Harmony Suites Rehabilitation and Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, it was determined the facility failed to ensure a resident had access to the facility's communication system. This was found to be evident for 1 out of 2 Residents (Resident #76) observed for accommodation of needs during the re-certification survey. The findings include: During a random observation conducted on 01/27/25 at 9:44 AM, the Surveyors observed Resident #76's call bell on the floor behind the head of the bed. On 01/27/25 at 9:45 AM, during an interview, Resident #76 told the Surveyors that the call bell was always on the floor out of reach. The Resident stated that he/she usually did not have access to the call bell and as a result would yell out for help when assistance was needed. On 01/27/25 at 10:27 AM, the Surveyors and License Practical Nurse (LPN) #34 observed Resident #76's call bell on the floor behind the head of the bed out of reach for the Resident. The Surveyors observed the LPN remove the call bell from the floor and place the call…

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, it was determined that the facility failed to ensure a Resident was offered information for an Advance Directive. This was evident for 1 (Resident #76) out of 1 resident reviewed for Advance Directives. The findings include: According to the Centers for Medicare and Medicaid (CMS) the definition of an Advance Directive is a document that appoints an agent and records a patient's medical treatment wishes based on their values and preferences. Advance Directives can be different from state to state. A record review on 01/28/25 at 07:38 AM showed there was not an Advanced Directive found or documentation that Advance Directive information was offered in the electronic medical record of Resident #76. A review of Resident #76 ' s paper chart on 01/28/25 at 08:16 AM revealed there was not an Advanced Directive or documentation that Advance Directive information was offered in the chart. On 02/03/25 at 11:32 AM, while interviewing Social Worker (SW) #23, this surveyor asked what the process was for obtaining an Advanced Directive for a Resident. 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 Reviews and Interviews it was determined that the facility failed to provide Beneficiary Notices to residents discharged from Medicare Part A Services with benefit days remaining. This was evident for 1(#19) out of 3 Residents reviewed for Beneficiary Notices. The findings include: The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) is provided to notify Residents/Beneficiaries that their services may no longer be covered by Medicare and allows the Resident time to decide on continuing services not covered. The Notice of Medicare Non-Coverage (NOMNC) notice is provided to inform the Resident/Beneficiary of their right to file an Appeal of the decision and the right to an expedited review of Medicare non-coverage services. This form should be provided at least two days before the last day covered by Medicare. On 2/03/25 at 07:15 AM, the Director of Nursing (DON) provided this surveyor with the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms that had been provided to the facility for completion. A review 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 observations and interviews, it was determined that the facility failed to provide a safe, comfortable, and homelike environment. This was found to be evident for 3 (Residents #23, #46 and #76) out of 4 Resident rooms observed for the physical environment. The findings include: 1) During an observation on 1/27/25 at 09:14 AM Resident #23 was found lying in bed with his/her television sitting on the bedside table turned off. The Resident was watching the television on the other side of his/her roommate ' s bed. An additional observation revealed another television lying on top of the Resident ' s portable closet. In the Resident ' s room, it was also found that the Hot water to the sink had no water flow upon turning the knob. There were also two ceiling tiles in his/her bathroom that were dislodged, angled downward and exposed the open space above the tiles. Additionally, there was an electrical socket behind the Resident ' s bed that had the electrical mounting box protruding out of the wall. During 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 observation, interview and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 1) the resident's refusal to use palm protector and 2) the use of an anticoagulant. This was evident for 2 (Residents #32 and #53) of 39 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. Palm Protectors offer relief from hand contractures and cramping. They are put over the thumb and around the hand, providing a cushioning pad for the fingers to curl onto. This prevents the nails from digging into the palms and keeps the fingers warm and supported. A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm 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 observation, record review and interviews, it was determined that the facility failed to ensure that residents receive podiatry services for overgrown toenails. This was evident in 1 (Resident #52) of 1 resident reviewed for podiatry care. The findings include: Resident #52 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Seizures, Adult Failure to Thrive and Major Depressive Disorder. On 01/28/25 at 8:11 AM the surveyor observed Resident #52 lying in bed. Resident #52's toenails on both feet were long, thickened and curled over the bottom of his/her toes. On 01/28/25 at 11:11AM a review of Resident #52's record revealed a physician order dated 10/17/24 for podiatry consult as needed. On 01/28/25 at 11:32 AM the surveyor interviewed Staff #9 and enquired about the process for podiatry care. Staff #9 stated that residents are assessed upon admission and as needed for podiatry care. The residents' facesheets and physician orders are then faxed to the podiatry service provider.…

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 interviews and review of medical records, it was determined that the facility failed to provide routine appointments for vision services. This was evident for 1 (Resident #36) out of 1 resident reviewed for vision services. The findings include: During an interview conducted on 01/27/25 at 12:18 PM, Resident #36 reported having a concern with seeing an eye doctor. The Resident stated that he/she now sees little black spots and had lots of headaches. The Resident further stated that he/she reported the need to see an ophthalmologist for an eye exam and for the recent little black spots to the nursing supervisor. On 01/31/25 at 08:04 AM, a record review of Resident #36 ' s nurse notes showed a note from 1/9/2025 at 12:00 PM by Licensed Practical Nurse (LPN) #30. The note stated Resident complained of having dark spots before her eyes. Medical Staff notified. Stated that it has been ongoing for 7 days but did not report it to anyone. A review of Resident #36 physician orders revealed a consult by Nurse Practitioner (NP) #28 that was placed on 01/10/2025. The consult DX…

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 #32) of 2 residents reviewed for positioning and mobility during the recertification survey. The findings include: A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. Palm Protectors offer relief from hand contractures and cramping. They are put over the thumb and around the hand, providing a cushioning pad for the fingers to curl onto. This prevents the nails from digging into the palms and keeps the fingers warm and supported. On 1/27/25 at 9:45 AM, Resident #32 was noted with left hand contracture. Also, the left thumb fingernail was observed curled inwards approximately half of an inch long. There was no evidence of any device was worn on the left…

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, clinical record review and staff interviews, it was determined that the facility failed to maintain respiratory therapy equipment according to professional standards of practice. This was found to be evident for 1 (#34) out of 2 residents reviewed for respiratory care during the annual survey. The findings include: Ipratropium- Albuterol is a medication used to treat wheezing and shortness of breath. It can be administered via an inhaler or via a nebulizer. A nebulizer turns the medication into a fine mist that is inhaled into the resident's lungs. Nebulizer treatments are considered an aerosol-generating procedure (AGP). On 01/28/2025 at 11:35 AM, the surveyor observed a clear, plastic zip lock bag on Resident #34's bedside table that contained two nebulizer face masks and nebulizer tubing. The nebulizer face mask and nebulizer tubing were not labeled as to when they were put to use or should be replaced. On 01/31/2025 at 08:46 AM, a review of Resident #34's clinical record revealed the following physician order: Date 04/08/2024 Ipratropium-Albuterol…

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 that pain medication was given consistent with the professional standards of practice. This was evident for 1 (Resident #53) of 2 residents reviewed for pain management during the recertification survey. The findings include: The medical abbreviation PRN stands for pro re nata, a Latin phrase that translates to as needed or as the situation arises. Oxycodone is strong painkillers from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. Pain parameters are the specific aspects of pain that are evaluated during an interview to understand a person's pain experience. On 1/30/25 at 9:18 AM, a record review of Resident #53's active physician orders indicated that he/she was on Oxycodone HCl Oral Tablet 15 MG (Oxycodone HCl) Give 2 tablets by mouth every 6 hours as needed for pain level 5-10, hold for sedation. On 1/30/25 at 10:47 AM, further review of Resident #53's Medication Administration Record (MAR) revealed that the facility staff failed to follow the pain…

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 Geriatric Nursing Assistant personnel files and staff interviews, it was determined that the facility failed to conduct yearly performance reviews at least every 12 months for 2 (Staff #18 and #22) of 5 staff members reviewed. The findings include: Performance reviews are to be completed at least every 12 months to identify in-service education needed to address competencies of the geriatric nursing assistants. On 01/28/25 at 11:02 AM the surveyor conducted a review of 5 Geriatric Nursing Assistants personnel files. Staff #18 was hired on 07/12/21 and Staff #22 was hired on 08/17/23. The records revealed that Staff#18's performance review was due on 05/31/24 and Staff #22's performance review was due on 08/17/24. A further review of the records revealed that performance reviews were not completed for Staff #18 and Staff #22 on the due dates, nor were they completed for the calendar year 2024. On 01/30/25 at 01:00PM in an interview with the Executive Director (EO), the surveyor was informed that annual performance reviews for geriatric nursing assistants were…

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 respond to the recommendation made by consulting pharmacist in a timely manner. This was evident for 1 (Resident #6) of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: On 1/31/25 at 10:05 AM, a review of Resident #6's medications revealed an order that read, Dicyclomine HCl Oral Tablet 20 MG (Dicyclomine HCl) Give 1 tablet by mouth every 8 hours for abdominal cramping. On 2/03/25 at 7:35 AM, the surveyor reviewed Resident #6's medical record, however, was unable to locate a Medication Regimen Review (MRR) in the electronic medical record and the paper chart. On 2/03/25 at 7:40 AM, in an interview with Licensed Practical Nurse (LPN #11), he/she described that after each consultant pharmacist visit. The pharmacy faxed the recommendations to the Director of Nursing (DON) and she forwarded the recommendations to be addressed by the attending physician. The physician indicated if there were changes that needed to be made to the current orders. 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 observations and interviews, it was determined that the facility failed to ensure that medications were stored properly. This was found to be evident for 3 (Residents #57& # 76 & 55) out of 5 Residents observed during medication storage. The findings include: 1) During a random observation conducted on 01/27/25 at 10:00 AM, the Surveyors observed Resident #57 at the entrance of his/her doorway. The Resident had asked a staff for water to take his/her medications. During an interview conducted on 01/27/25 at 10:02 AM, Resident #57 stated that the nurse put the medications on top of the nightstand to take after he/she ate breakfast. During an observation conducted on 01/27/25 at 10:07 AM, the Surveyors and Licensed Practical Nurse (LPN) #34 observed a medication cup with multiple medications. LPN # 34 stated that Resident #57 wanted to eat breakfast before he/she took the medications. The LPN further stated that the facility's expectation was to return the medications to the medication cart and store them in a secured medication cart when a resident refused to take 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 interviews and review of medical records, it was determined that the facility failed to provide routine dental services. This was evident for 1 (Resident #36) out of 1 resident reviewed for dental services. The findings include: During an interview conducted on 01/27/25 at 12:18 PM, Resident #36 stated that he/she had dental concerns. The Resident stated that he/she had not had a teeth cleaning in 3 years and had requested to have a dental appointment. However, the facility had not provided a dental service as of yet. On 01/31/25 at 08:04 AM, a record review of Resident #36 ' s physician ' s orders showed a consult for Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed placed on 12/26/2024 by Primary Attending Physician (PA) #29. During a follow up interview conducted on 01/31/25 at 11:04 AM, Resident #36 advised the surveyors that he/she notified PA #29 of the need for dental services. The Resident further stated that he/she had not been notified of a dental appointment scheduled since the notification to the PA. On 01/31/25 at 11:30 AM, this surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure appropriate infection prevention and control practices. This was found to be evident for the laundry department and 1(Resident #20) of 4 Residents observed for infection control. The findings include: 1) Resident #20 was admitted to the facility on [DATE] and required tube feeding for nutrition. On 01/28/25 at 08:15 AM during rounds the surveyor observed Resident #20 lying in bed with a bottle of tube feeding attached to a pump, hanging on a pole at the bedside. The pole was visibly dirty with dark brown spots scattered along the base and the shaft. On 01/28/25 at 10:17 AM a review of Resident #20's physician order dated 5/1/24 revealed that the resident required tube feeding for 20 hours per day via pump. On 01/28/25 at 11:44 AM Staff #9 was made aware of the condition of the pole. Staff #9 acknowledged the surveyor's findings and stated that the pole would be cleaned immediately. Staff #9 also stated that 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 observations and staff interviews it was determined that the facility failed to ensure a safe/functional/sanitary/comfortable environment. This was found to be evident in the laundry department during the annual recertification survey. The findings include: On tour of the laundry department in the basement of the facility on 1/30/2025 at 8:00 AM with the laundry aid #15 in attendance it was observed that there were four ceiling tiles grossly soiled with large brown stains, chipped, and missing. In an interview with the Environmental Services (EVS) Director #16 at 8:25 AM on 1/30/2025, the surveyor asked what the expectation was for the replacement of these ceiling tiles that were observed grossly soiled, chipped and missing in the laundry department. The EVS Director #18 stated that the Maintenance Department was responsible for the replacement of the ceiling tiles. The EVS Director #18 further stated that these ceiling tiles became soiled from the rain outside. The surveyor interviewed the Maintenance Assistant #6 on 1/30/2025 at 8:40 AM regarding the replacement 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 observations, staff interviews, and review of facility pest control records, it was determined that the facility failed to maintain an effective pest control program. This was evident for 4 of 4 random observations made during the annual survey. The findings include: During an initial tour of the facility on 1/27/2025 at 8:48 AM, the surveyor and Administrator observed a roach crawling in the hallway outside the kitchen door entry way. In an interview conducted with the Certified Dietary Manager (CDM) on 1/27/2025 at 9:45 AM, the CDM stated that she had not seen roaches in the kitchen area. During a follow up tour of the kitchen on 01/29/2025 at 08:00 AM, the surveyor observed a roach crawling on the floor under the steam table while staff prepared breakfast meal trays for residents. During an interview conducted with the District Manager (DM) on 1/29/2025 at 8:25 AM, the DM stated that he had not seen roaches in the kitchen area. The DM further stated that pest control services visit the facility weekly and as needed. On 1/29/2025 at 8:32 AM, the surveyor, DM and CDM…

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

Based on observations, interviews and record reviews it was determined that the facility staff failed to ensure nursing standards of practice were followed for medication-controlled drugs and security. This was found to be evident for 4 (Resident #45, #48, #77 and #384) out of 4 Residents reviewed for medication-controlled drugs and security. The findings include: The Maryland Nurse Practice Act (NPA) is legislation that influences the nursing profession by establishing Maryland Board of Nursing rules and regulations which outlines requirements for Maryland nursing education programs, setting minimum care standards that must be met. The NPA exists to regulate and protect the public from practitioners who are a risk to the health, safety, and welfare of the citizens within its state board jurisdiction. This protection principle is accomplished by assessing competence at initial licensure and throughout the career of the nurse. The NPA protects the public from incompetent and unsafe care. The primary purpose of the NPA is to protect the public and sets out the scope of practice. 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 a review of facility-reported incident investigation, record review and interview, it was determined that the facility failed to prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation was in progress. This was evident for 1 (Resident #53) of 6 residents reviewed for abuse during the recertification survey. The findings include: On 1/27/2025 at 11:25 AM, a review of facility-reported incident MD00213513 revealed that on 1/12/2025, Resident #53 reported that he/she fell on the floor and Licensed Practical Nurse (LPN #19) picked him/her and threw him/her back on the floor. The report also indicated that 2 Geriatric Nurse Assistants (GNA #26 and #27) assisted LPN #19. Registered Nurse Supervisor (RN #9) asked Resident #53 to describe the staff, he/she stated, don't play dumb, they're all Africans. He/she repeated this statement when he/she was interviewed by the local law enforcement. On 1/29/2025 at 9:15 AM, in an interview with Resident #53, he/she stated that he/she fell on the floor on January 12 and confirmed that LPN #19 along…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with staff it was determined the facility failed to provide services to maintain a clean, safe, comfortable and homelike environment. This was evident for 2 of 2 units in the facility and in the kitchen. The findings include: During observational rounds of the facility on 9/23/24: The surveyor observed on the 2nd floor at 10:15 AM- room [ROOM NUMBER] - A hand sink was located in a small alcove within the room on the wall to the left of the bathroom door. Three 4 inch by 4 inch (4x4) ceramic wall tiles, missing from the wall below and to the right of the sink, were stacked on the floor below the sink. A 1x1 hole was observed completely through the wallboard along the top of the rubber shoe molding, located between the bathroom door and the alcove. Numerous cracked floor tiles were observed throughout the room. The cracks and gaps in the seams between the tiles were black. The shared bathroom between rooms [ROOM NUMBERS] - A wall panel covered the long shower wall and extended…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to accurately and appropriately identify a residents health status and representative in order to change a resident's code status. This was evident during the review of 1 of 3 (#16) residents reviewed during a complaint survey. The findings include: The Maryland Orders for Life Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for CPR (on the front page) and other life-sustaining treatments (on the back page). The medical orders are based on a patient's wishes about medical treatments. Review of the medical record for Resident #16 on [DATE] at 9:37 AM revealed diagnosis to include chronic obstructive pulmonary disease and rheumatoid arthritis. Resident #16, who was admitted back in 2022 was transferred to this facility with a MOLST documenting that s/he was full code according to the patients' health care agent as named in their advanced directive. According to this ongoing…

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 staff interview; it was determined that the facility failed to protect resident (resident #9 and #28) from physical abuse from a facility staff member. This was evident for 2 of 41 residents reviewed during a complaint survey. The findings include: 1) Record review on 9/23/24 at 12:00 PM revealed resident #9 complained to the facility's administration that he/she received painful ADL care from GNA #15 on 3/7/24. The facility investigated the complaint from resident #9 and determined that GNA #15 failed to use a gait belt, an assistive device that is used to stabilize a physically impaired person during transfers including from bed to chair. The unsafe transfer caused resident #9 from his/her bed caused the resident to experience pain in the neck. Review of medical records after the incident revealed no evidence of psychosocial or physical pain from the improper transfer. Continued record review on 9/23/24 at 12:40 PM revealed the facility placed a corrective action for GNA #15 in the employee's personnel record on 3/8/24 which stated GNA #15 required…

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

Based on record review and interviews it was determined the facility staff failed to implement measures and reasonable care to prevent loss or theft of resident's belongings. This was evident for 1 (#24) of 41 residents reviewed during the survey. The findings include: A complaint pertaining to Resident #24 was reviewed on 9/26/24 at 9:25 AM. The complainant indicated that he/she discovered that 3 bags of Resident #24's clothing were missing on 8/30/22. When he/she reported it to Staff #14 at the front desk, Staff #14 informed the complainant that she observed a nurse taking bags of clothing to her car on 8/28/22. The complaint indicated that the complainant reported it to administrative staff who retrieved 2 of the 3 bags on 9/2/22 and informed him/her they would reimburse him/her for the 3rd bag. The complaint indicated that the Administrator said he would look into the matter, but the complainant never heard anything more about it. The event was reported to the police by the complainant. During a telephone interview on 9/26/24 at 9:11 AM the complainant recalled the incident.…

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

Based on record review and interviews it was determined the facility staff failed to report an allegation of misappropriation of resident belongings to the State Agency. This was evident for 1 (#24) of 41 residents reviewed during the survey. The findings include: A complaint pertaining to Resident #24 was reviewed on 9/26/24 at 9:25 AM. The complainant indicated that he/she discovered that 3 bags of Resident #24's clothing were missing on 8/30/22. When he/she reported it to Staff #14 at the front desk, Staff #14 informed the complainant that she observed a nurse taking bags of clothing to her car on 8/28/22. The complainant reported it to administrative staff who retrieved 2 of the 3 bags on 9/2/22 and informed him/her they would reimburse him/her for the 3rd bag. The complaint indicated that the Administrator said he would look into the matter, but the complainant never heard anything more about it. The event was reported to the police by the complainant. The state agency had no record that the facility filed a self-report regarding this alleged incident. In an interview on…

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

Based on record review and interviews it was determined the facility staff failed to conduct a thorough investigation after a reports of abuse and misappropriation of resident property. This was evident for 3 (#28, #24 and #11) of 41 residents reviewed during the survey. The findings include: 1) Review of facility reported incident (MD 00183660) on 9/25/24 at 9:54 AM revealed resident #28 reported being hit by Agency GNA#16 on 9/20/22. Surveyor review of the facility investigation revealed the facility failed to interview other residents on the unit to determine if other residents experienced abusive treatment by facility staff including Agency GNA #16 and to ensure the residents felt safe in the facility. Interview with the Director of Nursing (DON) on 9/25/24 at 11:00 AM confirmed that the facility failed to interview other residents on resident #28's unit to determine if other residents experienced abusive treatment by facility staff including Agency GNA #16 and ensure the residents felt safe in the facility. 2) A complaint pertaining to Resident #24 was reviewed on 9/26/24 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 interview, the facility nursing staff failed to follow standards of practice by failing to report a resident's injury to a provider (resident #31). This was evident for 1 out of 41 residents reviewed during a complaint survey. The findings include: Record review for resident #31 on 9/25/24 at 11:41 AM revealed NP #20 reported on 7/11/22 that LPN #19 failed to report the formation of a bruise on the resident's left knee. NP #20 discovered the left knee bruise when he/she assessed resident #31 on 7/11/22 at approximately 2:00 PM. Continued review of NP#20's complaint revealed the facility investigated the cause of resident #31's left knee bruise and determined that LPN#19 was aware of the left knee bruise on the morning of 7/11/22 but failed to report the injury to his/her supervisor or administration. Further review of resident #31's records revealed facility administration issued a teachable moment notice on LPN #19's personnel record on 7/12/22 . The facility required LPN#19 to be re-educated on facility policy on reporting injuries to supervision.…

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 resident and facility staff, it was determined that the facility failed to provide care to a resident that is dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 1 of 4 (#35 ) residents related to quality of care. The findings include: 1. Review of the medical record for Resident #35 on 9/30/24 at 8:05 AM revealed diagnosis which includes cellulitis and lymphedema in the bilateral lower extremities causing bed bound status. Resident #35, reported in 2022 concerns related to lack of care provided on the weekends of 3/5-3/7/22 and 3/11-3/14/22. A review of the bowel and bladder continence record for the month of March 2022 revealed no documentation on any of the 3 shifts that the resident had either a bowel or bladder movement on 3/6, 3/7, 3/11, 3/13 and 3/14. Surveyor met with Resident #35 on 9/30/24. Though care has improved, s/he verbalized and reiterated about the lack of care and treatment that was provided from the time reported in the complaint for the weekends in March…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff it was determined that the facility staff failed to ensure that residents received proper foot care and treatment. This was evident for 1 (#34) of 41 residents reviewed during the survey. The findings include: A complaint regarding the care and services provided to resident #34 was reviewed on 10/1/24 at 11:31 AM. The complaint indicated the resident experienced pain as they attempted to put shoes onto his/her feet in preparation for discharge and that upon closer look, Resident #34's toenails were long, and his/her feet and nails did not appear to have been adequately cared for by the facility. A review of Resident #34's medical record was conducted at that time and revealed the resident was admitted to the facility on [DATE] and discharged on 5/6/22. His/Her diagnoses included but were not limited to Diabetes Mellitus, and Dementia. A physician's order was written on 10/4/21 for consults including Podiatry. A care plan is a guide that addresses the unique needs…

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 have a discharge summary on the medical record. This was evident for 1 of 3 (#20) residents reviewed for discharges during a complaint survey. The findings include: During the review of the medical record for Resident #20 on 9/24/24 regarding a complaint related to timely discharge, it was noted that there was no physician discharge summary on the chart. The summary was requested on 9/24/24 at 1:35 PM. On 9/25/24 at 8:08 AM a physician discharge summary was provided to the survey team. Review of the summary noted that it was dated for 9/24/24 and stated that the resident was seen 'TODAY' in all capital letters in his/her room. However, according to record review on 9/24/24 and again on 9/25/24 at 8:12 AM, Resident #20 left the facility against medical advice on 11/19/22 and has not returned. This concern was reviewed with the regional nurse on 9/25/24 at 8:18 AM. The attending physician was interviewed on 10/1/24 at 12:10 PM. She stated that she was asked by the Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with staff it was determined the facility failed to ensure a functioning call system to allow residents to call for staff assistance in each toilet and bathing facility. This was evident for 2 of 4 resident bathrooms observed. The findings include: A tour of the facility was conducted on 9/24/24 at 10:00AM. 1) Observation of the bathroom located between and shared by the residents in room [ROOM NUMBER] and 217 revealed a call bell activation box on the wall in the shower approximately 6 feet above the floor. A short red cord was attached to the call bell activation switch. The end of the cord was located approximately 5 feet above the floor and could not be reached by a resident sitting/lying on the shower floor or seated on a shower chair. 2) The bathroom located between rooms [ROOM NUMBERS] had call bell activation switches located on the walls to the left and right of the toilet. The activation switch on the wall to the left of the toilet was in the up (off) position, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff and resident interview, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents. The findings include: On 9/23/24 at approximately 10:00 AM, the survey team observed evidence of mouse droppings and cockroach activity on the 1st and 2nd floors of the facility. The survey team observed pest activity in resident rooms on 9/24/24 - 9/26/24 on the 1st and 2nd floors of the facility during observation rounds and interviews with residents in their rooms. On 9/24/24 at 1:02 PM, the survey team informed the Assistant Executive Director of concerns of pest activity throughout the facility. The survey team also requested the facility's pest activity reporting documents to determine if the facility made attempts to provide a pest-free environment. On 9/24/24 at 1:15 PM, the survey team interviewed the Maintenance Director, Maintenance Assistant and the Assistant Executive Assistant regarding 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 the review of the residents' clinical records, a review of the facility's policy and procedures related to smoking, observations of residents and staff practices, and interviews with residents and facility staff, it was determined that the facility failed to consistently implement their smoking policy. This finding was evident for 3 of 3 residents reviewed for smoking (Resident #10, #21, #69). The findings include: On 01-30-2020 a review of the facility's current smoking policy and procedure revealed that the intent of the policy was to provide a safe smoking area for residents/patients that request to smoke and are capable of safe smoking behaviors either independently or with supervision. The procedures include the following: assessment, observation and the designation of the resident either being independent or supervised smoker. This designation will be made by the interdisciplinary team for each resident who requests to smoke and will be documented in the medical record system. These assessments will be done or re-evaluated at the time of the resident's admission,…

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 a resident and facility staff, it was determined that the facility staff failed to conduct timely quarterly care plan conferences with 1 of 22 residents selected for review during the survey (Resident #72). The findings include: On 01-29-2020 at 1:30 PM, surveyor interview with Resident #72 revealed that he/she had not participated in care plan meetings for some time. In addition, even though the resident is his/her responsible party, the resident's spouse would participate occasionally in the meeting. On 01-30-2020 around 1:00 PM, surveyor review of the clinical record revealed documentation of a quarterly care plan meeting for Resident #72, conducted in August 2019. There was no evidence that any further interdisciplinary quarterly care plan meetings, that included resident #72, had been completed after August 2019 as required. On 01-30-2020 at 2:10 PM, an interview with the Director of Social Work revealed not conducting care planning conferences with Resident#72 was an oversite. On 01-30-2020 at 4:30 PM, surveyor…

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

Based on the review of residents' clinical records and interviews with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice for 2 of 22 residents selected for review during the survey. This finding was evident for 2 of 22 residents selected during the survey (Residents #20 and #245). The findings include: 1. On 01-31-2020 a review of the clinical record for Resident #20 revealed that on 01-23-2020 the facility's wound consultant documented that the resident had a stage 2 pressure sore on the sacral area. A stage 2 pressure sore is when the skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion) or a shallow crater in the skin. Further review of the wound consultant's documentation revealed that the treatment plan for the wound was to apply Leptospermum honey (Medi Honey) and a dry protective dressing once daily for 23 days. On 01-31-2020 a review of Resident #20's Skin/Wound documentation, 01-23-2020 by 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, interview of the resident's representative and facility staff, it was determined that the facility staff failed to ensure that Resident #47 received outside services to manage a health condition for 1 of 22 residents selected for review during the survey (Resident #47). The findings include: On 01-29-2020 at 10:30 AM, an interview with Resident #47's representative revealed that the resident had an appointment scheduled with the oncologist (a medical professional who deals with treatment of cancer) on 01-02-2020. As of 01-29-2020, Resident #47 had not visited the Oncologist, and the facility had not communicated with the resident's representative about the Oncology appointment. On 01-29-2020 a review of Resident #47's clinical record revealed the resident was seen an Oncologist on 12-19-2019, with the recommendation for a follow up appointment on 01-02-2020. There was no documented evidence in Resident #47 attended this follow up appointment. On 01-30-2020 at 11:15 AM, an interview with the Upper Level Unit Manager revealed that…

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

Based on the review of the clinical record and interview with Hospice staff and the facility's staff, it was determined that the facility failed to ensure complete and accessible documentation in the clinical records for 2 of 22 residents selected for review during the survey (Residents #20 and #79). 1. On 02-03-2020 the review of Resident #20's clinical record revealed the resident receives nursing and supportive services from a community Hospice agency. Further review of the record revealed documentation by Hospice of monthly summaries for the resident. On 02-03-2020 at 1:00 PM an interview with the Director of Nursing revealed that a Hospice nurse makes weekly visits to the facility, conducts assessments and collaborates with the nursing staff on Resident #20's care. On 02-03-2020 at 3:15 PM interview with Hospice RN #7 and the Director of Nursing (DON) confirmed that his/her weekly visits notes provides the documentation of the collaboration between Hospice RN #7 and the facility's nurses at each visit. Hospice RN #7 further confirmed that this information was not previously…

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 a court appointed guardian and the facility staff, it was determined that the facility staff failed to revise an individual's care plan after the comprehensive assessment was completed. In addition, the facility staff failed to ensure that an individual participated in his/her own care plan meeting. This finding was evident for 4 of 25 residents selected for review during the survey (#13, #43, #9 and #49). The findings include: 1. On 03-28-19, review of resident #13's clinical record revealed that the resident had a court appointed guardian of person. In January 2019, a quarterly MDS assessment was completed. On 01-23-19, the court appointed guardian of person participated in the care plan meeting. The Minimum Data Set (MDS) is an assessment tool to reflect an individual's physical and functional status. Further review of the resident's current care plan related to pain management, hypertension, paranoid schizophrenia and glaucoma revealed that the facility staff would administer medications as ordered and monitor…

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

Based on surveyor observations, record review and interviews with facility staff and resident's representatives, it was determined that the facility failed to inform the resident's representatives regarding the discontinuation of a treatment for the prevention of elopement. This was evident for 1 of 1 (#52) residents selected for the notification of changes review during the survey. The findings include: 1. On 03-27-19 at 09:00 AM, review of resident #52's record revealed a physician's order, dated 01-17-19, to discontinue the wander guard (a sensor on a band used as an elopement prevention device). However, further review revealed that no evidence of notification to the resident's representative for the discontinuation of the wander guard. On 03-27-19 at 01:40 PM, interview with resident #52's representative revealed that he/she was not informed by the facility staff of the physician order to discontinue the resident's wander guard. On 03-27-19 02:00 PM, interview with the Director of Nursing revealed no additional information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record, interview with resident and facility staff, it was determined that the facility staff failed to notify the resident or the representative in writing when the resident was sent to the hospital. This finding was evident in 1(#36) of 2 residents selected for the hospitalization review during the survey. The findings include: On 03-26-19 at 09:30 AM, surveyor interview with resident #36 revealed he/she was sent to the hospital a couple of months ago. Surveyor review of the clinical record revealed a physician's order to transfer resident #36 to the hospital on [DATE] for further evaluation and treatment. Surveyor review of nurse's note written on 12-21-18 at 2:33 PM, revealed the resident's representative was called and made aware of the transfer. However, there was no evidence that a written notification of transfer was provided to resident #45 or his/her representative when the resident was transferred to the hospital. On 03-27-18 at 11:10 AM, the 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.

Based on surveyor review of the clinical records and interview of the facility staff, it was determined that the facility staff failed to meet the standard of nursing practice of documentation after a treatment was done. This finding was evident for 2 (#13,#58) of 25 residents selected for standard of practice review. The findings include: 1. On 03-27-19, review of resident #13's Treatment Administration Record (TAR) revealed that the nursing staff signed off that a blood sugar test was done once a week on 01-13-19, 01-21-19, 01-28-19, 02-25-19, 03-11-19 and 03-25-19 for diabetic management. However, there was no evidence that the nursing staff recorded the blood sugar results on the above dates. A blood sugar test is to determine how much glucose (sugar) is in a blood sample. On 03-27-19 at 2:30 PM, interview of the Director of Nursing revealed no additional information. As Code of Maryland Regulations 10.27.10.03D (3), Collection of data and reporting of problems that arise in the carrying out of the nursing plan. 2. On 03-27-19, surveyor observation of medication administration…

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

Based on surveyor observations, review of resident records, and interview with facility staff, it was determined that the facility staff failed to follow a physician's order. This was evident for 3 of 25 (#1, #52, #7 and #68) residents selected for this survey. The findings include: 1. On 03-25-19 1:45 PM Observed resident #52 with a wander guard (a sensor on a band used as an elopement prevention device) on his/her left wrist. On 03-27-19 at 9:00 AM review of resident #52's record revealed a physician order dated 01-17-19 to discontinue the wander guard. However, the wander guard was not discontinued as ordered. On 03-27-19 at 2:00 PM interview with the Director of Nursing revealed no additional information. 2. On 03-26-19 at 4:00 PM surveyor observation of medication cart #1 on the lower level unit with staff #4 a medication package for resident #1 that was scheduled to be given at 9:00 AM on 03-26-19 remained in the designated section for resident #1's scheduled medications. On 03-26-19 at 4:05 PM record review of resident #1's Medication Administration Record (MAR) revealed the…

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

Based on review of employee records and facility staff interviews, it was determined that the facility failed to complete a performance review at least once every 12 months for nurses aides. This was evident for 1 of 5 (#1) nurse aides selected for this survey. The findings include: 1. On 03-29-19 at 10:00 AM, surveyor review of GNA #1's employee record revealed that the GNA was hired 03-27-17 and there was no documentation that he/she received a yearly performance review by the facility. On 03-29-19 1:00 PM, interview with the Director of Nursing revealed no new information.

Based on surveyor observation and facility staff interviews, it was determined that the facility failed to label drugs and biologicals in accordance with accepted professional standards. This was evident for 1 of 4 (#1) medication storage carts selected for medication storage inspection during the survey. The findings include: 1. On 03-26-19 at 4:00 PM, surveyor observed a multiple use bottle of 1% Xylocaine (local anesthetic medication used to numb nerve signals in the body) opened and unlabeled. On 03-26-19 at 4:10 PM, interview with the lower level unit manager revealed no additional information. On 03-26-19 at 4:30 PM, interview with the Director of Nursing revealed no additional information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with facility staff, it was determined that the facility failed to ensure that residents' call lights were functional. This finding was identified in 2 of 10 bathrooms located on the upper level unit. The findings include: On 03-25-19 at 9:15 AM, surveyor tour of the ground floor unit of the facility revealed that room [ROOM NUMBER]'s bathroom call light system was nonfunctional. In addition, the cord/string used to trigger the emergency call system was not available. Additional observation of the general bathroom on the upper level unit revealed no cord or string for the emergency call system in the shower room. On 03-25-19 at 2:10 PM, surveyor interview with the maintenance director and the director of nursing revealed no new information. Following surveyor intervention on 03-25-19, the call system in room [ROOM NUMBER] and the general shower room on the upper level unit were restored.