revealed the initial dose 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 surveyor review of the clinical record, surveyor observations, review of the facility's policy and procedure, and interviews with residents and facility staff, it was determined that the facility failed to ensure that a systematic approach was identified with the hazards and/or risks consistently addressed for residents who smoke. This finding was evident for 4 of 4 residents reviewed for Smoking. (#86, #23, #19, and #51) The findings include: On 10-21-19 at 7:56AM and 7:58AM, surveyor observed resident #19 and resident #51 leaving the grounds of the facility in their wheelchairs. At 8:08AM and 08:12AM, both residents were observed returning to the front entrance of the facility. Surveyor interviewed resident #19 at 8:12AM, as he/she approached the facility grounds, and the resident stated that h/she leaves the facility to go smoke down the hill away from the facility's entrance. During the interview,the resident stated that other residents also go down the hill to smoke. Interview on 10-21-19 at 1PM…

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

Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to adequately provide ongoing assessment of resident #5's condition and monitoring for complications before and after dialysis treatments. This finding was evident in 1 of 4 residents selected for review of dialysis care during the survey. The findings include: 1. On 10-23-19 at 11:15 AM, surveyor review of the clinical record for resident #5 revealed that the resident was dependent on peritoneal dialysis (the process of removing excess water, solutes and toxins from the blood through the abdomen in people whose kidneys can no longer perform these functions naturally) due to his/her disease process. Further review of the physician order sheet (POS) for October 2019 revealed physician orders to check resident #5's vital signs before dialysis and weigh resident #5 every evening before dialysis and every morning after each peritoneal dialysis. Additional record review revealed that resident #5 received peritoneal dialysis from 9 PM through 7 AM daily. However,…

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

Based on record review and interviews with facility staff, it was determined that the facility failed to document a rational to continue an as needed anti anxiety medication beyond 14 days and document the justification for continued use of psychotropic medications. This finding was evident for 3 of 8 residents selected for the Unnecessary Medication/Behavior/Mood review. (#58, #92, #104) The findings include: 1. On 10-21-19, surveyor review of resident #58's clinical record revealed a physician's order was written on 04-04-16 for as needed Lorazepam (an anti-anxiety medication). Further review of the clinical record revealed there was no duration specified by the physician for the use of the anti-anxiety medication and resident #58 has not received any doses of the medication since 04-04-16. On 10-25-19 at 01:00 PM, interview with resident #58's attending physician revealed no new information. On 10-25-19 at 01:44 PM, interview with the Director of Nursing revealed no additional information. 2. On 10-24-19, surveyor review of the clinical record revealed that the following…

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 review of the clinical record, review of the facility's smoking policy and procedure, surveyor observations and interviews with residents and facility staff, it was determined that the facility failed to consistently implement their smoking policy for residents who smoke. This finding was evident for 4 of 4 residents reviewed for smoking. (#86, #23, #19, #51) The findings include: Interview on 10-21-19 at 1PM with the Director of Nursing revealed that the facility had a smoking policy that smoking is not permitted at the facility, since the facility maintains a smoke free environment. Review of the facility's current smoking policy revealed that, if a resident smokes or has recent history of smoking, the resident will be offered smoking cessation assistance or transfer to a facility where smoking is permitted. In addition, the resident will be informed that no cigarettes, lighters, matches or other smoking paraphernalia will be permitted while a resident resides at the facility. This policy…

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

Based on surveyor observations of dining service to residents and interview with facility staff, it was determined that the facility failed to ensure a homelike environment during meal services. This finding was evident for 1 of 2 main dining rooms within the facility. The findings include: On 10-21-19 at 12:29 PM, surveyor observation of the 3rd floor main dining room revealed facility staff serving lunch meals to residents seated at several dining tables. Staff placed the residents' trays in front of each resident at the table but removed only the plate covers and cup covers leaving the plate and utensils on the tray. Residents then proceeded to eat directly from the placed tray. Further observation revealed no evidence of music playing in the background nor other background stimulation. Staff were observed only directly communicating with one another and not with the dining room residents. Additionally, surveyor observation at 10-22-19 at 9 AM and 12:40 PM of the 3rd floor main dining room, revealed no evidence again of background music or any stimulation provided to residents…

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 administrative documents and interviews with residents and staff, it was determined that the facility failed to assist a resident with filing a grievance and promptly follow up on the grievance. This finding was evident for 1 of 6 residents reviewed for personal property concerns during the survey.(#123) The findings include: On 10-22-19 at 09:29 AM, surveyor interview with resident #123 revealed that he/she reported to the laundry personnel that 3 shirts and a gray blanket went missing approximately 3 weeks ago when they were taken to the laundry and no one had followed up on the missing items. On 10-23-19 at 07:41 AM, surveyor interview with staff #4 confirmed that resident #123 reported the missing items to them over a week ago and they had not yet been found. On 10-24-19 at 08:09 AM, surveyor interview with the Social Services Director/Facility Grievance Officer revealed that the facility's procedure for missing items was for the staff member (to whom the concern was reported) assist the resident with completing a written concern report and then submit it to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of clinical records and interviews with staff and residents, it was determined that the facility failed to provide written notification of a resident's transfer or discharge to the resident or representative. This was evident for 2 of 5 residents selected for review of hospitalization during this survey. (#123 and #27) The findings include: 1. On 10-22-19, surveyor review of resident #123's clinical record revealed that he/she was transferred and admitted to the hospital on [DATE], 05-25-19, and 09-20-19 for medical emergencies. Further review of the record revealed that resident #123 was self-responsible. However, there was no evidence that resident #123 was given any written notice of transfer. On 10-22-19 at 09:50 AM, interview with resident #123 revealed that he/she did not receive any written notification of the hospital transfers. On 10-24-19 at 01:07 PM, interview with the Director of Nursing revealed no additional information. 2. On 10-25-19, surveyor review of the clinical…

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 clinical record review and interviews with facility staff and residents, it was determined that the facility failed to provide the facility bed hold policy for residents that were transferred to the hospital. This was evident for 2 of 5 residents selected for review of hospitalization during the survey. (#123 and #27) The findings include: 1. On 10-22-19, surveyor review of resident #123's clinical record revealed that he/she was transferred and admitted to the hospital on [DATE], 05-25-19, and 09-20-19 for medical emergencies. Further review of the record revealed resident #123 was self-responsible and there was no evidence that resident #123 was given the facility's bed hold policy upon transfer to the hospital. On 10-22-19 at 09:50 AM, interview with resident #123 revealed he/she did not receive a bed hold policy during the hospital transfers. On 10-24-19 at 01:07 PM, interview with the Director of Nursing revealed no additional information. 2. On 10-25-19, surveyor review of the clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan to address residents' medical conditions. This finding was evident for 2 of 30 residents selected for review during the survey. (#51 and #68). The findings includes: 1.On 10-23-19 at 10:30 AM, surveyor review of the clinical record for resident #51 revealed that the resident was admitted to the facility's long-term care unit with multiple diagnoses including, but not limited to, unspecified pain. Further review of resident #51's medication administration record (MAR) revealed that Tylenol (medication for ache and pains) 1000 mg was given twice a day, Gabapentin (medication for nerve pain)200 mg three times a day for neuropathic pain, and Tramadol (opioid) 50 mg twice a day as needed for breakthrough pain. However, there was no evidence in the clinical record to indicate that a comprehensive care plan was developed for resident #51…

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

Based on surveyor review of the clinical records and interview of resident #115 and facility staff, it was determined that the facility staff failed to review a resident's plan of care quarterly. This finding was evident in 1 of 30 residents selected for review during the survey. (#115). The findings include: On 10-21-19 at 1:30 PM, surveyor interview with resident #115 revealed that he/she had not participated in a care plan meeting in a while. Resident #115 was self-represented and occasionally a friend also participated in the meeting. On 10-22-19 around 1 PM, surveyor review of the clinical record revealed that the last care plan meeting for resident #115 was in December 2018. Further record review revealed that resident #115 makes his/her own health care decisions. There was no evidence that a quarterly review of resident #115's care plan was done by the interdisciplinary team as required. In addition, resident #115 was not given the opportunity to participate in the review of his/her plan of care. On 10-22-19 at 2:10 PM, interview with the social worker revealed it was 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.

Based on surveyor observations, record review, and interviews with facility staff, it was determined that the facility failed to assess resident #81 for risk of entrapment and obtain informed consent from resident #81's responsible party prior to the installation of 1/2 length bed rails. This finding was evident for 1 of 2 (#81) residents reviewed for restraint use during the survey. The findings include: On 10-21-19 at 01:46 PM, 10-22-19 at 09:01 AM, and 10-23-19 at 09:33 AM. surveyor observed half length bed rails that were on both sides of resident #81's bed. On 10-21-19 at 01:46 PM, interview with resident #81 revealed that the facility installed the bed rails because he/she had a history of rolling out of bed while sleeping. On 10-23-19, surveyor review of resident #81's clinical record revealed no evidence that the resident was assessed for risk of entrapment prior to the installation of the bed rails. Furthermore, there was no evidence that the facility reviewed the risks and benefits or obtained informed consent from resident #81's responsible party for the use of the 1/2…

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, review of facility's consultant psychiatric services contract/addendum and interview with facility staff, it was determined that the facility failed to ensure that necessary behavioral health services were in place for resident #104. This finding was evident for 1 of 8 residents selected for the Unnecessary Medication/Behavior/Mood review. The findings include: On 10-24-19, surveyor review of the clinical record for resident # 104 revealed the following psychotropic medications ordered for administration: Zoloft 175 mg once daily for Major Depressive Disorder in September 2017, and in November 2018 Abilify 2 mg once nightly for Schizophrenia. On 05-03-19, documentation by the facility's consultant pharmacist, on the monthly report, revealed the recommendation for the attending physician to evaluate if dosage reduction for the Abilify could be attempted for resident #104. Further review of the 05-03-19 report revealed documentation by the facility's psychologist on 05-14-19 that the resident was not covered for Counterpoint services…

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 review of the clinical record, observation, and facility staff interview, it was determined that the facility staff failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. This finding was evident in 1 of 2 residents selected for review of infections not UTI related care area during the survey. (#227). The findings include: On 10-21-19 at 08:30 AM, surveyor tour of resident #227's room revealed a wound vac machine (a device that drains seeping liquid from a wound by forming airtight cover and pumping the liquid out) hooked to resident #227's left foot. On 10-24-19 at 9:12 AM, surveyor interviewed resident #227 who stated I have the wound vac because I have MRSA (Methicillin Resistant Staphylococcus Aureus) infection. Surveyor review of resident #227's clinical record revealed a hospital Discharge summary, dated [DATE], that documented the resident had a MRSA infection in the left foot wound. Further record review…

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.