Fairland Center

Based on resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to ensure residents received showers twice a week. This was evident for 3 (#30, #38, and #57) out of 3 residents reviewed for choices during the recertification/complaint survey. The findings include: 1. This surveyor interviewed Resident #30 on 4/8/25 at 8:06 AM. The resident stated that they have received only one shower each week. A review of the resident's clinical record revealed that from February 1 to April 11, 2025, the resident had only received 17 showers out of a possible 20. 2. This surveyor interviewed Resident #38 on 4/8/25 at 9:01 AM. The resident stated that they have not received two showers each week. A review of the resident's clinical record revealed that from February 1 to April 11, 2025, the resident had only received 17 showers out of a possible 20. 3. This surveyor interviewed Resident #57's spouse on 4/8/25 at 8:06 AM. The spouse said the resident had only received one shower each week. A review of the resident's clinical record 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 interview and record review it was determined the facility failed to ensure a resident representative was provided with written information and the offered the opportunity to formulate an advanced directive. This was evident for one (Resident #56) out of four residents reviewed for advanced directives during the facility's recertification/complaint survey. The findings include: On 4/8/25 at 9:40AM the surveyor observed the medical record of Resident #56 and noted that a surrogate was selected on the resident's Maryland Orders for Life Sustaining Treatment Form located within the hard chart at the nurse's station. Further reveiew of the hard chart revealed two certifications of incapacity were present for Resident #56. On 4/8/25 at 10:20AM the surveyor conducted a review of the medical record for Resident #56 at which time no documentation upon their admission to the facility could be found of the resident representative having been offered the opportunity to formulate an advanced directive, having been provided with information to formulate an advanced directive, or any…

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 and observation it was determined the facility failed to ensure the reporting of an allegation of abuse. This was evident for one resident, (Resident #56) during the surveyor's investigation of MD#00213104 during the recertification/complaint survey. The findings include: On 4/8/25 at 1:07PM the surveyor conducted an interview of a family member of Resident #56 who reported to surveyors that they had found a red mark on Resident #56's forehead upon visiting the resident, and when they had brought this to the attention of facility staff, they were informed that it was not reportable. At this time, surveyors observed a photo dated from March 2025 in which an elongated red mark appeared to be present on the resident's forehead. On 4/10/25 at 10:37AM the surveyor conducted an interview of Unit Manager #26 who confirmed the Director of Nursing and the Assistant Director of Nursing had inquired to them about the red mark on the resident's forehead, at which time they had first observed it to be present. Unit Manager #26 further reported they had observed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative in writing about the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident #42) of 1 Residents reviewed who were transferred to an acute care facility during the recertification/complaint survey. The findings include: On 04/10/25 at 11:30 am, medical review of Resident # 42 revealed that the Resident was admitted to the facility on [DATE] and was receiving long-term care. The resident was sent to the hospital due to a change in condition on 07/25/23. Review of the facility policy title AR102 - Bed - Holds revealed; When it is known that a resident will be temporarily transferred out of the service location, staff involved with the resident's transfer out (example; Nursing, admissions, and social services, etc.) will provide the bed hold notice of policy & authorization form to 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 review of medical records and interview with facility staff, it was determined that the facility failed 1) to ensure that residents and/or residents' representatives were provided with summaries of their baseline care plans including a list of their medications and 2) to complete a baseline care plan within the required timeframe. This was evident for 2 (#44, #55) of 24 residents reviewed during the recertification/complaint survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right…

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 and interview with facility staff, it was determined that the facility failed to revise care plans for residents quarterly. This was evident for 1 (Resident #55) of 24 residents reviewed during the recertification/complaint survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They describe residents' needs and the interventions to address them and must be reviewed and revised at least every quarter and/or as changes in the residents' conditions occur. The facility is required to have care plans developed and revised by an interdisciplinary team (IDT) including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). On 4/14/25 at 10:39 AM Resident #55's medical record was reviewed. During the review it was noted that the resident was admitted to the facility on [DATE], however, only one care plan…

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 the medical record and interview with facility staff, it was determined that the facility failed to complete a discharge summary of a resident . This was evident for 1 (Resident #84) of 3 residents reviewed for closed records during a recertification/complaint survey. The findings include: Resident #84's closed medical record was reviewed on 4/16/25 at 9:01 AM. The review revealed the resident was noted to have left against medical advice on 1/16/25. Further review revealed on 4/15/25 at 2:38 PM Nurse Practitioner (NP #25) wrote, Patient desires discharge AMA (Against Medical Advice). Notified the primary care provider, Dr. [Medical Doctor #16], via voicemail regarding the patient's situation and concerns. Notified the Director of Nursing about the patient's dissatisfaction and intent to leave AMA. Additionally, the last nursing progress note documented 1/16/25 at 8:29 PM revealed, Resident left against medical advice despite education in regard to risks and benefits, but resident still insisted on leaving, resident left via stretcher accompanied by 2 paramedical…

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 record review it was determined the facility failed to ensure a resident received necessary oral care. This was evident for one resident (Resident #56) during the surveyor's investigation of MD#00213104 during the recertification/complaint survey. The findings include: On 4/8/25 at 1:07PM the surveyor conducted an interview of Resident #56's family member who expressed concern for the resident's oral care. On 4/8/25 at 2:50PM the surveyor observed the resident's tongue to have a yellow, dry, crusty appearance, and their front upper teeth to have a thick, creamy film present. On 4/8/25 at 3:02PM the surveyor conducted a dual observation of the resident's oral condition described above with Unit Manager #26 and conducted an interview with them at the conclusion of the observation. The surveyor shared their concern with Unit Manager #26 who acknowledged and confirmed understanding of the concern and reported to the surveyor that the Respiratory Therapist (RT) was responsible for performing the resident's oral care and that oral care was performed 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to: ensure a resident (Resident #56) received the recommended frequency of visits for therapy care for rehabilitation, ensure consistent turning and repositioning needs were provided, and ensure medical orders were followed. This was evident for 1) one (Resident #56) out of three residents reviewed for positioning and for 2) one (Resident #44) of five residents reviewed for unnecessary medications during the facility's recertification/complaint survey. The findings include: 1) On 4/8/25 at 8:28AM the surveyor observed Resident #56 laying in their bed in a back lying position with the head of the bed elevated and observed their feet in a plantarflexed position (feet pointed downwards) laying directly on the bed without any intervention instituted for support. On 4/8/25 at 2:48PM the surveyor observed Resident #56 laying in their bed in a back lying position with the head of the bed elevated and observed their feet in 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 observation and interview it was determined the facility failed to ensure a chemical was stored in a locked location. This was evident for one (A wing) out of three nursing units on the facility's second floor during the facility's recertification/complaint survey. The findings include: On 4/14/25 at 8:08AM the surveyor conducted observations which included rounding of environmental concerns with the facility's Director of Maintenance #20 and Regional Director of Nursing #4 and during rounding the surveyor was able to freely access and open one of two closet doors on the A wing located between rooms A1 and A3 and observed a container of carpet cleaning chemical. At this time, the surveyor shared their concern with Director of Maintenance #20 and Regional Director of Nursing #4 who both observed, acknowledged, and confirmed understanding of the surveyor's concern. On 4/14/25 at 8:10AM the surveyor observed Director of Maintenance #20 attempt to lock the closet door which contained the carpet cleaning chemical, at which time it was observed that after attempting to lock 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 a review of staff training and staff interview it was determined that the facility staff failed to ensure all staff received the appropriate training. This was evident for 3 (Staff #10, Staff #23, Staff #24) out of the 5 staff reviewed for training during the recertification/complaint survey. The findings include: The employee files for the five employees were reviewed on 04/11/25 at 06:57 AM. Staff #10 was missing evidence of training for behavioral health, tracheotomy care, and ventilator care. Staff #23 was missing evidence of training for Resident rights, communication, behavioral health, ventilator care, and tracheotomy care. Staff #24 was missing evidence of training for abuse, resident rights, communication, ventilator care, and tracheotomy care. Staff #5 (Regional Clinical Resource Nurse) was interviewed on 4/11/25 at 8:27 AM. When asked what training staff must complete prior to working on the units she stated: safety- fire, electrical; infection control; dementia; skills- basic skills such as Range of Motion (ROM), Activities of Daily Living (ADLs), turning and…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure facility staff documented monitoring of behavioral symptoms. This was evident for 1(#38) out 24 residents reviewed during the recertification/complaint survey. The findings include: A review of Resident #38's clinical record revealed that the behavior monitoring that was ordered for the monitoring of the resident's depression symptoms for the month of April could not be found. The Director of Nursing (DON) was interviewed on 4/15/25 at 8:14 AM. The DON reviewed the electronic health record with the surveyor. She showed the surveyor that the button for who was responsible for the monitoring was clicked to Ancillary staff instead of nursing. The provider should have clicked nursing so that it would show up on the Medication Administration Record for nursing to document. She said she would change it.

Based on record reviews and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #44) of 5 residents reviewed for unnecessary medications during the recertification/complaint 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 4/14/25 at 1:33 PM the DON provided the survey team the 3 most recent (January - March 2025) months of the facility's Consultant Pharmacist's MRR: Listing of Residents Reviewed with No Recommendations lists. Review of the February 2025 list failed to reveal Resident #44's name. On 4/15/25 at 9:50 AM…

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 clinical record review and staff interview it was determined that the facility staff failed to 1) ensure residents received medication according to ordered parameters, and 2) ensure a resident was free from unnecessary pain medications. This was evident for 2 (Resident #45, Resident #55) out of 24 residents reviewed during the recertification/complaint survey. The findings include: 1) A review of Resident #45's clinical record on 4/14/25 at 7:51 AM revealed that the resident was ordered Atenolol (medication to treat hypertension) 25 mg two times a day and to hold it if the systolic (top number) blood pressure (SBP) was under 110. A review of the Medication Administration Records (MAR) for April revealed that the resident was administered the Atenolol on 4/7/25 at 9:00 PM even though the SBP was 100. A review of the February MAR revealed that the Atenolol was administered on 2/5/25 at 9:00 PM when the SBP was 107. A review of Resident #45's clinical record on 4/14/25 at 7:51 AM revealed that the resident was ordered to receive Humalog insulin 10 units, hold if blood sugar is…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to ensure that psychotropic medications were only used to treat a specific, diagnosed, and documented condition. This was found to be evident for 1 (Resident #44) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include: The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior (CMS, 2023). These drugs include, but are not limited to, drugs in the following categories: antipsychotic, anti-depressant, anti-anxiety, and hypnotic medications. These medications can have serious potential risks, including side effects, drug interactions, and the possibility of neuroleptic malignant syndrome (a rare but potentially life-threatening condition) or tardive dyskinesia (a movement disorder that can develop if you take an antipsychotic medication) therefore requiring careful…

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

Based on the review of administrative records and facility staff interviews, it was determined that the facility staff failed to demonstrate the presence of the required committee members for the Quality Assessment and Assurance committee (QAA), during the recertification/complaint survey. The findings include: On 4/16/25 at 8:13 AM, a review of the facility's QAA meeting required members' 12-month attendance revealed that QAA meetings had not occurred on a quarterly basis in the past 12 months, and the Nursing Home Administrator (NHA) provided 4 quarters of attendance: January, April, July, and November 2024. The October 2024 Quarterly required meeting did not occur, and minimum required members did not attend the quarterly required meetings in April 2024, July 2024, and October 2024. On 4/16/25 at 11:25, in an interview with the NHA, it was revealed that she/he has been working at the facility since September 2024, and she/he was in charge of QA meetings. Further review of QAA meeting attendance with NHA, she/he agreed with the findings.

Based on interview and record review it was determined the facility failed to maintain a preventative pest control program. This was evident during the facility's recertification survey and during the investigation of MD#00213104. The findings include: Review of MD#00213104 revealed a concern for the presence of mouse droppings and roaches within the facility. On 4/14/25 at 6:52AM the surveyor conducted an interview of the facility's Director of Maintenance #20 who reported that they held this position previously, 13 months prior to their most recent start date in January 2025. During the interview, Director of Maintenance #20 reported to the surveyor that when they previously held their position, pest control came to the facility for preventative visits on a bi-weekly basis, however, upon their return to their position as Director of Maintenance in January of 2025, they noticed they had not seen pest control visit the facility, and when they looked for a pest control log, they didn't see any. Director of Maintenance #20 reported observations of roaches at times in the past within…

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 employee files and interviews with facility staff, it was determined that the facility failed to provide evidence that all nursing staff had completed abuse training. This was evident for 1 (Geriatric Nursing Assistant #30) of 5 employee records reviewed during the facility's recertification/complaint survey. The findings include: HealthStream training is a web-based, self-paced software application of online learning and development resources designed for the healthcare industry. It helps healthcare organizations improve staff competency, enhance patient care, and ensure compliance with regulations and standards. HealthStream provides a variety of learning management systems, including e-learning courses, clinical development programs, and competency-based training. On 4/11/25 at 1:12 PM, the surveyor requested and was provided with Geriatric Nursing Assistant (GNA #30's) complete employee file which consisted of 3 manilla folders: an employee health folder, a training/education folder and the folder that held those 2 folders along with all other employee related…

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 a review of intake #MD00212446, observation, and staff interview it was determined that the facility staff failed to ensure residents are free of abuse. This was evident for 1(#70) out of 3 residents reviewed for abuse during the recertification/complaint survey. The findings include: A review of the facility investigation on 4/14/25 at 12:29 PM revealed that on Thursday [DATE], a state surveyor observed Staff #22 pointing at a resident who was in bed and calling the resident crazy. Staff #22 was observed to have repeated the sentence multiple times. According to the surveyor, Staff #22 told the resident that the resident was crazy, and the resident was the reason why she was behind in her work. The surveyor tried to intervene by asking the employee her name, but she refused to identify herself. Staff #22 was working at the nursing home that day but was an agency employee. Staff #22 was asked to leave the facility by the facility administrative staff. The incident was then reported to the state agency.…

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

Based on observation and interview it was determined the facility failed to ensure a thorough investigation of an allegation of abuse was performed. This was evident for one resident, (Resident#56) during the surveyor's investigation of MD#00213104 during the recertification/complaint survey. The findings include: On 4/8/25 at 1:07PM the surveyor conducted an interview of a family member of Resident #56 who reported to surveyors that they had found a red mark on Resident #56's forehead upon visiting the resident, and when they had brought this to the attention of facility staff, they were informed that it was not reportable. At this time, surveyors observed a photo dated March 2025 in which an elongated red mark appeared to be present on the resident's forehead. On 4/9/25 at 7:33AM the surveyor made a request to Regional Clinical Resource Nurse #5 for all facility reported incidents regarding Resident #56 to be provided to the surveyor. On 4/10/25 at 10:37AM the surveyor conducted an interview of Unit Manager #26 who confirmed the Director of Nursing and the Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, record review, observation, and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. This was evident on 3 of 4 nursing units observed. The findings include: On 12/3/24 at 11:30 AM a review of complaint MD00211814 alleged that there was black mold in the ceiling of resident rooms. On 12/3/24 at 11:45 AM an environmental tour was conducted, and the following observations were made: In room Dogwood Vent D2-B 3 Bed in the bathroom in the shower, there was water dripping through the ceiling light in the shower. There were towels on the floor. There was an out of order sign on the bathroom door. There was a musty odor in the bathroom. The wall behind both beds in the bedroom was spackled without paint. In the adjacent room, which was the Rehab gym, the ceiling in the bathroom was spackled approximately 3 ft. by 3 ft. The Director of Rehab was there and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a complaint survey the facility failed to ensure to treat each resident in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality for one resident (Resident #56) of three residents reviewed for resident rights. Specifically, Resident #56 was not able to wear their own clothing because the facility did not ensure their clothing was clean and available for them to wear. The findings include: Review of the policy and procedure titled, Resident Rights Under Federal Law, last revised 2/1/23, read in pertinent part that residents had the right to self-determination and the facility must promote and facilitate resident self-determination through support of resident choice. Resident #56 was admitted to the facility with diagnosis which included hemiplegia and hemiparesis affecting the right dominant side (paralysis impacting one side of the body) and heart disease.…

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 with facility staff, it was determined that the facility failed to ensure that physicians were notified when a resident had a significant medication error. This was evident for 1 (#3) of 42 residents reviewed for a complaint during a complaint survey. The findings include: On 12/12/24 at 9:50 AM, a review of complaint #MD0020957 was conducted. In the complaint, the complainant reported that from 11/19/23 to 11/23/24, Resident #3 was administered the wrong dose of Trileptal (Oxcarbazepine) (anti-seizure medication). Review of Resident #3's medical record revealed resident was initially admitted to the facility in mid-November 2023 following an acute hospitalization, with diagnosis which included cerebral palsy and seizures. Review of Resident #3's hospital discharge summary with a discharge date of 11/16/23 documented Resident #3 had a history of epilepsy (seizure disorder), that there was no recommendation at this time to escalate antiseizure medications, and to resume Oxcarbazepine 900 mg BID. Included in the discharge summary was a list of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse, neglect, and missappropriation of property. This was evident for 4 (#11, #35, #36, #37) of 23 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) On 12/3/24 at 10:16 AM a review of facility reported incident MD00207461 alleged that Resident #11 did not receive adequate care at the facility. The allegation was reported through the facility's compliance line. The facility became aware of the concern on 7/8/24. Review of the facility's investigation revealed 25 staff members were interviewed for care provided between 5/31/24 and 6/7/24. Review of the actual worked nursing schedule for that time period revealed out of the 25 staff members that were interviewed and answered the questions, only 3 took care of the resident during that time period of 8 days. The other staff members…

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, the facility failed to assist two Residents (R)9 and R58 who were dependent upon staff for assistance with activities of daily living (ADLs). Specifically, staff served R9 breakfast while the resident ' s brief was soiled with feces and waited several hours after breakfast to be assisted with toileting needs. The sample size was three. The census was 75. Findings include: Record review of the facility policy titled Activities of Daily Living last revised 5/1/2023 documented, based on comprehensive assessment of a resident and consistent with residents' needs and choices the facility, must provide the necessary care and services to ensure a Residents ADLs are maintained or improved and do not diminish unless circumstances of the Residents clinical condition demonstrate that a change was unavoidable. ADLs include Hygiene, Bathing, Dressing, Grooming, Toileting and Oral Care. A Resident who is unable to carry out ADLs will receive the necessary level of ADL assistance 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 medical record review and staff interview, it was determined that the facility failed to provide adequate supervision to prevent a vulnerable resident who was assessed, and care planned as an elopement risk, from leaving the facility unattended. This was evident for 1 (#36) of 3 residents reviewed for elopement. 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. Upon entry to the facility on [DATE] a list of facility reported incidents was provided to administration. At that time the request was for all investigations to be provided to the surveyors. 1) On 12/3/24, a review of facility reported incident, MD00182148 documented that Resident #36 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's Dementia with behavioral disturbance, that s/he was able to walk independently, and wore a wanderguard to alert…

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 that medication irregularities were identified during monthly drug regimen reviews. This was evident for 1 (#3) of 42 residents reviewed for a complaint. The findings include: On 12/12/24 at 9:50 AM, a review of complaint #MD0020957 alleged that Resident #3 was administered the wrong dose of Trileptal (oxcarbazepine) (anti-seizure medication) from 11/19/23 to 11/23/24. A review of Resident #3's medical record revealed resident was initially admitted to the facility in mid-November 2023 with diagnoses which included cerebral palsy and seizures. A hospital discharge summary with a discharge date of 11/16/23 documented Resident #3 had a history of epilepsy (seizure disorder) and there was no recommendation to escalate (increase) the resident's antiseizure medications at this time, and to resume oxcarbazepine 900 mg twice a day. The discharge summary listed the medications that Resident #3 was to continue to take in the facility that included an order for oxcarbazepine 900 MG…

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 failed to keep residents free from significant medication errors. This was evident for 1 (#3) of 42 residents reviewed for a complaint during the complaint survey The findings include: On 12/12/24 at 9:50 AM, a review of complaint #MD0020957 was conducted. In the complaint, the complainant reported that from 11/19/23 to 11/23/24, Resident #3 was administered the wrong dose of Trileptal (Oxcarbazepine) (anti-seizure medication). Review of Resident #3's medical record revealed resident was initially admitted to the facility in mid-November 2023 following an acute hospitalization, with diagnosis which included cerebral palsy and seizures. Review of Resident #3's hospital discharge summary with a discharge date of 11/16/23 documented Resident #3 had a history of epilepsy (seizure disorder), that there was no recommendation at this time to escalate antiseizure medications, and to resume Oxcarbazepine 900 mg BID. Included in the discharge summary was a list of the medications that Resident #3…

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

Based on observation and staff interview, it was determined the facility staff failed to ensure treatment carts were locked and secured when unattended. This was evident on 1 of 3 nursing hallways observed. The findings include: On 12/3/24 at 1:41 PM, during an observation of C wing, 2 medication carts were observed to be parked, side by side, on the left wall of the hallway. At that time, a nurse was observed in front of the 1st medication cart and appeared to be preparing medication for a resident. On 12/3/24 at 1:50 PM, during an observation of the C wing hallway, 2 medication carts were observed to be unlocked and unattended. The 2 medication carts were parked, side by side, on the left wall of the hallway, in an area where they could be accessed by residents and were not within direct observation of authorized staff. The surveyor stood near the medication carts for at 5 minutes, then at 1:55 PM, Staff Member #12, Licensed Practical Nurse (LPN), walked up to the medication carts and the nurse was made aware of the surveyor's observations. At that time, Staff #12 observed 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 staff interview and medical record review, it was determined that the facility failed to accurately document a Resident assessment on the MDS (Minimum Data Set) as evidenced by inaccurate coding for a Resident. This was found to be evident for 1 (Resident #1) out of 1 Resident reviewed for accuracy of MDS assessments. The findings include: The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each Resident's functional capabilities and helps nursing home staff identify health problems. On 5/9/24 at 11:00 am the surveyor conducted a review of Resident #1's medical record. The admission MDS dated [DATE] revealed that the Resident did not use a wander/elopement alarm as documented in section P - Alarms of the MDS assessment, but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and interviews it was determined that the facility failed to ensure accurate medical records in accordance with accepted professional standards of practice as evidenced by staff inaccurately documented a resident's wanderguard placement and functionality. This was found to be evident for 1 (resident #1) out 1 resident reviewed for elopement. The findings include: A Wanderguard is a bracelet that a resident wear that has a sensor. When the sensor comes in range of a door with a sensor, the sensor will trigger an audible alarm to alert the caregiver that a wanderer is in range of a door with a sensor. During a review of Resident #1's progress note conducted on 05/09/2024 at 11:32 AM, the surveyor read a note dated 04/11/2024 that stated Resident was seen and evaluated by medical director today and deemed competent to make own decisions. Wondergaurd [Wander Guard] order has been discontinued. A review of the physician orders conducted on 05/09/2024 at 11:35 AM did not reveal an order…

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 observations and interview with facility staff, it was determined that the facility failed to ensure that services provided by staff met professional standards of practice. This finding was evident in 4 of 28 residents selected for review (Residents #44, #61, #71, and #174). The findings include: This finding was identified during investigation of facility reported incident #MD00162308. 1. On 4-21-2021 a review of administrative records related to the facility's investigation of MD00162308 revealed, on 1-05-2021 during the 3:00 PM-11:00 PM shift, Licensed Practical Nurse (LPN) #1 provided Resident #174 with a cup of hot water at the resident ' s request. According to LPN #1's written statement, he had used the microwave for two (2) minutes to heat Resident #174's water. At approximately 8:00 PM the same evening, Resident #174 made LPN #1 aware that he/she had spilled the hot water on his/ her lap. LPN #1's statement indicated that his assessment of Resident #174's skin on 01-05-2021 did not reveal an injury. On 04-21-2021 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, clinical record review and interviews with the facility staff, it was determined that the facility staff failed to follow physician's orders to provide treatment and care. This was evident for 10 out of 28 residents selected for review (#3, #5, #6, #14, #22, #35, #57, #65, #224 and #225). The findings include: This finding was identified during the investigation of complaint MD00166310. 1. On 04-26-2021 a review of Resident #6's clinical record revealed a physician's order on 12-29-20 to cancel the current Baclofen order of 5 mg to be administered two times a day and to start Baclofen 5 mg to be administered three times a day. However, on 04-26-2021 a review of Resident#6's Medication Administration Records for December 2020, January 2021, February 2021, March 2021, and April 2021 that Baclofen 5 mg was administered two times a day instead of three times a day. On 04-26-2021 at 1:00 PM an interview with the Director of Nursing revealed no additional information. 2. On 04-22-2021 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 clinical records, surveyor observations, and interview with facility staff, it was determined that the facility failed to ensure behavior monitoring of residents' use of psychotropic medications. This finding was evident for 2 of 3 residents selected for the Behavioral/Emotional care area review (Residents #19 and #28). The findings include: 1. Surveyor observation on 04-19-2021 at 11:05 AM revealed Resident #19 in the designated smoking area talking to self and later making delusional references for facility staff to leave the sliding door open so the, Kids can also come in, the facility as he/she made motioning signals for the kids to enter. Further observation on 04-20-2021 at 12:46 PM revealed the resident self ambulating around the unit talking to self and when staff questioned the resident, the resident's responses were disorganized and inconsistent. On 04-21-2021 surveyor review of the clinical record revealed documentation by the attending nurse practitioner on 04-19-2021 that Resident #19 was prescribed multiple psychotropic medications for…

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

Based on surveyor record review and interviews with facility staff, it was determined that the facility failed to ensure staff could provide Cardiopulmonary Resuscitation (CPR) in accordance with physician's orders and the resident's wishes. This finding was evident for 1 of 4 residents selected for advanced directives review during the survey (Resident #53). The findings include: On 04-20-2021 a review of Resident #53's record revealed a physician order, dated 03-01-2021, for Do Not Resuscitate (DNR) - can intubate and have artificial ventilation. However, further review of Resident #53's record revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST), dated 04-07-2021, and the resident selected the option to perform cardiopulmonary resuscitation (CPR) if a cardiac and/or pulmonary arrest occurs, which was inconsistent with the 03-01-2021 physician's order. The Maryland MOLST form is a two-page portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based 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 surveyor review of the clinical record, surveyor observations and interview with facility staff, it was determined that the facility failed to ensure Resident #72 received proper foot care and treatment. This finding was evident for 1 of 5 residents selected for Activities of Daily Living review. The findings include: On 04-21-2021 at 6:02 PM surveyor observation during medication pass to Resident #72 revealed the resident's toe nails bilaterally were observed as long, thick and unkempt. Further observation revealed the resident was found to be bedbound with lower extremity contractures bilaterally. Subsequent observation on 04-26-2021 at 1:15 PM with the Arbor wing unit manager reveled Resident #72 was in bed with bilateral toe nails still observed as long in length and thick. No evidence of any nail/foot care provided. On 04-26-2021 at 1:30 PM interview with the Arbor wing unit manager reported being unaware of the time frame for when Resident #72 had last received care by the facility's consulting podiatrist and stated that the surveyor would need to follow up with the…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure accurate documentation in the clinical record for residents. This was evident for 3 out of 28 residents selected for review during the survey (Residents #6, #16, and #67). This finding was identified during the investigation of complaint MD00166310. The finding includes: 1. On 04-23-2021 a review of Resident #6's clinical record revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST), dated 12-10-2020, with the medical provider Staff #8 selecting the patient's guardian of the person as per the authority granted by a court order instead of selecting the patient's surrogate as per the authority granted by the Health Care Decisions Act. On 04-26-2021 at 4:00 PM interview with medical provider Staff #8 stated there was no court order and that she selected the wrong option. The Maryland MOLST form is a two-page portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other…

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 interviews with facility staff, it was determined that the facility staff failed to ensure that interdisciplinary care plan conferences were conducted timely after each MDS assessment for residents, failed to review and revise a resident's plan of care and failed to offer a resident's representative the opportunity to participate in the resident's care plan meeting. This finding was evident for 9 of 30 residents selected for review during the survey (#2, #4, #36, #64, #62, #42, #69, #3 and #22 ). 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. The ARD is the specific end point of look-back periods in…

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

Based on surveyor observations and interview with facility staff, it was determined that the facility failed to use the appropriate cleaning agent for the use of glucometers. This finding was evident for 4 of 5 medication carts observed during the survey. The findings include: The glucometer is blood glucose monitoring system used to test and obtain blood glucose readings for residents. Its use is to determine the approximate concentration of glucose in the blood CDC (Centers for Disease Control and Prevention) recommends for infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens: that if a glucometer is used for one resident and must be reused for another resident, the device must be cleaned and disinfected. This requires after each resident use, that a disinfect cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim must be used. Alcohol should never be used since it is not an EPA-registered detergent/disinfectant. a. On 08-14-19 at 5:30PM, surveyor observation 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 surveyor review of the clinical record, surveyor observations and interviews with facility staff, it was determined that the facility failed to ensure that resident #4 was treated with dignity and provided care in a manner and in an environment that promoted maintenance of his/her quality of life. This finding was evident for 1 (#4) of 6 residents selected for the Dignity review. The findings include: 1. On 08-13-19, surveyor review of the clinical record for resident #4 revealed that the resident responded with eye contact and minimal verbal responses. Further review revealed he/she was dependent on facility staff for all activities of activities of daily living (ADLs). Review of the August 2019 ADL Record revealed documentation by the assigned GNA (Geriatric Nursing Assistant) staff that resident #4 was dependent for care in bed baths, personal hygiene care, bowel and bladder incontinence care, and dressing; this care was provided to resident #4 daily. In addition, staff turned and positioned the resident daily while in bed . Further review of the August 2019 ADL Record,…

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 facility staff and family interviews, it was determined that the facility failed to promptly notify a resident's representative when a pressure ulcer wound was identified. This finding was evident in 1 of 8 residents reviewed for pressure ulcers during the survey. (#61) The findings include: On 08-15-18 at 11:10 AM surveyor review of resident #61's clinical records, revealed facility staff documentation on 07-30-19 that indicated a newly identified pressure ulcer was located on the resident's sacrum. Further record review revealed a skin evaluation sheet that indicated that resident #61 had no skin issues and that the resident's skin was intact prior to the finding. Additional clinical record review revealed wound consultant documentation of a 2 x 2 x 1cm pressure wound (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) located on resident's sacrum. On 08-15-19 at 11:25 AM surveyor interview with the Assistant Director of Nursing (ADON) revealed that resident #61 developed a stage 2 (When the…

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

Based on surveyor review of the clinical record, surveyor observations and interview with facility staff, it was determined that the facility staff failed to ensure standards of nursing practice for residents. This finding was evident for 2 of 30 residents selected for review during the survey. (#4, #36) The findings include: 1. On 08-13-19 at 11:53AM, and 08-16-19 at 9:11AM, surveyor observation revealed resident #4 w in bed with a large amount of white, thick secretions emanating from the mouth. The resident was dependent for all activities of daily living, including personal care needs. Interview on 08-13-19 at 2:30PM with respiratory therapist # 5 revealed that resident #4 has had periods of excessive secretions from the mouth even prior to the discontinuation of the resident's tracheal tube. (Tracheal tube is a tube inserted that allows a person to breathe without the use of the nose or mouth). The tracheal tube was discontinued in June 2019 with the resident able to breath on their own. Further record review revealed that, in September 2018, the attending physician ordered the…

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

Based on surveyor review of the clinical record, surveyor observations and interviews with facility staff, it was determined that the facility failed to ensure an ongoing activity program to support residents' physical, mental and psychosocial well-being. This finding was evident for 2 of 4 residents selected for the Activities review. (#4, #5) The findings include: 1. On 08-13-19, surveyor review of the clinical record for resident #4 revealed documentation by the Director of Activity, on the 07-30-19 Recreation Quarterly Progress Note and Care Plan Evaluation, that the resident does not participate in group engagement, but participates in individual engagement once to 3 times a week. Interventions for activities included football or sports reading materials, keep up with news by discussions with another person, group discussions, and listening to the radio. The goal summary identified for the resident included that the resident enjoyed to hear about the local football team, watch TV with his/her roommate, and room visits by facility activity staff/volunteers 2-3 times a week.…

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 interviews with resident #32 and facility staff, it was determined that the facility failed to follow physician orders for medication administration of the residents. This finding was evident for 2 of 30 residents selected for review during the survey. (#32 and #72) The findings include: 1. On 08-12-19 at 3 PM, surveyor interview with resident #32 revealed that the resident had not received a scheduled 6 AM dose of Hydralazine medication for his/her blood pressure the other morning. The resident was unable to recall the name of the assigned nurse, but stated it was the 11PM -7AM nurse that was supposed to administer the 6 AM medication. Surveyor review of the clinical record for resident #32 revealed that, in February 2019, the attending physician ordered the blood pressure medication, Hydralazine, three times a day. Further review revealed that the Hydralazine medication was scheduled for administration at 6 AM, 2 PM and 10 PM. Review of the August 2019 MAR (Medication Administration Record) revealed no evidence that the 2 PM dose…

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 and staff interviews, it was determined that the facility staff failed to store, prepare and serve food under sanitary conditions. This finding was evident in the facility's kitchen during the surveyor's initial tour and later during the dining observation of the passing of trays during lunch. The findings include: On 08-12-19 at 08:20 AM, surveyor tour of the kitchen revealed the following: A. Interior of ice maker observed soiled with a black substance around splash guard. B. Back of cooking stove noted with various food debris and trash. C. Can opener blade noted with black sticky substance and dried up substance that resembled tomato sauce. D. Pool of standing water underneath dish washing sink. E. Kitchen tiles that looked dirty and were sticky when walking on them. On 08-12-19 at 8:30 AM, surveyor interview with the Dietary Manager revealed no further information. 2. On 08-12-19 at 12:59 PM, surveyor observed facility staff GNA #9 passing lunch trays on the A-wing. Surveyor observed staff #9 delivered trays to rooms 5,7, 8 and 9. 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.