Autumn Lake Healthcare At Silver Spring

Based on observations, medical record review, and interviews, it was determined that the facility failed to follow provider orders. This was found to be evident in 1 (Resident #3) of 47 residents reviewed during the recertification survey.The findings include:A midline intravenous (IV) or midline catheter is a thin, flexible tube inserted into a vein in the upper arm that provides longer-term access than a standard IV, typically lasting up to four weeks. The sterile dressing must be changed regularly-usually once a week-to protect the insertion site from bacteria, moisture, and debris that could cause a serious infection.On 3/23/2026 at 10:07 AM, Resident #3 was observed to have a midline IV in their left arm. The dressing covering the IV site was dated 3/17/2026.On 3/26/2026 at 1:00 PM, Resident #3's midline IV dressing was observed and was dated 3/17/2026.On 3/27/2026 at 9:10 AM, Resident #3's medical record was reviewed which revealed an active order placed by the nursing facility provider dated 3/18/2026 that stated, Change midline insertion site dressing, every evening shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with facility staff, it was determined that the facility failed to ensure monthly Medication Regimen Reviews were completed by a provider and to respond to and address recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #29) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include:The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. On 3/24/26 at 12:54 PM review of Resident #29's medical record revealed the 1/8/26 and 2/8/26 MRR documented as See [pharmacist's] report. 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 observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control program as flying gnats were observed throughout the first floor of the building. This was found to be evident during the survey. The findings include: During an environmental tour of the first floor unit on 03/23/2026 at 9:47 AM, the surveyor observed a plethora of gnats flying around in the hallway. The surveyor observed a more concentrated amount of flies upon entrance into room [ROOM NUMBER], in comparison to those noted in the hallway. During an interview with one the residents in room [ROOM NUMBER] the surveyor observed more than 20 gnats resting on the resident's right side of the bed and on the resident's privacy curtain. When asked by the surveyor, the resident stated that the flies are always in the room. However, the resident neither confirmed or denied reporting this issue to facility staff. On 3/23/2026 at 10:30 AM the Director of Environmental Services and the surveyor…

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

Based on medical record review and interview with facility staff, it was determined that that facility failed to ensure that care plan meetings were scheduled quarterly and included the resident and representative. This was evident during the review of a complaint and review of 1 of 3 resident (1).The findings include:Review of the complaint #2577970 on 8/4/25 at 6:45 AM revealed concerns related to communication with the facility and involvement in care plans. A review of the medical record for Resident #1 revealed the last care plan meeting occurred on 10/22/24. The last social work note in the system was a 'social determinants of health' completed on 6/14/25. However, that was not a complete official care plan meeting. Interview with the facility social worker, staff #4 at 12:25 PM revealed that she is in communication with the family regularly but there was not a recent care plan meeting. Concerns were reviewed at 12:45 pm with the Director of Nursing and Nursing Home Administrator that there have not been care plan meetings with the family since 10/22/24. This surveyor 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 random observations of the Arcadia unit, it was determined that the facility failed to ensure the doors exiting the unit were in good repair and created a safe and comfortable environment for residents. The findings include:Observations of the double doors exiting the Arcadia unit revealed plastic kick plates covering the bottom half of both doors. The plastic kick plates were secured to the doors by multiple screws. On the right door, black tape was covering the top of the plastic kick plate and down the right side where the plastic was coming unsecured from the door. There were also many areas with cracks and chips and jagged edges where the plastic has broken around the screws. On 8/4/25 at 12:00 PM Resident #4 was observed standing at the door picking at the top of the plastic kick plate where there was the observed jagged edges with the broken plastic kick plate.The NHA and DON were notified of the concerns and observations at 12:30 PM on 8/4/25.

Based on observation, interview, job description review, document review and policy review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition department having the potential to affect all residents. The facility failed to ensure adequate oversight of dietary/nutrition services from the Registered Dietitian (RD), who worked part time, had not been to the facility since July of 2024. In addition, the facility failed to ensure the Food Service Director (FSD) was qualified. This resulted in failures to provide palatable food, provide food alternates/choices, provide snacks, serve meals without extended timeframes between dinner and breakfast, and provide nutritional interventions to prevent unplanned weight loss. Findings include: Review of the undated Dietitian job description provided by the facility revealed the primary purpose of the position was to, plan, organize, develop, and direct the overall operation of the Dietary Department . to assure that quality nutritional services are…

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, interview, document review, and policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to 126 out of 129 residents (three residents received nutrition via feeding tubes). Specifically, dietary staff did not adhere to hand hygiene/glove use requirements for ready to eat food and the dishwasher was not operating in accordance with manufacturer's specifications. Findings include: Review of the facility's policy titled, Dishwasher Temperature dated 01/31/23 and provided by the facility revealed, It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures . Manufacturer's instructions shall be followed for machine washing and sanitizing . For high temperature dishwashers (heat sanitization): The wash temperature shall be 150 - 165 degrees F [Fahrenheit] . The final rinse temperature shall be 180 degrees or above . Review of the facility's policy titled, Dietary Employee Personal Hygiene…

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, interview, and policy review, the facility failed to maintain the outdoor garbage area in a sanitary manner for three of three days of the survey creating the potential for the harborage of pests which could affect all 129 residents. Findings include: Review of the facility's policy titled, Safe and Homelike Environment dated 01/27/23 and provided by the facility revealed, the facility will provide a safe, clean, comfortable and homelike environment . Sanitary includes, but is not limited to , preventing the spread of disease-causing organisms . 1. Observation and interview of the garbage dumpster/compactor area 12/03/24 at 11:55 PM with the Regional Certified Dietary Manager (CDM) and the Housekeeping Manager revealed a significant amount of garbage strewn around the garbage compactor area extending approximately fifteen feet away. Garbage included pieces of plastic, drink cartons, condiment packets, paper refuse, silverware, pieces of cardboard, garbage bags with trash, a pile of scrambled eggs on the pavement, and disposable gloves. The Regional CDM and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and policy review, the facility failed to ensure two of 37 sampled residents (Residents (R) R184 and R19) received nutritional interventions to address significant weight loss. Specifically, these two residents were not served enough food; did not receive prescribed nutritional interventions; were not offered alternates when they did not eat, when they experienced significant unplanned weight losses. Staff documented R19 and R184 eating meals and consuming supplements that they did not eat or consume. Findings include: Review of the facility's Weight Monitoring policy dated 12/15/22 and provided by the facility revealed, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status . unless the resident's clinical condition demonstrates that this is not possible . A weight monitoring schedule will be developed upon admission for all residents: . Residents with weight loss -…

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, interview, record review, document review and policy review, the facility failed to ensure the food was palatable for 13 out of 37 sampled residents (Resident (R)88, R84, R46, R99, R123, R338, R21, R85, R60, R101, R7, R121, and R18). The food was not appetizing, prepared according to standards/recipes, or hot when residents received their meals. This created the potential for dissatisfaction and weight loss. Findings include: Review of the facility's policy titled, Standardized Menus dated 02/2023 and provided by the facility revealed, The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents . The facility will make reasonable efforts to provide food that is appetizing . 1. Residents' comments about the food were as follows: a. During an interview on 12/04/24 at 10:05 AM, R101 stated the food tasted bad. R101 stated she/he did not like the meat. Review of the undated Face Sheet in the Electronic Medical Record (EMR) under the Profile tab…

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, interview, record review and policy review, the facility failed to ensure that resident's preferences/dislikes were assessed and followed; that alternatives were available; and that alternatives were offered to residents who did not eat what was served for 10 of 37 sampled residents (Residents (R)85, R46, R88, R121, R7, R95, R58, R60, R94 and R184). This created the potential for weight loss and resident dissatisfaction. Findings include: Review of the facility's policy titled, Standardized Menus dated 02/2023 and provided by the facility revealed, Reasonable effort means assessing individual needs and preferences and demonstrating actions to meet those needs and preferences . Alternative menus will be available if the primary menu or immediate selections for a particular meal are not to a resident's liking . Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated 12/15/22 and provided by the facility revealed, Resident requests will be honored…

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, record review, document review and policy review, the facility failed to ensure that nutritional needs were met for four of 37 residents (Resident (R)46, R84, R88 and R18) frequency of meals and receiving snacks at bedtime. These failures could result in potential health issues due to deficiencies in vitamins, minerals, protein, and calories when nutritional body requirement needs are not being met. Findings include: Review of the facility's policy titled, Frequency of Meals dated 01/31/23 and provided by the facility revealed, The facility has scheduled three regular meal times, comparable to normal mealtimes in the community, per day and has scheduled three regular snack times .There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this meal time span . Nutritious snacks and convenience foods (i.e. canned soups, peanut butter crackers,…

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

Based on observation, interview, and policy review, the facility failed to ensure one of four (Licensed Practical Nurse (LPN) 3) followed infection control practices when dispensing medication in that LPN3 dropped a pill on top of the medication cart and then picked up the pill and placed it in the medication up for one of five residents (R) 100) administered medications. Findings include: During an observation on 12/06/24 at 9:23 AM, LPN3 retrieved R100's blister pack for Oxycontin 10 milligram (mg) one tablet from a locked compartment inside of the medication cart. When she went to push the Oxycontin tablet out of the blister pack, the tablet landed on the top of the medication cart. LPN3 then used her bare fingers, picked up the tablet, and then put the tablet in the medication cup along with R100's other medications. LPN3 did not sanitized her hands after touching the other medication blister packs and opening and closing the drawers of the medication cart prior to touching the dropped medication. During an interview on 12/06/24 at 9:40 AM, LPN3 stated that she always sanitized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to notify the resident's responsible party (RP) and physician timely when a resident had a change of condition (Resident #21). This was evident for 1 of 28 residents reviewed during a complaint survey. The findings include: Review of Resident #21's medical record on 2/2/24 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include subarachnoid hemorrhage and was incapable to make medical decisions. Further review of the Resident's medical record revealed the Resident had a change of condition on 4/22/22, the physician was notified and ordered a urinalysis that was obtained on 4/22/22. The urinalysis was sent for culture and sensitivity on 4/22/22 and facility was advised of the abnormal results on 4/25/22. Further review of the Resident's medical record revealed the Resident's abnormal urinalysis culture and sensitivity results were not reported to the physician and 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 records and interview, it was determined that the facility failed to conduct a thorough investigation. This was found to be evident for 1 out of 3 facility reported incidents. The findings include: On 02/05/2024 at 8:45 AM, a record review revealed that a facility reported incident (FRI), MD00185638 regarding Resident #19 was received by the Office of Healthcare Quality on 11/15/22 at 1:42 PM. In the FRI, the facility reported that per Resident #19, on 11/14/22 was raped by Resident #28. The facility's investigation and self-report is missing. On 2/5/24 at 8:30 AM an interview with Resident # 19 revealed that the resident denies any physical, verbal, or sexual abuse while in the facility. On 2/5/24 at 9 AM an observation of Resident #28 revealed that the resident is on a secure locked unit due to dementia. Resident #28 denies any physical, verbal, or sexual abuse while in the facility. On 2/5/24 at 7:30 AM, when asked to locate the missing self-reports, the Nursing Home Administrator admitted that he did not know where the investigation was and reach out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #4). This is evident for 1 of 28 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according 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 (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility nursing staff failed to inform facility nursing management that a resident (#17) with a diagnosis of Schizophrenia became increasingly combative with staff after a reduction in a mood regulating medication. This is evident in 1 of 28 residents reviewed during a complaint survey. Findings includes: On 10/2/23, the State of Maryland's Office of Health Care Quality received complaint MD00197733 which alleged resident #17 sustained an injury of unknown origin to his/her left arm and bruises to the left hand after care from facility staff. Review of Resident #17's medical records on 2/5/24 at 11:30 am revealed the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia and emphysema for long-term care. Review of progress notes revealed the resident was observed by facility nursing staff to be agitated when facility nursing staff cared for the resident. Continued review of resident #17's medical records on 2/5/24 at 11:45 am revealed…

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

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure each resident's drug regimen was free from unnecessary drugs (resident #14). This was evident for 1 of 28 residents reviewed during a complaint survey. The findings include: 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. Review of resident #14's medical record on 1/31/24 at 10:30 am revealed the resident was admitted to the facility for rehabilitation after heart surgery. Review of the resident's MAR for 3/2023 revealed the resident was prescribed 100 mg Metoprolol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #4) This was evident for 1 of 28 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #4's medical record on 1/31/24 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include multiple sclerosis. Further review of the Resident's medical record revealed the Resident was seen weekly by the Wound Physician. Review of the Resident #4's medical record on 1/31/24 for Wound Physician notes revealed the last Wound Physician note was 10/2/23. After Surveyor…

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

Based on record review, interview with facility staff, Hospice case manager, and surveyor observation, it was determined that the facility failed to develop a comprehensive person-centered care plan for each resident. This finding was evident for 3 of 26 residents (#9, 70, & 292) selected for review during the survey. The findings included: 1. On 07-30-19 at 09:58 AM, surveyor observed an isolation cart in front of resident #292's room. Review of resident #292's clinical record revealed that a physician's order was written on 07-19-19 and 07-23-19 for contact isolation precautions secondary to a transmissible infection. However, there was no evidence of a care plan to address the infection or need for contact isolation precautions. On 08-02-19 at 11:35 AM, surveyor interview with the Director of Nursing revealed no additional information. 2. On 08-01-19, surveyor review of the clinical record for resident #70 revealed that, in November 2018, the resident was admitted to Hospice Care Services for end of life care. Interview on 08-01-19 at 11AM, with resident #70's community Hospice…

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, review of residents' clinical records, and interviews with facility staff and residents and resident's representatives, it was determined that the facility failed to ensure residents' rights to participate in activities inside and outside the facility. This finding was evident for 2 of 3 (#34 & 106) residents selected for review of transmission-based precautions. The findings include: 1. On 07-30-19 at 10:04 AM, surveyor observed an isolation cart in front of resident #106's room. On 07-30-19 at 10:10 AM, surveyor interview with resident #106 revealed he/she was told by staff that they were not allowed to leave their room because they were on contact isolation precautions. Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the patient or items in the room. The healthcare workers should wear a gown and gloves while in the patient's room. On 07-30-19, review of resident #106's clinical record revealed a physician's order was written on 05-07-19 for contact isolation precautions secondary to a…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice in obtaining physician/nurse practitioner clarification for medical orders. This finding was evident for 2 of 32 residents selected for review during the survey. (#96, #133) The findings include: 1. On 08-01-19, surveyor review of the clinical record for resident #96 revealed that, on 07-26-19, the attending nurse practitioner documented an order to initiate Fluid restriction to 1500 ml per days due to low sodium. In addition, orders were documented to repeat the blood testing for a Basic Metabolic Panel ((BMP) which gives the status of the body's metabolism and includes a sodium level) in 1 week, as well as an order for a dietary consult. Further review revealed licensed nursing documentation on the July 2019 MAR (Medication Administration Record) of the 500 ml of fluid allowance at each shift (three times daily) for the 1500 ml total that was ordered. However, review of the resident #96's breakfast and lunch…

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, clinical record review, interviews with the Ombudsman, resident representatives and facility staff, it was determined that the facility failed to maintain grooming and personal hygiene for a resident who was unable to carry out activities of daily living. This finding was evident for 1 of 2 (#12) residents reviewed for dignity during the survey. The findings include: On 7-30-19 at 9:00 AM, surveyor observed resident #12 lying in bed with chin hairs that are not to be expected for this type of resident. Interview with resident #12 was attempted however, the resident was unable to answer surveyor questions. On 7-30-19 at 12:30 PM, interview with resident #12's representative stated she asked the facility during a care plan meeting if she could wax resident #12's chin hairs and the facility informed the representative that she could not. The representative also stated that, during that same meeting, the first-floor unit manager informed her that the facility staff would shave resident #12's chin hairs while providing personal hygiene for the resident. 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 surveyor observations, clinical record reviews, and interviews with facility staff, it was determined that the facility failed to provide care in accordance with professional standards of practice as evidenced by not following a physician's order. This finding was evident for 1 of 26 residents (#141) reviewed for this survey. The findings include: On 8-2-19 at 10:00 AM, record review of resident #141 revealed a physician order, written on 7-19-19, for Lisinopril 5 mg tablet by mouth twice daily for hypertension and to hold for a systolic blood pressure less than 110 or a heart rate less than 60. The systolic blood pressure is the top number and the diastolic is the bottom number of the blood pressure results. Further review of the July medication administration record revealed that nurse #1 withheld the resident's blood pressure medicine on three days in July. A. On 7/24/19 blood pressure 116/52 and heart rate 73, the medication was not given. B. On 7/25/19 blood pressure 121/58 and heart rate 71, the medication was not given. C. On 7/27/19 blood pressure 113/62 and heart…

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

Based on surveyor observation and interview with facility staff, it was determined that the facility failed to appropriately store medications and failed to appropriately dispose of expired medications. This finding was evident for 2 of 3 nursing stations (1st and 2nd floor). The findings included: 1. On 07-31-19 at 01:23 PM, surveyor observation with RN#3 revealed a an opened bottle of Iron Sulfate 325 milligram (mg) tablets with an expiration date of December 2018 that was stored in the Team one medication cart on the first floor. The expired bottle of Iron Sulfate was discarded after surveyor intervention. On 08-02-19 at 10:41 AM, surveyor interview with the Director of Nursing revealed no additional information. 2. On 08-02-19 at 10:05 AM, surveyor observation with the first floor unit manager revealed an opened bag of medications sitting at the first floor nurse's station unattended and unsecured. The opened bag of medications included a box of Duoneb, a tube of Clobetasol, and a package of Therahoney. The bag of medications was removed from the first floor nurse's station 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.