Fox Chase Healthcare

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure medications were properly stored and labeled. This was evident for 2 of 2 medication carts observed for medication storage. The findings include: During an observation of the Potomac Hall medication cart on 3/04/25 at 11:39 AM with Licensed Practical Nurse (LPN) #5 it was revealed to contain expired medications. The following medications were found: Oxycodone 5 mg Tablets had expired on 12/05/24 for Resident #25. Two boxes of Albuterol Sulfate Inhalation Solution vials 0.083% 2.5mg/3mL had expired February 2025 for Resident #36. During an observation of the Chesapeake Hall medication cart on 03/04/25 at 1:59 PM with LPN #1 it was revealed to contain expired, unrefrigerated, and undated open medications. The following medications were found: An Insulin Lispro Injection 100 unit/mL vial is unopened, not dated, or refrigerated for Resident #11. A Lantus Solostar 100 unit/mL pen is opened with no opening date for Resident #11. A Basaglar Injection 100 unit pen is unopened, 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 observation, interview, and record review it was determined the facility failed to use appropriate infection control practices for 1) conducting ongoing surveillance for infections and 2) urinary catheter maintenance and ensuring that staff observed appropriate practices for enhanced barrier precautions during a high contact care for residents with indwelling urinary catheters and with pressure ulcer. This was found to be evident on the tour of the laundry department, during a record surveillance for infections and for 3 (Resident #48, #58 and #272) of 44 residents reviewed for infection control during the recertification survey The findings include: 1) On 03/05/25 at 06:56 AM the surveyor toured the laundry department in the basement of the facility with the Environmental Services Director (EVSD) #16 and the Laundry Aide #17. During this tour of the laundry department with EVSD #16 and Laundry Aide #17 the surveyor observed the following: staff personal items in clean laundry area (coat on chair, water bottle, bottle of tea and coffee cup on folding table), cardboard box…

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 failed provide a family meeting to discuss grievances regarding the care of a resident. This was evident for1 (Resident #336) of 44 residents reviewed during the recertification survey. The findings include: On 03/3/25 at 9:56AM, the surveyor reviewed a complaint (MD#00201345) from Resident #336's family stating that they requested a family meeting with the facility's social service department regarding grievances regarding inadequate care of Resident #336. The review of the resident's medical record on 03/3/25 at 10:00AM revealed no evidence that the facility social services department provided the resident's family with a family meeting. During a interview with the Director of Nursing (DON) on 03/6/23 at 7:58AM, the DON reviewed Resident #336's medical record and confirmed that the resident's family did not receive the requested meeting.

Based on medical record review and interview, the facility staff failed to thoroughly investigate a facility reported incident of resident-to-resident abuse. This was evident for 1 (Resident #330) of 44 residents reviewed during survey. The findings include: Review of Residents #330 and Resident #333's facility reported incident (MD 00181638) on 03/6/25 at 10:05AM revealed the Resident #330 alleged that Resident #333 touched his/her private area. Review of the facility investigation documents on 03/6/25 at 10:10AM revealed that the facility was unable to substantiate abuse. Further review of the facility investigation documents revealed that the facility failed to interview other residents and staff members regarding abuse before concluding that the alleged resident-to-resident abuse was unsubstantiated. During an interview with the Director of Nursing on 03/6/25 at 11:00AM, the DON confirmed that the facility failed to thoroughly investigation Resident #330's allegation of abuse

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide written notification of the Resident's transfer or discharge to the Resident or Resident Representative and the facility Ombudsman. This finding was found to be evident for 3 (Resident #2, #27 and #54) of 3 residents reviewed for notice requirements before transfer or discharge to the hospital. The findings include: On 03/06/25 at 07:30 AM the surveyor conducted a record review of a closed medical record for Resident #2. The review of the medical record revealed that Resident #2 was transferred to the hospital 02/23/25, 02/25/25 and 02/27/25. Further review of the medical record on 03/06/25 revealed that the INTERACT Transfer assessment form was completed by nursing and that the responsible party was notified of Resident #2's transfers to the hospital, but there was no evidence that written notification of transfers was provided to the Resident or the Responsible Party and the facility Ombudsman. On 03/3/25 at 10:05 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide written notification of the bed hold policy for Residents that were transferred to the hospital. This finding was found to be evident for 3 (Resident #2, #27 and #54) of 3 residents reviewed for notice requirements of bed hold policy before or upon transfer to the hospital. The findings include: A Bed Hold is the act of holding or reserving a Resident's bed while the Resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility Residents regardless of payment source. The Bed Hold policy should be disclosed in the admission packet during an initial admission to the facility and it should be disclosed to Resident/Resident Representative at the time of transfer. On 03/06/25 at 07:30 AM the surveyor conducted a review of the closed medical record for Resident #2. Review of the record revealed that Resident #2 was transferred to the hospital on [DATE], 02/25/25 and 02/27/25…

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, surveyor record review and facility staff interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS) assessment for residents, 1) with oxygen usage and 2) with discharge status. This was found to be evident for 2 (Resident #28 and #71) of 2 resident reviewed for accuracy of MDS assessments. The findings include: The MDS (Minimum Data Set) assessment is a standardized tool used to evaluate the health and functional status of Residents in skilled nursing homes (SNFs) in the United States. The purpose is to provide a comprehensive picture of the Resident's physical, cognitive, social and emotional needs; to guide care planning and ensure that Residents receive appropriate services; and to collect data for quality improvement, research and policymaking. 1) On the initial tour of the nursing unit on 03/03/25 at 09:50 AM the surveyor observed Resident #28 with oxygen in use. The surveyor conducted a record review of Resident #28's medical record 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 interview, it was determined that the facility failed to ensure that a resident was provided with summaries of the baseline care plan. This was evident for 2 (Resident #48 and #8) of 44 residents reviewed for baseline care plan during the recertification survey. The findings include: A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 03/03/25 at 8:52 AM, Resident #48 stated that he/she has not been involved in any care plan meetings. On 03/06/25 at 8:21 AM, a review of Resident #48's medical record revealed that he/she 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 record review and interview, it was determined that the facility failed to develop, implement and update a comprehensive care plan to include 1) smoking, 2) the residents' functional abilities and 3) the residents' use of anti-psychotic medications. This was evident for 2 (Resident #58 and #57) of 44 residents reviewed for care planning during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 03/04/25 at 10:52 AM, a review of the smoking policy dated 10/30/22 and reviewed on 10/27/23 indicated the following: Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated areas, at designated times, and in accordance with his/her care plan. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors and volunteers who will be responsible 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 interviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) were 1) provided with showers and 2) properly groomed. This was evident for 3 (Resident #335, #12 and #53) of 44 residents reviewed during the recertification survey. The findings include: Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The Minimum Data Set (MDS) is a federally mandated assessment tool used to evaluate the health status of residents in nursing homes. The information collected helps nursing home staff identify health problems and develop individual care plans for residents. 1) A review of MD00210657 from October 2024 revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, and interviews, it was determined the facility failed to 1) document the delivery of daily wound care to a resident with a pressure ulcer and 2) implement recommendations made by the wound care team to treat pressure ulcers. This was evident for 2 (Resident #28 and #23) of 2 residents evaluated for pressure ulcer care. The findings include: A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). 1) During the initial tour 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.

Based on observation, record review and interview, it was determined that the facility failed to provide the prescribed treatment for limited mobility. This was evident for 1 (Resident #53) of 1 resident reviewed for positioning and mobility during the recertification survey. The findings include: A splint is a medical device that stabilizes part of the body and holds it in place. Healthcare providers use them to protect and support the body after an injury or to treat certain health conditions On 03/03/25 at 11:07 AM the surveyor observed Resident # 53 sitting in a wheelchair in the dining room. The resident's fingers were contracted on both hands and bent towards his/her palms. Resident #53's fingernails were approximately 1/2 inch long and visibly dirty with brown substance under the fingernails. The resident was not wearing a splint on either hand. The resident stated that his/her contractures were caused by arthritis of the hands. On 03/05/25 at 10:14 AM a review of Resident #53's clinical record revealed an active physician's order dated 01/12/24 which stated R hand splint -…

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

Based on medical record review and staff interview, it was determined that the facility failed to provide adequate management of a resident's Intravenous antibiotic schedule. This was evident for 1 (Resident #324) of 44 resident reviewed during the recertification survey. The findings include: A review of Resident #324's medical records on 03/04/25 at 12:26PM revealed that the resident was ordered Intravenous (IV) antibiotics once a day for 6 weeks from 1/19/23 to 03/18/23 to prevent infection. Further review of resident 324's medical record on 03/04/25 at 12:40PM revealed that the resident was seen by Maximed Associates Inc on 02/01/23 to ensure that the IV antibiotics were affective at preventing infection. Maximed Associates recommended that the resident be given an MRI (a type of diagnostic test that creates detailed images of structures and organs in the body) one week prior to completing the IV antibiotics to determine if the resident needed to prolong IV antibiotics administration. Continued review of Resident #334's medical record on 03/04/25 at 1:00PM revealed that 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.

Based on observation, record review and interview, it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 1 (Resident #28) of 1 resident reviewed for respiratory care and services during the recertification survey. The findings include: On tour of the Nursing Unit on 03/03/25 at 09:50 AM the surveyor observed Resident #28 with oxygen in use. Further observation revealed an oxygen cannula in the Resident's nostrils and an oxygen humidifier bottle and oxygen tubing attached to the oxygen concentrator without a date on the tubing and without a date on the humidifier bottle. The surveyor interviewed Resident #28's Nurse #5 on 03/04/25 at 12:42 PM. The surveyor asked Nurse #5 what the expectation was for dating and labeling oxygen tubing and oxygen humidifier bottles. Nurse #5 stated that the oxygen tubing and the humidifier bottle were to be labeled and dated by the night shift. Nurse #5 observed the oxygen tubing, and the oxygen humidifier bottle not dated for Resident #28, and Nurse #5 stated that she would take…

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

Based on record review and interview, it was determined that the facility failed to ensure annual performance evaluations and skill assessments were completed. This was found to be evident for 2 (#3 and #6) of 5 Geriatric Nurse Assistants (GNAs) reviewed for Sufficient and Competent Nurse Staffing. The findings include: On 03/07/25 at 11:54 AM, a record review of employee files showed that GNA #3 did not have an annual performance evaluation in her chart. It was also found that there was not a skills competency assessment completed for GNA #6. During an interview on 03/10/25 at 8:41 AM conducted with the Administrator, she confirmed that based on GNA #3 ' s hire date, she should have an annual performance completed in her file. It was also confirmed by the Administrator that GNA #6 should have a record of a skills competency assessment completed. The Administrator explained that she would check with the Director of Nursing (DON) to locate these records, and report back if anything was found. On 03/10/25 at 10:00 AM, this surveyor received written confirmation from the Administrator…

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

Based on record review and interview, it was determined that the facility failed to monitor the behaviors of residents receiving anti-psychotropic medications. This was evident for 1 (Resident #57) of 1 resident reviewed for Dementia care. The findings include: Psychotropic medications are drugs that affect the brain and central nervous system, altering mood, thoughts, perceptions, and behaviors. They are primarily used to treat mental health conditions, such as anxiety, depression, schizophrenia, and bipolar disorder. Resident # 57 was admitted to the facility with diagnoses including Vascular Dementia, Mild, with Agitation and Cognitive Communication Deficit On 03/04/25 at 6:18PM a review of Resident #57's active medication orders revealed that the resident was placed on anti-psychotic medication Quetiapine (Seroquel) for anxiety on 09/11/24 and for agitation at bedtime from 09/27/24. Further review of Resident#57's clinical record revealed no evidence that the resident's behaviors were monitored, neither was there a physician order or a care plan to address the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide adequate behavior monitoring for resident on psychotropic medications. This was evident for 1 (Resident #58) of 4 residents reviewed for unnecessary medications during the recertification survey. The findings include: Psychotropic medications are drugs that affect the brain and central nervous system, altering mood, thoughts, perceptions, and behaviors. They are primarily used to treat mental health conditions, such as anxiety, depression, schizophrenia, and bipolar disorder. On 03/04/25 at 3:05 PM, a review of Resident #58's medical record revealed that he/she was readmitted on [DATE]. His/her BIMS (Brief Interview for Mental Status) was completed on 02/17/25 with a score of 15/15 which indicated that he/she was cognitively intact. A review of Resident #58's active physician orders revealed that he/she was on the following psychotropic medications: 1. Aripiprazole Oral Tablet 2 MG (Aripiprazole) Give 2 mg by mouth one…

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

Based on interview and record review, it was determined that the facility failed to ensure that residents who require dental services on a routine basis receive the recommended dental service in a timely manner. This was evident in 2 (Resident #9 and #12) of 2 residents reviewed for Dental services. The findings include: 1) On 03/03/25 at 04:50 PM during an interview with Resident #9 ' s family member, he/she reported that during the most recent care plan meeting it was discussed that Resident #8 had not seen a dentist in about a year ago. The family member reported that he/she recalled the social worker reported to him/her that an appointment had been made for the dentist to visit Resident #9. However, he/she still did not know when that appointment would be. According to the Centers for Medicare and Medicaid Services, the definition of care planning is Establishing a course of action with input from the resident (resident ' s family and/or guardian or other legally authorized representative), resident ' s physician and interdisciplinary team that moves a resident toward…

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 Administration documents and interviews it was determined that the facility failed to obtain a Transfer agreement to the local hospitals. This was found to be evident for 1 out of 1 Dialysis Agreement document reviewed during the Extended Survey. The findings include: A written agreement outlines the arrangements between an End Stage Renal Dialysis (ESRD) facility and a nursing home. The agreement establishes a connection between both entities and fosters accountability that is vital to patient health and the success of the care plan. The ESRD facility should collaborate with the nursing home to develop and implement protocols for the delivery of dialysis services, and to the extent possible, ensure that nursing home dialysis patients are provided with the same standard of care as dialysis patients receiving treatments in a dialysis facility. During a review of the Administration documents conducted on 03/06/25 at 11:09 AM, it was determined that there was not a Dialysis Agreement within the documents provided. During an interview conducted on 03/06/25 at 12:05…

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 Administration documents and interviews it was determined that the facility failed to obtain a Transfer agreement to the local hospitals. This was found to be evident for 1 out of 1 Transfer Agreement document reviewed during the Extended Survey. The findings include: A nursing home transfer agreement with a local hospital ensures smooth and timely transfers for residents needing hospital care, including medical information exchange and a plan for emergency situations. During a review of the Administration documents conducted on 03/06/25 at 11:09 AM, it was determined that there was not a Transfer Agreement with the local hospitals within the documents provided. During an interview conducted on 03/06/25 at 12:05 PM, the Administrator stated that she was unable to locate the Transfer Agreement but was actively searching and would let me know if she was able to locate it. During a phone interview conducted on 03/12/25 at 1:04 PM, the Administrator advised she had reached out to the local hospitals to obtain a Transfer Agreement however she had not received 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 record reviews and interviews, the facility failed to maintain an effective QAPI program that addresses the deficient practices in the facility. This was evident during the revisit recertification survey. The findings include: On 5/29/2025 at 12:00 PM, a review of the facility ' s Plan of Correction and credible evidence for the deficiencies found during the annual recertification survey was reviewed. In the plan of correction and credible evidence for multiple citations, there was missing evidence to support the compliance of multiple deficiencies including F578, F623, F695, F699, F711, F744, F812, F842, F880, and F883. On 5/29/25 at 12:15 PM, After review of the 34 cited Federal regulations and 2 cited State regulations from the annual recertification survey ending on 3/10/2025, 10 Federal regulations (F578, F623, F695, F699, F711, F744, F812, F842, F880, and F883) were recited as noncompliant. On 5/29/2025 at 12:38 PM, an interview was conducted with the facility ' s Director of Nursing (DON) and Nursing Home Administrator (NHA). When asked who was in charge 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.

Based on record review and interview, it was determined that the facility failed to have an Infection Preventionist (IP) participate in the facility's Quality Assessment and Assurance (QAA) committee meetings. This was evident in 9 of the 11 months of attendance records reviewed for the Quality Assurance Improvement Program. The findings include: The Quality Assessment and Assurance (QAA) committee is responsible for identifying and addressing quality deficiencies, developing and implementing corrective actions, and monitoring the effectiveness of those actions to ensure quality care and quality of life for residents. On 03/07/25 at 10:41AM a review of the monthly QAA sign-in sheets from January 2024 through September 2024 failed to reveal that an IP participated in the facility's QAA meetings. The dates of the meetings were 1/23/24, 02/20/24, 03/19/24, 04/23/24, 05/28/24, 06/25/24, 07/23/24,08/20/24, and 09/24/24. On 03/08/25 at 1:06PM in an interview, the findings were brought to the Administrator's attention. The Administrator reviewed the sign-in sheets and stated that she…

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 facility staff interviews, it was determined that the facility failed to provide documentation that Residents were offered the pneumococcal vaccine. This was found to be evident in 3 (Resident #27, 54 and 56) of 5 Residents reviewed for pneumococcal immunization. The findings include: The surveyor conducted record reviews of Resident #27, 54 and 56's medical records on 03/05/25 at 08:50 AM. Reviews of the medical records revealed that Residents #27, 54 and 56 lacked up to date documentation of the pneumococcal immunization. The MDS (Minimum Data Set) assessment is a standardized tool used to evaluate the health and functional status of Residents in skilled nursing homes (SNFs) in the United States. The purpose is to provide a comprehensive picture of the Resident's physical, cognitive, social and emotional needs; to guide care planning and ensure that Residents receive appropriate services; and to collect data for quality improvement, research and policymaking. Further review of the medical records on 3/6/25 at 9:10 AM of Resident #27, 54 and 56 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined that the facility failed to provide 1) a safe, clean, comfortable, homelike environment and 2) an environment that included comfortable temperature levels. This finding was found to be evident on a tour of the laundry department, 3 (Rooms #25, #26 and #28) of 8 resident rooms observed for safe, clean, comfortable, homelike environment and 2 of 15 complaints reviewed during the recertification survey. The findings include: 1) On 03/03/25 at 08:15 AM the surveyor observed Residents' rooms with items in disrepair on the initial tour of the nursing unit: the dresser was cracked with chipped wood and a wooden mouse trap with a metal spring was behind the door on the floor in room [ROOM NUMBER]; the door frame and door cracked in room [ROOM NUMBER]; bathroom sink faucet loose, water basin on bathroom floor, doors marred, dressers marred with chipped wood and black writing on one of the dresser tops in room [ROOM NUMBER]. The Director of Nursing (DON) 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 interview and record review, it was determined that the facility failed to provide transportation services for residents' appointments. This was found to be evident for 1 (Resident #8) of 1 resident reviewed for transportation services during the recertification survey. The findings include: During an interview on [DATE] at 10:18 AM, the surveyor discussed concerns with Resident #8 about his/her wound care. The Resident reported that family members had to call 911 twice to transport him/her from the facility to the hospital for wound treatment. On [DATE] at 09:35 AM, a record review of the wound assessment note from [DATE] showed that there was a wound acquired on [DATE]. On [DATE] at 09:55 AM, a record review of progress notes showed a note from [DATE] stated Appointment(s) for infectious disease and GI [gastrointestinal] scheduled at GWMFA [The [NAME] University Medical Faculty Associates]. Transportation issues due to no DCMA [District of Columbia Medicaid] coverage - expired [DATE]. Spoke with (BOM)…

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 a complaint, record review and interview, it was determined that the facility failed to document the incidents of falls, implement and update the interventions to prevent falls for a resident who was identified as a fall risk. This was evident for 1 (Resident #58) of 2 residents reviewed for accidents during the recertification survey. The findings include: On 03/05/25 at 7:35 PM, a review of a complaint MD00213458 dated 01/13/2025 revealed that per the complainant, Resident #58 had a fall incident, and the resident was left on the floor for long periods of time. . A review of the electronic medical record revealed that Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that he/she was cognitively intact. On 03/06/25 at 5:56 PM, a review of Resident #58's care plan that was initiated on 11/20/2024 and revised on 02/6/2025 revealed the following: The resident was at risk for falls r/t paraplegia and limited physical mobility. The following interventions were as follows: o Anticipate and meet needs Date Initiated: 11/20/2024…

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 interviews, it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma, received the appropriate trauma informed care. This was evident for 1 (Resident #328) of 4 residents reviewed for trauma informed care during the recertification survey. The findings include: On 03/03/25 at 12:00PM, a review of complaint MD00193440 and a facility reported incident MD00193348 revealed that Resident #328 alleged that a unidentified male touched the resident inappropriately. A medical record review for Resident #328 on 03/04/25 at 9:30 AM revealed the resident was admitted to the facility on [DATE]. Further review revealed no evidence that a trauma informed assessment or care plan had been completed to ensure the resident received trauma informed care. On 03/05/25 at 10:00AM, an interview of the Director of Nursing (DON) regarding the trauma informed care policy. The DON confirmed resident trauma informed assessments should be done…

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 the Nurse Practitioner's (NP#21) admission history and physical progress note included new order for Resident #329 under the plan of care that was not written as orders. This was evident for 1 (Resident #329) of 44 residents reviewed during a recertification survey. The findings include: On 03/04/25 at 11:00 AM, a review of Resident #329's medical record revealed the Resident was admitted to the facility on [DATE] and was discharged to an acute care facility on 07/05/24. Further review of Resident's medical record revealed the NP#21 admission progress note on 06/28/24, with the following plan: Continue all medications as prescribed. Attach live vest and monitor q shift. Neurology consults as needed. PT/OT- evaluation and treatment as required. Pain evaluation as required and Cardiology consult. A review of Resident #329's orders did not include the following, attach live vest and monitor q shift, Neurology consult as needed, Pain evaluation 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.

Based on medical record review, observation and interview, it was determined that the facility failed to accurately 1) record a medication administration in a resident's medical record, 2) document the route of a medication administered to a resident and 3) maintain complete records in accordance with accepted professional standards. This was evident for 3 (Resident #328, #56 and #326) of 44 residents reviewed during an facility's annual survey. The findings include: 1) Review of resident #328's medical records on 03/03/25 at 9:56AM revealed the resident was ordered to receive injectable insulin at bedtime for control of Diabetes. Review of the resident's medication administration record on 3/3/25 at 10:30AM revealed that the facility failed to record the insulin administration on 1/30/22. During an interview with the Director of Nursing (DON) on 03/3/25 at 10:30AM, the DON confirmed that the facility nursing staff failed to document the insulin administration for Resident #328 on 1/30/22. 2) Tube feeding, also known as enteral nutrition, is a medical procedure where a tube 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, review of the facility investigation, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, 2) immediately initiate an investigation into the allegation of resident abuse, and 3) report an allegation of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 1 (Resident #5) of 5 residents reviewed during a complaint survey. The findings include: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of complaint MD00196939 on 09/18/23 revealed an allegation a resident was allegedly abused by another facility resident on 09/12/23. In an interview with the facility administrator and the director of nurses (DON) on 09/18/23 at 1:52 PM, 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 administrative documents and interviews with facility staff, it was determined that the facility failed to complete an annual performance review of nurse aides and provide in-service education based on the outcomes of the reviews. This finding was evident for 3 of 3 Geriatric Nursing Assistants (GNAs) selected for review of in-service education during the survey (GNAs #2, #3, and #4). The findings include: 1. On 01-17-2020 at 10:00 AM surveyor requested GNA #2's annual performance review and in-service education record from the facility administrator. On 01-17-2020 at 2:00 PM interview with the Administrator and Regional Clinical Consultant revealed the facility was unable to show any annual performance reviews or in-service education for GNA #2. 2. On 01-17-2020 at 10:00 AM surveyor requested GNA #3's annual performance review and in-service education record from the facility administrator. On 01-17-2020 at 2:00 PM interview with the administrator and regional clinical consultant revealed the facility was unable to show any annual performance reviews or…

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 with facility staff and residents and review of administrative documents, it was determined that the facility administration failed to use its resources effectively and efficiently to provide activities of daily living to residents, to maintain sufficient nurse staffing and to follow their self-identified staffing patterns as per the facility assessment. This finding was evident for 2 of 2 nursing units reviewed for the survey. The findings include: Interviews with staff and residents and review of four clinical records of dependent residents requiring staff assistance with activities of daily living (ADL) revealed that the Geriatric Nursing Assistants (GNAs) did not provide shower assistance required by the Plan of Care for four (4) of the seven (7) residents reviewed. a. On 01-15-2020 at 11:45 AM, surveyor observed resident #1 sitting in the activity room and dressed. When asked whether they had been given a shower today, Wednesday, the resident responded No by shaking the head. 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 review of administrative records and interviews with facility staff, it was determined that the facility failed to review and follow their facility assessment. This finding was evident for 1 of 1 facility assessment reviewed during the survey. The findings include: On 01-17-2020, surveyor review of the facility assessment tool section 3.2, staffing plan, revealed the facility identified that the ratio of Geriatric Nursing Assistants (GNAs) to patients for the 7:00 AM to 3:00 PM shift should be 1:10, the ratio of GNAs to patients for the 3:00 PM to 11:00 PM shift should be 1:13, and the ratio of GNAs to patients for the 11:00 PM to 7:00 AM shift should be 1:20. Surveyor review of nursing assignments revealed the following: on 11-13-2019 during the 11:00 PM to 7:00 AM shift, there were zero (0) GNAs and two licensed nurses for 51 residents with a GNA to patient ratio of 0 to 51 residents. On 12-31-2019 during the 11:00 PM to 7:00 AM shift, there were zero (0) GNAs and two licensed nurses for 51 residents with a GNA to patient ratio of 0 to 51 residents. On 01-14-20 during the…

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

Based on interview with facility staff, it was determined that the facility failed to identify quality deficiencies and develop and implement appropriate plans of action. This finding was evident for 1 of 1 quality assurance improvement programs presented by the facility administrator. The findings include: On 01-17-2020 at 2:41 PM, surveyor interview with the administrator revealed the facility's Quality Assurance Performance Improvement (QAPI) committee met on 09-30-2019, 10-29-2019, 11-12-2019, and 12-17-2019. The administrator presented that the emergency preparedness plan was discussed in QAPI committee, which was signed by the interdisciplinary team. There was no evidence that other facility's employees were trained regarding the emergency preparedness plan. When asked if the QAPI committee identified and developed plans of action for other quality deficiencies, the administrator was unable to answer. When asked if the QAPI committee identified and discussed the insufficient staffing on the 11:00 PM to 7:00 AM shift on 11-13-2019 and 12-31-2019, the administrator was unable to…

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

Based on surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to have an adequate system to monitor antibiotic usage and to review the antibiotic stewardship annually. This finding was identified during review of the antibiotic stewardship program and was evident facility wide. The findings include: On 01-17-2020 surveyor review of the last Infection Prevention and Control Committee Policy was dated July 2016. On 01-17-2020 at 2:15 PM surveyor interview of Staff #16 responsible for the Infection Control Program revealed that the facility did not have an antibiotic stewardship program running, there was no protocol to address the treatment of infections and to ensure that residents who require antibiotics were prescribed the appropriate antibiotics, there were no tracking measures of outcomes surveillance related to use of antibiotics, and there was no annual review of the antibiotic stewardship.

Based on observations, review of clinical records, and interviews with residents and facility staff, it was determined that the facility failed staff failed to provide the necessary services to residents that require assistance or total care to complete activities of daily living. This finding was evident for 4 of 7 residents selected for the activities of daily living (ADL) review (Residents #1, #10, #30, and #48). Activities of daily living are routine activities people do every day. The six basic ADLs include eating, bathing (which includes showering), getting dressed, toileting, transferring, and incontinence care. The Minimum Data Set (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. The findings include: 1. On 01-14-2020 at 9:40 AM, an interview with Resident #10 revealed the resident is scheduled to get showers on Wednesday and Saturday…

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 review, and interviews with residents and facility staff, it was determined that the facility failed to provide treatment according to physicians' orders. This finding was evident for 3 of 16 residents selected for review during the survey (Resident #29, #33, and #48). The findings include: 1. On 01-14-2020 surveyor review of Resident #48's clinical record revealed a physician's order was written on 01-07-2020 for nectar thickened fluids. On 01-14-2020 at 08:15 AM surveyor observation with the Director of Nursing revealed a pitcher of water that was not thickened at Resident #48's bedside. On 01-14-2020 at 12:45 PM interview with the facility's speech therapist revealed she completed a swallowing evaluation on Resident #48 on 01-07-2020 and recommended the resident only consume nectar thickened liquids due to the resident being at risk for aspiration (which can result in the resident chocking). On 01-15-2020 at 2:00 PM interview with the Director of Nursing revealed no new information. 2. On 01-16-2020 at 1:00 PM surveyor interview with Resident #29'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 surveyor observations; interviews with residents and staff; and the review of clinical records, staff schedules and assignments, and the facility assessment, it was determined that the facility failed to provide personal care needs to residents in a timely manner. This finding was evident for 2 of 2 nursing units in the facility (the North unit and the East unit). This finding and was related to complaints #MD00147732. The findings include: a. On 01-13-2020 at 11:00 AM observations of the nursing station revealed a staff board posted. According to the staff board, the Geriatric Nursing Assistant (GNA) to patient ratio was 1:15 (one GNA for every 15 patients) for the 7:00 AM to 3:00 PM shift for that day. Care needs for the North and East units included personal care needs for residents as well as getting residents up and ready for therapy services. On 01-14-2020 at 7:30 AM observations of the staff board at the nurses' station revealed the GNA to patient ratio was 1:12 (one GNA for every 12 patients) for the 7:00 AM to 3:00 PM shift for that day. Care needs for the North…

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

Based on surveyor review of the clinical records and interview of facility staff, it was determined that the facility failed to ensure that the use of as needed (PRN) orders for psychotropic drugs were limited to 14 days period, failed to monitor and document the side effects of psychotropic medications and failed to document the necessity for increasing psychotropic drugs and monitoring target behaviors for which the psychotropic drugs were prescribed. This finding was evident for 4 of 6 (Resident #1, #17, #23, and #27) residents selected for review of psychotropic medications. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic. Psychotropic medications (any medication affecting the mind,emotions and behavior). The findings include: 1. On 01-16-2020 at 11:10 AM surveyor review of the clinical records revealed that Resident #27 was admitted to the facility's rehabilitation unit after 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 administrative documents and interviews with facility staff, it was determined that the facility failed to provide at least 12 hours of in-service education to nurses aides. This finding was evident for 3 of 3 Geriatric Nursing Assistants (GNAs) selected for review of in-service education during the survey (GNA #2, #3, and #4). The findings include: 1. On 01-17-2020 at 10:00 AM, surveyor requested GNA #2's annual performance review and in-service education record from the facility administrator. On 01-17-2020 at 2:00 PM, interview with the administrator and regional clinical consultant revealed the facility was unable to show any annual performance reviews or in-service education for GNA #2. In addition, there was no evidence of dementia management, resident abuse prevention, or care of the cognitively impaired training. 2. On 01-17-2020 at 10:00 AM, surveyor requested GNA #3's annual performance review and in-service education record from the facility administrator. On 01-17-2020 at 2:00 PM, interview with the administrator and regional 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 observation and interviews of residents and facility staff, it was determined that the facility failed to provide an environment that promotes residents' respect and dignity. This finding was evident in 1 of 3 residents selected for dignity review (Resident #33). The findings include: On 01-13-2020 the surveyor made three (3) separate observation of Resident #33 (at 9:30 AM, 12:10 PM and 3:45 PM), and two (2) separate observations on 01-14-2020 (7:30 AM and 9:20 AM). Each observation of the resident revealed a Foley catheter (a flexible tube which passes through the urethra and into the bladder to drain urine) hanging from the side of the resident's bed with no privacy bag (a cover for the Foley catheter's drainage bag from plain sight) present. Resident #33's door was wide open and the Foley catheter bag could be observed by anyone who walked in the hallway including visitors. On 01-14-2020 at 9:30 AM, the surveyor interviewed Resident #33. The resident stated, Staff has no respect for me. They leave my door wide open all the time. On 01-14-2020 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interviews with facility staff and residents, it was determined that the facility failed to provide a safe, homelike environment to residents. This finding was evident for 2 of 39 resident rooms observed during the survey (rooms #19 and #39). The findings include: 1. On 01-14-2020 at 8:00 AM, surveyor interview with Resident #10 revealed the resident complained to the facility staff about their bathroom being in disrepair, but nothing was done. The resident further stated they almost tripped on a hole in the bathroom door. On 01-14-2020 at 8:05 AM, surveyor observation of Resident #10's bathroom (room [ROOM NUMBER]) revealed an open call light panel next to the toilet and a large hole measuring approximately 6 inches x 6 inches in the lower right-hand corner of the bathroom door, which posed a potential tripping hazard. On 01-14-2020 at 12:00 PM, surveyor interview and observation of Resident #10's bathroom with the administrator revealed no new information. 2. On 01-13-2020 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 review of clinical records and interview with staff, residents and residents' representatives, it was determined that the facility failed to provide written notification of a resident's transfer or discharge to the resident or representative. This finding was evident for 2 of 2 residents selected for review of hospitalizations (Residents #33 and #202). The findings include: 1. On 01-15-2020, surveyor review of Resident #202's clinical record revealed the resident was transferred to an acute hospital for evaluation of a medical emergency. There was no evidence that a written notification of transfer containing all the requirements stated in regulation 483.15(c)(5) was sent to Resident #202's responsible party. Further review of Resident #202's record revealed an acute care transfer form on 11-03-2019, which contained information pertaining to the reason for transfer, effective date of transfer, and location of transfer. There was no information pertaining to a statement of resident's appeal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and facility staff interviews, it was determined that the facility failed to provide written notification of the bed hold policy for residents that were transferred to the hospital. This finding was evident for 2 of 2 residents reviewed for the hospitalization care area during the survey (Residents #33 and #202). The findings include: 1. On 01-15-2020, a review of Resident #202's clinical record revealed that they were transferred by the facility staff on 11-03-2019 to the acute hospital for evaluation of a medical emergency. There was no documented evidence that the facility sent a bed hold policy to Resident #202's responsible party upon transfer. On 01-16-2020 at 9:00 AM, surveyor interview of Resident #202's responsible party revealed that they did not receive a copy of the facility's bed hold policy when Resident #202 was transferred to the hospital. On 01-17-2020 at 11:00 AM, surveyor interview with the Director of Nursing revealed no new information. 2. On 01-13-2020 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 record review and an interview with facility staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for discharge planning. This finding was evident for 1 of 16 residents selected for the survey (Resident #25). On 01-16-2020 at 11:49 AM, surveyor review of the clinical record revealed that Resident #25 was admitted for rehabilitation and was to be discharged to home. Surveyor review of the care plan for Resident #25 revealed no evidence that a discharge care plan was developed. On 01-16-2020 at 12:30 PM, surveyor interview of DON revealed no further information.

Based on record review and interviews with facility staff, it was determined that the facility failed to revise residents' comprehensive care plans. This finding was evident for 2 of 16 residents selected for review during the survey (Resident #29 and #33). The findings include: On 01-13-2020, surveyor review of Resident #29's clinical record revealed that the resident was taking an antibiotic to prevent the development of an urinary tract infection (UTI) since 09-20-2019. There was no evidence in the clinical record that a care plan was developed regarding the antibiotic use and monitoring for potential side effects. On 01-15-2020 at 11:00 AM, an interview with Resident #29's attending physician revealed the antibiotic was prescribed when the resident was at the hospital due to the resident's history of multiple UTIs and comorbidities (simultaneous presence of two or more chronic conditions). On 01-17-2020 at 10:00 AM, interview with the Director of Nursing revealed no new information. 2. On 01-15-2020 at 1:30 PM, the review of Resident #33's clinical record revealed 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.

Based on the review of clinical records and an interview with facility staff, it was determined that the facility failed to arrange a consultation with an outside physician specialist as ordered by a facility physician. This finding was evident for 1 of 16 residents selected for review during the survey (Resident#17). The findings include: On 01-13-2020 surveyor review of Resident #17's clinical record revealed they were seen and examined by the facility psychiatrist on 12-05-2019 and 01-05-2020 for pain management. A psychiatrist is a physician that treats a variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. Further review of the clinical record revealed on 12-12-19, the facility psychiatrist ordered the facility staff to arrange a rheumatology consult with an outside rheumatologist for Resident #17. A rheumatologist is a physician that specializes in the diagnosis and treatment of musculoskeletal diseases and systemic autoimmune conditions. There was no evidence that the facility attempted to arrange an…

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

Based on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility failed to maintain infection control practices during blood glucose monitoring for 1 of 1 resident observed for glucose testing (Resident #39). The findings include: 1. On 01-16-2020 at 2:30 PM, Surveyor review of the clinical records for Resident #39 revealed a medical condition in which their body doesn't use insulin properly resulting in unusual blood sugar levels. Further record review revealed a physician's order that stated check blood sugar before each meal and at bedtime. Give insulin per sliding scale. On 01-16-2020 at 4:30 PM, surveyor observed Staff #15 checking Resident #39's blood sugar prior to dinner. Staff #15 removed the glucometer (medical device to determine the approximate concentration of glucose in the blood) from its pouch and used it to check the blood sugar level. After completing the task the nurse placed the glucometer back in its case. Surveyor did not observe Staff #15 clean the glucometer before…

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

Based on surveyor observation and facility staff interview, it was determined that the facility failed to inspect the bed frame and mattress to identify areas of possible entrapment for 1 of 16 residents selected for review during the survey (Resident #16). The findings include: The FDA identified that the space between the inside surface of the foot board and the end of the mattress may present a risk of entrapment when considering the mattress compressibility, any shift of the mattress, and degree of play from loosened foot boards. (Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10. 2006). On 01-14-2020 at 8:15 AM surveyor observed that there was a gap of 10 inches between the foot board of Resident #16's bed and the mattress. This created a possible risk for entrapment. Surveyor review of manufacturer's instructions for setting up the bed revealed that the length of the bed was expandable and required screws to lock the bed frame at the requested length. Furthermore, the bed was equipped with a mattress retainer to secure the bed onto 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 facility staff interview, it was determined that the facility staff failed to verify the authority of the decision maker, and failed to clarify conflicting orders for cardiopulmonary resuscitation. This finding was evident in 2 of 3 residents selected for review of the advance directive care area (#44 and #37) The findings include: 1. On 01-15-19 at 11:37 AM, review of the clinical record for resident #44 revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form completed on 08-01-18 which directed that CPR (cardiopulmonary resuscitation) be attempted in the event of cardiopulmonary arrest. The certification for the basis of the order was based on the patients health care agent as named in the patient's advance directive, however there was no advance directive found in the clinical record. On 01-17-19 at 2:58 PM, interview with the social worker revealed that facility staff requested a copy of the advance directive on 08-02-18, however, no further effort was made to obtain the document necessary to identify 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 staff interview it was determined that the facility staff failed to provide pertinent information to the receiving facility upon discharge of a resident. This finding was evident in 1 of 3 records selected for review of the discharge care area. (#164) The findings include: On 01-18-19, review of the clinical record for resident #164 revealed a weight obtained on 03-05-18 of 162.8 pounds. A weight obtained on 04-04-18 revealed a weight of 141 pounds which reflected a weight loss of 21.8 pounds in 30 days or a 13% loss of the resident's body weight. The attending physician ordered lab tests as recommended by the dietitian to determine the source of the weight loss. In addition, the dietitian implemented nutritional interventions to stabilize the weight. On 05-14-18 the resident weighed 144 pounds. Subsequent weights were 140.8 pounds on 06-08-18 and 140.4 pounds on 07-10-18. On 07-26-18, resident #164 was discharged from the facility and relocated to another long term care facility. Review of the clinical record revealed no evidence…

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, it was determined that the facility staff failed to properly dispose of expired medication and biologicals. This finding was evident in 1 of 1 medication rooms. The findings include: On 01-17-19 at 4:28 PM during observation of the facility medication room [ROOM NUMBER] boxes of Biscodyl Suppositories with an expiration date of 05-18 were found in a medication room cabinet. (Biscodyl is a stimulant laxative) In addition, 38 red top blood tubes with an expiration date of 12-06-17 were also discovered in the medication room. Finally, 1 box of Juven (nutritional supplement) dispensed by the pharmacy on 12-29-16 was also discovered to have expired on 08-18. Upon surveyor intervention all expired products were removed by the unit manager. On 01-17-19 at 4:40 PM, interview with the Director of Nursing provided no additional information.