Complete Care At Springbrook

Based on observation and interview, it was determined that the facility failed to ensure food was stored to maintain food safety. This was evident during the initial observation of the kitchen upon survey entry.The findings include:1) On 04/27/2026 at 7:34 AM, an initial observation of the kitchen revealed in the freezer there were french toast sticks, green beans, and chicken patties which were all opened and unlabeled.At the same time, further observation of the kitchen fridge next to the freezer revealed turkey bacon which was opened and unlabeled.On 04/27/2026 and 7:46 AM, further observation of the kitchen on a top shelf above a preparation table revealed a box of, quick creamy wheat, which was opened and unlabeled, plastic square containers with lids of what looked to be oatmeal and creamy wheat, which were opened and unlabeled, all purpose flour opened and unlabeled, and a large jug of, salsa picante, which was opened and unlabeled with the date it was opened. At the same time, further observation of the kitchen fridge with salad dressings had a plastic container with a lid…

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 staff failed to ensure resident medical records were accurately documented and maintained according to professional standard of practice. This was evident for 3 (Resident #3 #78 and #13) of 7 residents reviewed for advance directives and medical records accuracy. The findings include: 1.On 04/28/2026 at 7:55 AM, review of Resident #3's medical record revealed a document titled, Social Services Assessment and Documentation, dated 3/20/2025 signed by Director of Social Services #3 that indicated on line 5b. that the resident did not have an advanced directive, on line 5c. that additional conversation regarding advanced care planning was not provided, 5d. that the opportunity to complete an advanced directive was not provided, and 5e. that advanced directive educational materials were not provided to the resident. On 04/28/2026 at 8:14 AM, review of Resident #78's medical record revealed a document titled, Social Services Assessment and Documentation, dated 3/02/2026 signed by Director of Social Services #3 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was the determined that the facility failed to report an incident involving a resident who had a serious injury of unknown source, where abuse or neglect had not been ruled out, to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.The findings include:The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs.On 04/01/2026 at 10:46 AM, a review of Resident #12's clinical record revealed that on 03/23/2026, Resident #12 had an unwitnessed event in the facility. The resident's spouse reported the resident's legs were hanging off the side of the bed and were put back in place. Staff did not witness the event, and the resident could not explain what happened. The resident complained of left leg pain and was sent to the hospital 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 record review and staff interview, it was determined that the facility failed to complete a thorough and timely investigation of an incident involving a resident who had a serious injury of unknown source. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.The findings include: On 04/01/2026 at 10:40AM, a review of Resident #12's clinical record revealed that on 03/23/2026, Resident #12 had an unwitnessed event in the facility. The resident's spouse reported the resident's legs were hanging off the side of the bed and were put back in place. Staff did not witness the event, and the resident was not able to explain what happened. The resident complained of left leg pain and was sent to the hospital on [DATE]. Review of Emergency Department (ED) records dated 03/24/2026 showed the resident had an acute left hip periprosthetic (around an artificial joint or implant) fracture. On 04/03/2026 at 11:13 AM, during an interview, the Administrator stated that Resident #12's…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) discharge assessments were completed for a discharged resident. This was evident for 1 (Resident #2) of 13 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.On 4/1/26 at 12:12 PM a review of Resident #2's medical record was conducted and revealed Resident #2 was transferred to an acute care facility on 2/3/26. Review of MDS assessments in Resident #2's medical record failed to produce a discharge MDS assessment.On 4/1/26 at 12:15 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, it was determined that the facility failed to ensure implementation of care planned interventions necessary to prevent accidents for a resident identified as high risk for falls. This was evident for 1 (Resident #12) of 3 residents reviewed for accidents during the complaint survey.The findings include:On 04/01/2026 at 10:46 AM, Resident #12's clinical record was reviewed to reveal the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, altered mental status, hydrocephalus, seizures, intracranial injury, and muscle weakness.Review of Resident #12's care plan revealed the resident had a history of multiple unwitnessed falls, including 01/09/2026, 01/15/2026, 02/12/2026, and 02/19/2026. The fall care plan, initiated on 02/19/2026, included the use of a fall mat for fall prevention.Review of Resident #12's hospital Discharge summary dated [DATE] revealed the resident was transferred to the hospital on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, facility staff interviews, the facility failed to provide medication administration that meets professional standards for 5 of 8 sampled residents reviewed for medication administration. (Resident #27, Resident #23, Resident #28, Resident #29 and Resident #30). 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of the physician's orders dated 11/22/25 revealed Resident #27 was prescribed insulin lispro injection solution; inject as per sliding scale if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units Blood sugar above 400, give 7 units. Repeat Blood Sugar in 15 minutes and call provider., subcutaneously before meals and at bedtime for diabetes. A medication administration observation was conducted on 12/16/25 at 11:49 am with Staff Nurse #6. Staff Nurse #6 was observed checking Resident #27's blood glucose level. Staff Nurse #6 indicated that Resident #27's blood…

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 interviews, observations and recorded reviews, the facility failed to provide a direct communication system which relays Resident(R) calls when assistance was needed to ensure appropriate response from staff members at a centralized staff working station for three Residents, R35, R36, and R37. The facility census was 78. Findings Include: Record review of the facility undated policy titled Call Lights, Accessibility and Timely Response documented, the purpose of the policy was to assure the facility equipped Residents with a call light at each Resident bedside, toilet and bathing area to allow Residents to call for assistance. Call lights will directly be relayed to staff member or centralized location to ensure appropriate response. Policy directed staff to ensure the call light was within reach and secured as needed. Policy further directed staff to report problems with a call light system immediately to the supervisor and or maintenance director and provide immediate or alternative solutions, such 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 interviews of observations and recorded reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three Residents(R). R13, R33 and R34, when facility failed to replace a damaged and leaking commode toilet in R33 and R34s bathroom for several months and failed to provide a sanitary environment in R13s room. The census was 78.Findings Include: Record review of the facility undated policy titled Safe and Comfortable Environment dated 12/11/2024 and last reviewed on 2/11/2025 documented; in accordance with Residents rights, the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. The facility will minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department. 1.Record review of R13s face sheet (a document containing Resident information 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 record review, resident, facility and pharmacy staff interviews, the facility failed to administer medication as ordered by the physician to meet the resident's need of 3 of 8 sampled residents reviewed for pharmacy services. (Resident #23, Resident #29 and Resident #30). a. Resident #23 was admitted to the facility on [DATE] with a diagnosis of seizures adjustment disorder, hypertension, diabetes and dysarthria. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. A review of the physician's orders dated 11/3/25 revealed Resident #23 was prescribed Biofreeze cool the pain external gel 4% (menthol topical analgesic) apply to right shoulder topically two times a day for pain. A medication administration observation was conducted on 12/16/25 at 9:22 am with Staff Nurse #5. Staff Nurse #5 was observed to not have administered the medication biofreeze cool the pain external gel 4%(menthol topical analgesic) to Resident #23 as per physician orders. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review , staff and pharmacist interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 5 errors out of 43 opportunities observed. The medication error rate was 11%. 1. A review of the physician's orders dated 11/3/25 revealed Resident #23 was prescribed Biofreeze cool the pain external gel 4% (menthol topical analgesic) apply to right shoulder topically two times a day for pain. A medication administration observation was conducted on 12/16/25 at 9:22 am with Staff Nurse #5. Staff Nurse #5 was observed to not have administered the medication biofreeze cool the pain external gel 4%(menthol topical analgesic) to Resident #23 as per physician orders. During interview on 12/18/25 at 10:33 am, Staff Nurse #5 stated that she thought she administered the medication to Resident #23. 2. A review of the physician's orders dated 12/11/22 revealed Resident #28 was prescribed amlodipine besylate 2.5mg 1 tablet by mouth one time a day for hypertension 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 observations, and staff and pharmacist interviews, the facility failed to label opened insulin pens with the patient name, physician name, date used for 1 insulin pens for 1 of 3 medication carts reviewed for medication storage (West Wing Medication Cart). The [NAME] Wing Medication Cart was observed on 12/16/25 at 11:49 am in the presence of Staff Nurse #6. The observation revealed 1 opened and used insulin pen of Humalog (insulin lispro) that was stored with no label indicating patient name, physician name and order. The facility insulin pens policy copyright 2025, provided by the Director of nursing , indicated that Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date.During interview on 12/17/25 at 12:33pm, Staff Nurse #6 indicated that he used an unlabeled insulin lispro kwikpen , to administer insulin. Staff Nurse #6 stated that the kwikpen, had a room number, manually handwritten on the kwikpen, with a black marker. Staff Nurse #6 indicated that he did not…

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

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 6 (Resident #77, #7, #38, #48, #90 & #85) out 14 residents reviewed for medication regimen review and medication administration. The findings include: 1a) On 3/7/25 at 10:46 AM the surveyor observed Licensed Practical Nurse (LPN) #14 prepare medications that were scheduled to be given at 9 AM for Resident #77. LPN #14 stated that lactulose was not available but had 2 of the medications, amlodipine Besylate and Loratadine. The surveyor next observed LPN #14 administer the medications to Resident #77 at 10:51 AM. The surveyor noted this was over an hour from the due time. 1b) On 3/7/25 at 10:56 AM the surveyor observed Licensed Practical Nurse (LPN) #14 prepare medications that were scheduled to be given at 9 AM for Resident #7. LPN #14 stated that fluticasone furoate-vilanterol inhaler and furosemide were not available and had to be re-ordered. Ferrous sulfate, folic acid, extra strength tylenol,…

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 interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was found evident of 1 (Resident #85) of 19 Residents reviewed for care planning during an annual and complaint survey. The findings include: On 3/14/25 at 8:18 AM, the surveyor reviewed Physical Therapy (PT) notes for Resident #85. The review revealed a note written on 1/21/25 that stated, Resident # 85 was educated and engaged in bilateral (both) lower extremities home exercise program to improve strength. It further stated that the Therapist communicated with the unit manager about the Resident's inability to see and hear. On 3/14/25 at 12:30 PM, the surveyor reviewed Resident #85's Minimum Data Set (MDS) assessment dated [DATE] and 1/21/25. The review revealed that on 10/15/25 Resident #85 was assessed to have adequate hearing ability and on the 1/21/25 Resident #85 was assessed to have minimal difficulty (difficulty in some environments,…

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, meal ticket review and interview, it was determined that the facility staff failed to ensure the residents' food preferences were honored. This was found to be evident for 1(Resident #9) out of 38 residents reviewed for food/nutrition. The findings include: Observation of the kitchen serving lunch, on 03/12/25 at 11:40 AM, found that East unit #1 food cart arrived at 11:43 AM in the hallway. Resident #4 refused his lunch tray containing rice, he stated because he dislikes rice. Reviewing his meal ticket revealed that no rice was printed on his meal tickets. Shared above info. with the Kitchen's Manager (Staff #4) that he agreed it was an error. Interview, on 03/12/25 at 01:20 PM, the Administrator stated that he agreed to the error that kitchen staff made as a deficiency practice.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse within the required timeframe for 3 (Residents #13, #27, and #32) of 19 residents reviewed for abuse allegations. Findings included: The facility policy titled, Abuse, Neglect, Exploitation, revised on 09/12/2024, indicated, The facility strictly prohibits abuse, mistreatment, neglect, or exploitation of all residents, or the misappropriation of resident property. The facility will report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. 1. Resident #27's admission Record indicated the facility admitted the resident in October 2018. According to the admission Record, the resident had a medical history that included…

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, record review, facility document review, and facility policy review, the facility failed to conduct a thorough investigation into an allegation of neglect by failing to conduct interviews with facility staff assigned to care for the resident. This affected 1 (Resident #13) of 19 residents reviewed for abuse and neglect. Findings included: A facility policy titled, Abuse, Neglect, Exploitation, revised [DATE], specified, The facility will perform an investigation that focuses on whether abuse or neglect occurred and to what extent, clinical evaluation for any signs of injury, causative factors, and interventions to prevent further injury. Resident #13's admission Record indicated the facility admitted the resident in [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of paraplegia, end stage renal disease, pressure ulcer, and dependence on renal dialysis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE],…

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, record review, and facility policy review, the facility failed to ensure necessary treatment and services were provided to promote healing of pressure ulcers for 2 (Resident #3 and Resident #21) of 13 residents reviewed for pressure ulcers. Specifically, the facility failed to ensure weekly wound assessments were consistently completed and documented as per the care plan and to promptly consult with the attending physician or wound nurse practitioner (NP) regarding deterioration of a pressure ulcer for Resident #3. Additionally, the facility failed to provide wound treatments as ordered for Resident #21. Findings included: A facility policy titled, Resident Participation - Assessment/Care Plans, revised 10/2019, indicated, The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The policy further indicated, The resident/representative's right to participate in the development…

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, record review, facility document review, and facility policy review, the facility failed to ensure a physician-ordered intervention for bed rails was consistently implemented to assist the resident with safe bed mobility and minimize the risk of falls out of bed for 1 (Resident #4) of 5 residents reviewed for falls. Findings included: The facility policy titled, Fall Prevention Program, revised on 09/05/2023, indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility policy titled, Use of Bed Rails, initiated on 03/14/2023, indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. The policy also indicated, Informed consent from the resident or resident representative…

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, record review, and facility policy review, the facility failed to ensure the complete medical record was retained for a minimum of five years from the date of the residents' discharge for 2 (Resident #33 and Resident #34) of 45 residents whose medical records were reviewed. Findings included: A facility policy titled, Maintenance of Electronic Clinical Records, revised on 03/14/2023, indicated, Policy: This facility will maintain electronic records for each resident in accordance with acceptable standards of practice. The Policy Explanation and Compliance Guidelines specified, 5. Records will be retained in the electronic database per state law or five years from the date of discharge when there is no requirement in state law. 1. Resident #33's admission Record indicated the facility admitted the resident on 08/13/2021. According to the admission Record, the resident had a medical history that included diagnoses of acute hematogenous osteomyelitis of the left ankle and foot, anemia in chronic kidney disease, diabetes mellitus due to underlying condition with…

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

Based on observation and staff interview, it was determined that the facility staff failed to label drugs and biologicals in accordance with accepted professional standards. This was evident for 1 of 1 medication storage room selected for medication storage inspection during the survey. The findings include: On 09-16-2020 at 12:45 PM, a surveyor observed a 5 ml vial of TB (tuberculosis) skin test in the refrigerator with an open date marked 07-30-2020. It should have been discarded on 08-30-2020. Further observations revealed more than 100 syringes of 5 ml heparin flush with an expiration date of 06-13-2019 in medication storage room. The surveyor also observed multiple expired phlebotomy tubes (used to draw blood for lab testing). There were 3 cases (each case with 50 tubes) of red top tubes with an expiration date of 09-10-2020, six (6) additional red top tubes with an expiration date of 02-05-2020, one (1) green tube with an expiration date of 09-12-2019, and 15 purple tubes with expiration date of 11-11-2019. The charge nurse of the unit discarded expired tubes. On 09-16-2020 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility staff failed to ensure infection control practices to prevent development and transmission of communicable disease and infections for residents. This finding was evident for 3 of 25 residents reviewed during annual survey (Resident #16, #67, and #281). The findings include: 1. On 09-10-2020 at 8:30 AM, surveyor tour of Resident #67's room revealed oxygen tubing connected to an oxygen concentrator (a device which concentrates the oxygen from the surrounding air). The tubing was observed on the floor with the nostril section (nasal cannula, the tip that goes into the nose) under the resident's bed. Further observation revealed that the tubing and the humidifier bottle was dated 07-19-2020. Surveyor review of the clinical records for Resident #67 revealed a physician order to Change and date oxygen tubing every week and as needed. Rinse oxygen concentrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, interviews and observations, the facility failed to safeguard the disclosure of medical information. This was evident for 1 resident of 25 residents reviewed during the survey (Resident #63). The findings include: During observation of medication pass on 09-15-2020 at 8:50 AM, surveyor observed a poster with range of motion exercises in room [ROOM NUMBER]-A where Resident #65 resided post; however, the poster had Resident #63's name on it. On 09-15-2020 surveyor review of Resident #63's medical records revealed that the resident had started physical therapy on 07-16-2020 and that the physical therapist had instructed the Geriatric Assistant Nurses (GNAs) on therapeutic exercises for Resident #63. On 09-15-2020 at 9:56 AM, surveyor interviewed Staff #3. Staff #3 acknowledged that the poster should not have been posted and that it was in the wrong room. Staff #3 further stated that upon residents' discharge from physical therapy, the physical therapists instruct the nursing…

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

Based on record review, facility staff and resident interviews, it was determined that the facility staff failed to assist residents to file a grievance on a missing personal belonging. It was evident for 1 of 1 resident selected for the personal property review (Resident #74). The findings include: On 09-10-2020 at 3:17 PM, an interview with Resident #74 revealed the resident's robe was missing since 04-25-2020. Resident #74 reported the missing robe to Registered Nurse (RN) #4. However, RN #4 did not assist the resident to file a grievance for her/his missing robe. On 09-14-2020 at 1:35 PM, an interview with RN #4 confirmed Resident #74 reported the missing a robe to her. RN #4 told the surveyor she went through the resident's belongings in the resident's room and also checked with laundry department, but no one found it. However, RN#4 did not assist Resident #74 to file a grievance and did inform he pass management that Resident #74 reported missing property. On 09-14-2020 at 2:36 PM, an interview with the administrator revealed no additional information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interviews, it was determined that the facility staff failed to meet professional standards of care. This finding was evident for 1 of 25 residents reviewed for standards of care during the survey (Resident #2). The findings include: On 09-15-2020 at 1:41 PM, Resident #2's record review revealed she/he was readmitted to the facility on [DATE] from a hospital. Upon readmission, the resident's attending physician discontinued orders for Depakote (Depakote is an anticonvulsant used to treat seizure disorders, certain psychiatric conditions such as manic phase of bipolar disorder and to prevent migraine headaches). Further review of Resident #2's clinical record revealed the resident had a visit with a psychiatrist on 09-10-2020, the psychiatrist listed Depakote 500 mg twice a day for mood stability as current medication. However, the resident ' s record review revealed she/he was not on Depakote since 06-08-2020 and there was no evidence the facility staff communicated this…

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

Based on resident record review and staff interviews, it was determined that the facility staff failed to follow physician order to provide resident care. This finding was evident for 1 of 25 residents reviewed for quality of care during the survey (Resident #278). The findings include: On 09-16-2020 at 10:10 AM a review of Resident #278's record revealed the resident had a physician's order, dated on 08-22-2020, to administer Humulin 70/30 (It is a mixture of 70% intermediate-acting insulin (isophane) and 30% short-acting insulin (regular). It starts to work as quickly as regular insulin but lasts longer) 45 units subcutaneously (A subcutaneous injection is a method of administering medication under the skin) twice a day (7:30 AM and 4:30 PM) for diabetes. The medication was ordered to be given 30 minutes before meals. Further record review revealed the resident did not receive Humulin 70/30 on 08-23-2020 at 4:30 PM and on 08-24-2020 at 7:30 AM. Record review revealed there was no documented evidence as to why Resident #278 did not receive Humulin 70/30 as ordered by the physician.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, review of the clinical records and facility staff interview, it was determined that the facility staff failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This finding was evident for 1 of 5 residents selected for review of range of motion during the survey (Resident #5). The findings include: On 09-14-2020 at 9:15 AM, surveyor review of Resident #5's clinical record revealed that the resident was readmitted to the facility on [DATE]. Review of Resident #5 nursing assessment upon admission revealed resident has contractures and a loss of range of motion and physical limitations of the left upper extremities. Further record review revealed physical therapy assessment and recommendations dated 10-02-2019 for a left palm protector and elbow splints to be worn 6-8 hours every shift to prevent further contractures and further decline. However, surveyor observations on 09-10-2020 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 surveyor review of the clinical record, surveyor observation and interview with a resident and facility staff, it was determined that the facility failed to ensure that a current physician's order was in place for the use and assessment for oxygen use by residents. This finding was evident for 2 of 3 residents selected for the Respiratory Care review. (#37,#55) The findings include: On 09-08-19 at 11 AM, surveyor observation revealed that resident #55 had an oxygen concentrator (portable oxygen) in his/her room with a nasal cannula connected and an oxygen setting at 2 liters/ minute. Further observation of the resident's room on 09-09-19 at 11:28 AM revealed thst the oxygen concentrator was in place with a setting of 2 liters/minute, and the nasal cannula, which was dated for 09-08-19 was found at the resident's bedside. In addition, a portable nebulizer machine ( turns liquid medicine into a mist to help treat asthma) was sitting on the resident's bedside stand with an attached face mask, that was dated for 09-08-19. On 09-09-19 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 record review and interview with facility staff, it was determined that the facility failed to develop a complete baseline care plan. This finding was evident for 1 of 25 residents selected for review during the survey. (#9) The findings include: On 09-10-19 at 01:30 PM, surveyor review of resident #9's clinical record revealed he/she was admitted to the facility on [DATE] with a physician's order to take Simvastatin. Simvastatin is a medication that is used to lower cholesterol. There was no evidence in the clinical record that a care plan was developed regarding the use and monitoring of Simvastatin or associated medical conditions. On 09-11-19 at 1 PM, interview with the Director of Nursing revealed no new information.

Based on surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan to meet residents' medical condition. This finding was evident in 1 of 25 residents selected for review during the survey. (#61) The findings include: On 09-12-19 at 9:15 AM, surveyor review of resident #61's clinical record revealed that the resident had been receiving Trazodone, a psychotropic (any medication capable of affecting the mind, emotions or behavior) medication since July 2019. However, review of the care plan for resident #61 revealed that there was no care plan developed specific to the use of the Trazodone. On 09-12-19 at 10:10 AM, surveyor interview with the director of nursing (DON) revealed no additional information.

Based on surveyor review of the clinical record, interview with facility staff and with residents' court appointed guardian, it was determined that the facility staff failed to ensure that interdisciplinary care plan conferences were conducted timely after each resident's MDS assessment. This finding was evident for 3 of 25 residents selected during the survey. (#55, #20,#21) The findings include: The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. 1. On 08-11-19, surveyor review of the clinical record for resident #55 revealed that a quarterly MDS was completed with an ARD (Assessment Reference Date) of 05-13-19. However, there was no documented evidence in 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.

Based on surveyor review of the clinical record, surveyor observation of medication pass and interview with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice for residents. This finding was evident for 2 of 25 residents selected for review during the survey. (#23 and #68) The findings include: 1. On 09-10-19 at 5:34PM, surveyor observation of medication administration for resident #23 revealed LPN (Licensed Practical Nurse) # 1 administered 9 medications to the resident. However, review of the clinical record and the September 2019 MAR (Medication Administration Record) revealed that 7 of the 9 medications administered were scheduled for administration at 4:30PM and 5PM daily. The other 2 administered medications were not scheduled until 9PM. Further observation at 5:45PM on 09-10-19 revealed that LPN # 1 signed for the administration of the 4:30PM and 5PM medications after administration. However, there was no evidence that the medications that were scheduled for 9 PM were signed by LPN # 1 after administration. On 09-10-19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to follow physician's orders. This finding was evident in 1 of 5 residents selected for unnecessary medication review during the survey. (#72) The findings include: On 09-10-19 at 08:30 AM, surveyor review of the clinical record for resident #72 revealed a physician order, written on 08-15-19, that read check blood sugar before meals and at bedtime for type 2 diabetes mellitus. Please notify provider for blood sugar less than 70 and greater than 250. Additional record review of medication administration record (MAR) for the month of August and September revealed facility nursing staff documentation of blood sugar results on the following days: 08-17-19 before breakfast 47 09-03-19 before lunch 294 09-03-19 before dinner 375 09-04-19 before lunch 324 09-04-19 before dinner 320 09-05-19 before lunch 321 09-06-19 before lunch 342 09-06-19 before dinner 351 09-07-19 before breakfast 61 There…

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.