Layhill Nursing And Rehabilitation Center

Based on record reviews and interview it was determined that the facility failed to ensure Pharmacy Medication Regimen Review (MRR) recommendations were reviewed in a timely manner. This was found to be evident for 1 (Resident #4) out of 5 Residents reviewed for unnecessary medications during the recertification and complaint survey. The findings include: A pharmacy Medication Regimen Review [MRR] is a comprehensive evaluation of all a patient's medications-prescription, OTC [over the counter], and herbal-conducted by a pharmacist to ensure safety, efficacy, and appropriateness. It identifies, prevents, and resolves issues like drug interactions, duplicate therapies, improper dosages, and noncomplianceOn 02/18/2026 at 8:33 AM a review of Resident #4's MRR showed that the physician had not reviewed the pharmacy recommendations within the 30 days per the facility's policy. On 09/20/2025 the pharmacy made a recommendation for a reduction in the dosage from 40 milligram (mg) to 20 mg for Pantoprazole. The physician reviewed, agreed and signed the recommendation on 11/15/2025. A review…

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

Based on observation, interview and record review, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 3 out of 29 medications administered during the observation.The findings include:Dysphagia is a condition that involves difficulty swallowing food, liquids, or medications.On 02/11/2026 at 9:17 AM, this surveyor observed Licensed Practical Nurse (LPN) #15 begin medication administration to Resident #3.On 02/11/2026 at 9:20 AM, while reviewing Resident #3's medical record, LPN #15 stated that the resident has a diagnosis of dysphagia and reported that she routinely crushes medications for residents with this condition. The surveyor inquired whether there was a physician's order to crush medications for Resident #3. LPN #15 and the surveyor reviewed the resident's orders together, and LPN #15 confirmed that there was no order authorizing medications to be crushed.On 02/11/2026 at 9:35 AM, LPN #15 reported that, despite there being no physician's order to crush medications, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #22 and #9) of 2 residents reviewed for medical record documentation during the recertification survey.The findings include:1. PASRR stands for Pre-admission Screening and Resident Review. It is a federal mandate requiring that all applicants to Medicaid-certified nursing facilities be screened for serious mental illness (SMI), intellectual disabilities (ID), or developmental disabilities (DD) prior to admission. The process ensures proper placement, preventing inappropriate nursing home admissions and guaranteeing individuals receive necessary, specialized services in the most appropriate setting.During a review of Residents medical records on 02/09/2026 at 2:08 PM it was discovered that that Resident #22 was admitted on [DATE] and did not have a completed PASRR documented in his/her medical records.During an interview with the Social…

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 interviews it was determined that the facility failed to ensure staff practiced infection control. This was found to be evident for 2 (Residents #13 and #22) out of 2 Residents observed for infection control during the recertification survey. The findings include:2. During an observation of the hallway for Resident #13 on 2/09/2026 at 10:18 AM Geriatric Nursing Assistant (GNA) #17 was seen exiting the room of Resident #13 and entered into the room of Resident #22. GNA #17 returned from the room of Resident #22 holding a plastic bottle. He took the bottle back into the room of Resident #13.During an interview with GNA #17 on 2/09/2026 at 10:19 AM he reported that GNA #18 was giving a bed bath to Resident #13 and was out of body wash. GNA #18 had asked him to get her more body wash. He reported he had taken the body wash from the room of Resident #22 and took it to GNA #18 to so she could continue with the bed bath for Resident #13.During an interview with GNA #18 on 2/09/26 at 11:01 AM she confirmed that she was giving Resident #13 a bed bath and had run out…

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

Based on observations and interviews it was determined that the facility failed to ensure a Resident's smoke detector was in working condition. This was found to be evident for 1 (Resident #44) out of 9 Resident smoke detectors observed during the recertification and complaint survey. The findings include: During a random observation conducted on 02/08/2026 at 10:28 AM, the Surveyor heard a chirping sound from the 2nd floor nurse's station. The Surveyor followed the sound to Resident #44's room and determined the chirping sound came from the ceiling smoke detector.During an interview conducted on 02/08/2026 at 10:30 AM, Resident #44 reported that the smoke detector had been chirping for an extended period. During the interview the Surveyor observed Licensed Practical Nurse (LPN) #20 with her medication at the entry door of Resident #44's room. During an interview conducted on 02/08/2026 at 10:33 AM, LPN #20 reported that although she was in front of Resident #44's room she did not hear the smoke detector chirping so therefore she had not reported it the maintenance. On 02/08/2026 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 record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for professional standards of practice during the complaint survey. This deficient practice was identified as past non-compliance. The findings include:Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the Facility Reported Incidents (FRIs) #365430 and #365429 investigations was conducted on 10/06/25 at 9:54 AM. The investigation reported that following a discussion with Resident #5's Cardiologist on 4/23/25, it was determined that an error had occurred. It was identified that the therapeutic drug level of anti-rejection medications was low…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to ensure all medications were ordered as listed on the hospital discharge summary. This was evident for 1 (resident #5) out of 22 residents reviewed for physician services during the complaint survey. The findings include: Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the Facility Reported Incidents (FRIs) #365430 and #365429 investigations was conducted on 10/06/25 at 9:54 AM. The investigation reported that following a discussion with Resident #5's Cardiologist on 4/23/25, it was determined that an error had occurred. It was identified that the therapeutic drug level of anti-rejection medications was low which indicated that the Resident had not taken the medications as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to ensure that an accurate pharmacy medication regimen review was conducted. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for pharmacy medication regimen review during the complaint survey. The findings include: During a review of the Resident #5's medical records conducted on 10/06/25 at 10:07 AM, it was discovered that the Resident was transferred and admitted to a local hospital on [DATE]. A further review of Resident #5's medical record showed that the Resident was re-admitted to the facility on [DATE] following the hospital admission on [DATE]. Antirejection medications, also known as immunosuppressants, are drugs used to prevent the body's immune system from attacking and rejecting a transplanted organ. These medications are essential for ensuring the success of organ transplants and maintaining the health of the transplanted organ. A review of the discharge summary conducted on 10/06/25 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 it was determined that the facility failed to notify a Resident's Representative of a change in condition. This was found to be evident for 2 (Resident #18 and #11) out of 2 Residents reviewed for notification during a complaint survey. The findings include: 1) A gastrostomy tube (G-tube) is a feeding tube inserted through the abdomen directly into the stomach to provide nutrition, liquids, and medications. G-tubes are placed through a surgical procedure and are used for conditions where a person cannot get adequate nutrition by mouth. The surveyor reviewed Complaint #365422, by Resident #18's Representative which stated that the resident's G-tube feeding was changed from infusion via pump to bolus and they were not informed. On 10/7/24 at 9:00AM a review of Resident #18's clinical record revealed a physician's order dated 07/23/24 for Osmolite 1.5 at 60 ml/hour x 16 hours/day. The order was discontinued on 10/28/2024 at 8:16 AM and replaced with a new order for Osmolite 1.5 to be given via bolus 240 ml four times a day. Further review 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 interviews it was determined that the facility failed to ensure a Resident Fund Account was accurately managed. This was found to be evident for 1 (Resident #14) out of 1 Resident reviewed for resident funds during the complaint survey. The findings include: During a review of complaint #365431 conducted on 10/08/25 at 10:00 AM it was reported that the facility had not managed Resident #14's fund account accurately. During a review of Resident #14's billing record conducted on 10/08/25 at 10:07 AM, it was revealed that the Resident was charged $571 for Beauty Shop/Barber services. During an interview conducted on 10/08/25 at 10:11 AM, the Business Office Management (BOM) explained that the previous BOM failed to pay for Beauty Shop /Barber service charges that the Resident had incurred for 1 year. The BOM stated that she would provide the accounting of the barber services. During a review of the Senior Salon log sheets conducted on 10/08/25 at 10:32 AM, it was revealed that Resident#14's barber chargers totaled $515 and not $571 that was charged to the…

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

Based on review of the facility's investigative report and staff interview, it was determined the facility failed to report an allegation of abuse to the State Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of the alleged incident. This was found to be evident for 2 (Resident #19 and #7) out of 7 Residents reviewed for abuse during the complaint survey. The findings include: 1) On 10/6/25 at 9:00AM a review of Resident # 19's clinical record revealed that the resident was admitted to the facility with diagnoses which included Shortness of Breath, Dementia and Osteoarthritis of the Right Shoulder. Further review of Resident #19 clinical record revealed the resident sustained 2 large skin tears on both forearms while being assisted out of his/her chair by Hospitality Aide #12 who was not qualified to provide care to the resident. The sizes of the skin tears were not documented in the clinical record. However, in Complaint #365421 the resident's representative stated that the skin tears measured 2.5 inches by 1.65 inches. Hospitality Aide #12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, record reviews, and staff interviews, it was determined that the facility failed to ensure a complete and accurate written discharge summary was provided to a resident at the time of discharge. This was evident for 1 (Resident #2) of 1 resident reviewed for transfer and discharge process during the complaint survey.The findings include:Total Parenteral Nutrition (TPN) is nutrition provided through an intravenous (IV) line when a resident is unable to eat or absorb nutrients by mouth.Intravenous (IV) means within a vein. This allows the medicine or fluid to enter the bloodstream right away.On 10/08/25 at 10:17 AM, Resident #2's closed medical record was reviewed in relation to complaint #2563521. Resident # 2 was discharged to a group home on [DATE] with an abdominal drain and total parenteral nutrition (TPN). On 10/08/25 at 11:57 AM, a review of Resident #2's Discharge summary, dated [DATE], revealed that the nursing instructions section was incomplete. Information regarding…

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 review and revise the interdisciplinary care plans to reveal accurate interventions for a resident. This was evident for 1 (Resident #8) of 1 resident reviewed for care planning.The findings include:Resident #8 diagnoses include Dementia, Muscle Weakness (Generalized) and Cognitive Communication Deficit. The resident was admitted to the facility in May 2025 and discharged in October 2025. The surveyor reviewed Complaint #2624448 which was submitted anonymously and stated that the facility failed to provide appropriate care to the resident after a fall.On 10/08/25 at 10:21 AM a review of Resident #8's clinical record revealed that the resident fell on [DATE] at 8:00 PM in his/her room while trying to get something from his/her drawer. A Licensed Nurse completed an assessment which included neuro checks and documented that there were no injuries.A further review revealed a Nurse's Note Post Fall Documentation dated 9/12/2025 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 record review, observation and interviews, it was determined that the facility failed to ensure that wound dressings were labeled to indicate when the dressing change occurred. This was evident for 2 (Resident #21and #22) of 3 wound dressing observations.The findings include:On 10/07/25 at 7:45 AM a review of Resident #21's clinical record revealed that the resident was being treated for a skin tear to the Left Elbow 3 times a week and prn (as needed). The physician order dated 10/02/25 stated Left Elbow 1.Cleanse with normal saline, pat dry. 2. Apply Xeroform to base of the wound. 3. Secure with Bordered gauze. 4.Change every Mon, Wed, Fri and PRN every day shift every Mon, Wed, Fri. Start Date: 10/03/25On 10/7/25 at 8:05AM the surveyor accompanied by Wound Nurse RN #2 made random observations of residents' wound dressings. The surveyor observed that Resident #21's dressing to the Left Elbow was not initialed and not labeled as to when it was last changed and on what shift. 2) Resident #22's 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 medical record reviews and staff interviews, it was determined that the facility failed to provide treatment and services necessary to prevent pressure ulcer. This was evident for 1 (Resident #16) out of 1 resident reviewed for facility acquired pressure ulcer during the complaint survey process. The findings include:An in-house acquired pressure ulcer is a skin or tissue injury that develops while a resident is in the nursing facility, which was not present at the time of admission. These pressure ulcers occur due to prolonged pressure, friction, shear, or other risk factors and indicate a failure to implement preventive measures or provide timely interventionsDuring record review on 10/08/25 at 7:30 AM, it was revealed that Resident #16 was admitted from the hospital to the facility on 2/27/2025 with medical diagnoses of morbid (severe) obesity due to excess calories and type 2 diabetes mellitus without complications and had no pressure ulcers at the time of admission.On 10/08/25 at 8:00AM review of Resident #16's admission assessment record revealed a Braden Scale…

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, interviews and review of facility investigation documents, it was determined that the facility failed to keep a resident free from accidents and hazards by failing to provide a qualified caregiver to assist the resident. This was evident in 1 (Resident #19) of 1 resident reviewed for accidents and hazards during the complaint survey.The findings include:A review of Complaint #365421 made by Resident #19's Representative stated that the resident was observed on 10/21/24 with 2 lacerations on both arms, both measured 2.5 inches by 1.65 inches. Further, they were not notified of the injuries and when asked, the facility gave four different versions of the incident.On 10/6/25 at 9:00AM a review of Resident # 19's clinical record revealed that the resident was admitted to the facility with diagnoses which included Shortness of Breath, Dementia and Osteoarthritis of the Right Shoulder.Further review of the clinical record revealed a note dated 10/20/24 at 16:30 by LPN Staff #9 which stated that she was called to the resident's room and observed two large skin tears…

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 have an effective system in place to ensure interdisciplinary care plan meetings were occurring after assessments; and failed to ensure care plans were being reviewed and revised as needed. This was found to be evident for 8 (Resident #30; #23; #95; #78, #55. #84, #10, #100 ) out of 17 residents reviewed during the survey The findings include: 1) Review of Resident #30s medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but were not limited to, high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident has a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. On 9/13/24 at 11:09 AM, the unit nurse manager #12 reported care plan meetings are scheduled and family and residents are invited, and that therapy, dietary,…

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 post nursing staffing. This was evident during the staffing investigation portion of the recertification survey and had the potential to affect all residents, residents' representatives and visitors. The findings include: On 9/10/24 at 7:00 AM, the survey team entered the facility. A brief observation revealed a staffing list on the reception desk which contained a list of nursing staff by unit and by shift. On 9/12/24 at 8:52 AM, an interview with the Staffing Coordinator (Staff #3) was conducted to review the staff posting at the reception desk. Staff #3 provided multiple copies of the daily staffing lists that were posted at the reception desk and explained that they listed nurse staffing for each unit and each shift. She further explained that staff were expected to initial or sign next to their name when they arrived at the facility to work. There were also handwritten names which she explained were orientee staff names written next to the staff who were training them that shift.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on pertinent document review and interview, it was determined that the facility failed to address identified issues with the facility MOLST forms to ensure that residents wishes regarding CPR treatments were correctly documented in the residents' medical record. This has the potential to affect all residents in the facility. The findings are: A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status. The facility's annual survey conducted on [DATE] through [DATE] identified non-compliance for the failure to have a system in place to properly void MOLST forms and ensure there was only one active MOLST in a Residents electronic…

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 establish a quality assurance committee that included a medical director at every quarterly meeting. The findings include: On 9/19/24, the Facility Administrator (NHA) provided the quality assurance committee meeting with attendance sheets [DATE] through August 2024. Review of the attendance sheets failed to reveal that the medical director attended the meetings in May 2024, June 2024, and July 2024. On 9/19/24 at 3:44 PM during an interview, the NHA confirmed that the Medical Director (Staff # 26) was absent for three monthly consecutive meetings, which is equivalent to one quarterly meeting in the time period of September 2023, through August 2024. In addition, the NHA reported that there was not a substitute medical director that attended the quality assurance committee meetings in May 2024, June 2024 and July 2024.

Based on record review and interview, it was determined that the facility failed to ensure that staff had training in interpersonal communication. This was evident for 9 staff (NHA, DON, ADON, SW #11, SW #19, Staff #27, Staff #12, Staff #14, LPN #28, and Staff #29) of 10 staff training records reviewed during the extended survey portion of the recertification survey and had the potential to affect all residents. The findings include: On 9/19/24 at 10:29 AM, extended survey task triggered due to an Immediate Jeopardy situation related to duplicate but conflicting Medical Orders for Life Sustaining Treatment (MOLST) and resuscitation code status documents in resident records, which was determined on 9/13/24. In the morning of 9/19/24, The Director of Human Resources was asked to provide the training records for the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), both Social Workers (SW#11 & SW #19), the Director of Rehabilitation (Staff #27), the Unit Managers (Staff #12, Staff #14), and 2 Licensed Practical Nurse (LPN) nursing…

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

Based on record review and interview, it was determined that the facility failed to honor residents' right to self-determination. This was evident for 1 resident (Resident #37) of 17 residents reviewed for Medical Orders for Life Sustaining Treatments (MOLST) documentation related to the Immediate Jeopardy investigation during the recertification survey. This had the potential to affect all residents who could make their own decisions. The findings include: On 9/13/24, an Immediate Jeopardy situation was declared due to conflicting resuscitation (code status) instructions for Resident #328. As a result of this situation, the facility conducted an audit to confirm all residents' choice of code status. On 9/17/24 at 2:27 PM, a review of Resident #37's clinical records revealed that the resident was evaluated by the Medical Director on 7/18/24 and was determined to have capacity to make decisions. On 9/17/24 at 2:39 PM, a review of documentation was conducted to verify that the facility had confirmed Resident #37's code status choice. The record contained a progress note, dated…

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, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility. The findings include: 1a) On 9/10/24 at 2:37 PM, surveyor noted carpet in hallway near room [ROOM NUMBER] was stained in multiple areas. Continued observations made throughout the survey, on both the first and second floor, revealed multiple stains to the carpeting. On 9/13/24 at 10:04 AM during an interview with the Housekeeping Supervisor (Staff #49), she reported they have cleaned the carpets but the stains were still there and she was hoping they could pull them up. On 9/16/24 at 12:50 PM, in an interview with the Maintenance Director (Staff #25) it was reported that the facility had a plan in motion for the carpets and was just told by their supervisor a few weeks ago to get some quotes. The NHA was made aware of the concern regarding the carpeting on 9/18/24 at 4:20 PM. 1b) On 9/11/24 at 9:48 AM,…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psychotropic medications. This was evident for 1 (#78) of 5 residents reviewed for unnecessary medications, and 1 #(78) of 5 residents reviewed for unnecessary medications. 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 residents care The findings include: 1) On 9/18/24 at 12:04 PM, a review of Resident #78's medical record documented the resident was admitted to the facility at the end of June 2024 and had a diagnosis which included depression. Review of Resident #78's September 2024 Medication Administration Record (MAR) revealed an 8/20/24 order for Escitalopram Oxalate (Lexapro) (antidepressant) (psychotropic medication) by mouth one time a day for Depression that was documented as given every day from 9/1/24 to 9/13/24. Review of Resident #78's care plans revealed a care plan with the focus, 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 medical record review, observation and interviews, it was determined that the facility failed to ensure that activities were provided to meet the needs of the residents. This was found to be evident for 4 (Resident #30, #95, #13 and #109) out of 4 residents reviewed for activities during the survey. The findings include 1) On 9/11/24 at 10:40 AM, Resident #30 was observed alone in his/her room in a wheelchair by, no music or other activity was observed at that time. On 9/12/24, review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but were not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set (MDS) assessment, with a reference date of 6/5/24, revealed that the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. Review of the 9/5/24 MDS Section B revealed that the resident had clear speech and the ability to be understood and to understand others. Continued review 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 interview and observation, it was determined that the facility 1). failed to provide a Resident with a physician ordered pain medication. 2). failed to ensure that residents' pain was evaluated and managed. 3). failed to develop and implement non-pharmacological interventions prior to administering pain medication and failed to administer the pain medication on time. This was evident for 3 (Resident # 31, # 57 #50,) out of 4 residents reviewed for pain management during a survey. The finding include: 1). On 9/16/24 at 11:19 AM, Resident #31, a long-term care resident, requested an interview with surveyor. During the interview, s/he expressed concerns that he/she was not receiving his/her oxycodone pain medication. On 9/16/24 at 11:53 AM, Resident #31's physician orders were reviewed. The review revealed an order for oxycodone HCL oral tablet 20mg 4 times a day for pain management. On 9/16/24 at 11:55 AM, Resident 31's Medication administration record review revealed that from September first through September 16th at 8:00 AM, the resident received his medication 42 times…

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

Based on observation, medical record review, and staff interview, it was determined that prior to the installation or use of bed rails, the facility failed to ensure, 1) appropriate alternatives were identified and used, 2) the resident's risk of injury or entrapment was assessed, 3) the risks and benefits of bed rails was discussed with the resident/representative, 4) informed consent for bed rails was obtained, and 5) failed to ensure that a care plan with measurable objectives and specific interventions was developed for a resident's use of a bed rail. 6) that monitoring and supervision were provided during the resident's use of the bed rails, This was evident for 4 (#78, #380, #13, #57) of 4 residents reviewed for side rails. The findings include: Bed rails are adjustable bars that attach to the bed and are available in a variety of types, shapes, and sizes. As enablers, bedrails facilitate movement and may promote independence. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. 1) On 9/11/24 at 11:00 AM, 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 medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow physician ordered blood pressure parameters for administering medication, and 2) failing to ensure prescribed medications had adequate parameters in place to indicate when to administer as needed medications for pain. 3) failing to ensure that an attending provider's orders for a resident's topical anesthetic medication included a time to remove it This was evident for 3 (#78, # 25, # 50) of 5 residents reviewed for unnecessary medications, and 1 (#380) of 4 residents reviewed for pain management. The findings include: 1) On 9/13/24 at 12:36 PM, a review of Resident #78's medical record revealed the resident was admitted to the facility at the end of June 2024 following an acute hospitalization with multiple diagnosies including left hip fracture, and hypotension (low blood pressure). 1a) Review of Resident #78's July 2024 Medication Administration Record (MAR) revealed a 7//1/24 order for Oxycontin…

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, review of meal tickets and interview, it was determined the facility failed to ensure residents were served the correct portions and items as indicated on their meal tickets. This was found to be evident for one out of one test tray obtained during the survey. The findings include: On 9/11/24 at 10:44 AM, Resident #115 reported the physician had advised him/her to get a high protein diet but there seemed to be a disconnect because the resident was not getting that diet consistently. On 9/12/24 at 11:45 AM, observation of the tray line revealed a 1/2 cup scoop was being used for the portions, except for the beef pepper steak (Chopped up thinnly sliced beef) which was being served by the [NAME] (Staff #63) with a set of tongs. When asked about this practice, the [NAME] confirmed only using the tongs and proceeded to pick up a portion stating it was three ounces. During this observation, surveyor picked a tray at random from trays already made up and on the food cart. A copy of the ticket was obtained. The ticket was for Resident # 35 and indicated the tray was…

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

Based on observation, medical record review and staff interview, it was determined the facility failed to conduct a regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure the equipment was inspected and maintained according to manufacturer's recommendations and requirements and timeframes. This was evident for 3 (#78, #380, #13) of 3 residents reviewed for bed side rails and had the potential to affect all residents. The findings include: On 9/11/24 AT 10:37 AM, an observation was made of Resident #380 lying in bed and bilateral bed rails were observed attached to the resident's bed. On 9/11/24 at 11:00 AM, an observation was made of Resident #78 lying in bed and bilateral bed rails were observed attached to the resident's bed, and on 9/18/24 at 2:39 PM, Resident #78 was again observed lying in bed with bilateral bed rails observed attached to the resident's bed. On 9/11/24 at 11:36 AM, an observation was made of Resident #13 lying in bed. At that time, a quarter side…

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 faciltiy failed to have an effective system in place to ensure code status was discussed with residents and or their responsible party when new MOLSTs were created. This was found to be evident for 3 (Resident #30, #23. #97) out of 17 residents reviewed for code status during the survey. The findings include: 1). A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status. On [DATE] at 10:05 AM, Resident #97's MOSLT order, dated [DATE], was reviewed. The review revealed an order for Resident #97 not to receive CPR (DNR) if s/he should suffer cardiac arrest. Further…

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

Based on interview, and observation, it was determined that the facility failed to ensure that a resident received services with dignity. This was evident for 1 (Resident #42), out of 132 residents observed during a survey. The findings include: On 9/13/24 at 8:33 AM, Resident # 42 was interviewed. During the interview, he reported that sometimes the facility staff entered his room without knocking. On 9/13/24 at 840 AM, during an interview with Resident #42, a certified nursing assistant (CNA) (Staff #10) entered the room and delivered a lunch tray. An observation during the interview with Resident #42 on 9/13/24 at 840 AM, failed to reveal that Staff #10 knocked before entering the room. On 9/13/24 at 9:01 AM, Staff # 10 was interviewed. During the interview, Staff #10 reported that she introduced herself to the resident earlier in the morning, but she confirmed she did not knock when bringing the resident his/her lunch tray. Staff #10 reported that she just found out she had to knock prior to entering a room. On 9/20/24 10:50 AM, the above concern was discussed with the…

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

Based on records review and interviews, it was determined that the facility failed to provide residents with information to formulate an advance directive. This was evident in 3 (Resident #24, #37, #55) of 17 residents reviewed for advance directives. The findings include: 1). An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 9/17/24 at 2:27 PM, a review of Resident #37's clinical record revealed that there was no documentation related to advance directives. Further review revealed a document written by the facility's Medical Director on 7/18/24 that indicated the resident had capacity to make decisions. On 9/20/24 at 11:23 AM, another record review revealed a care plan meeting note dated 4/11/24, which contained 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 medical record review and interview, it was determined that the facility failed to notify a resident's representative of changes in the resident's treatment. This was found to be evident for 1 out of (Resident #23) one resident reviewed for notification of change. The findings include: During an interview with the resident's Health Care Power of Attorney (HCPOA) on 9/11/24 at 1:22 PM concerns were revealed regarding the HCPOA not being informed about the resident's care. On 9/17/24, review of Resident #23's medical record revealed the resident was admitted in June 2024 after a hospitalization. Review of the 6/11/24 Minimum Data Set (MDS) assessment revealed the resident was rarely or never understood, had functional limitations in range of motion on both sides for upper extremities (arms) and impairment on one side for lower extremities (legs). The resident was dependent on staff for activities of daily living and for eating. The resident was receiving occupational, speech and physical therapy. On 9/17/24, further review of the medical record revealed two cerifications 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 medical record review and interview, it was determined that the facility administered an intramuscular injection of an antipsychotic medication without adequate indication. This was found to be evident for one (Resident #30) out of five residents reviewed for unnecessary medication. The findings include: 1) Review of Resident #30's medical record revealed that the resident had resided at the facility for several years and whose diagnoses included, but were not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. Review of the medical record revealed that the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36. Review of the June 2024 Medication Administration Record (MAR) revealed that the resdient received IM injections of haloperidol (Haldol) and diphenhydramine (Benedryl) on 6/9/24 for…

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

Based on records review and interviews, it was determined that the facility failed to prevent further potential abuse while an investigation was in progress as evidenced by an inaccurate immediate assessment of the alleged victim. This was evident in 1 (Resident #232) of 5 residents reviewed for abuse. The findings include: Resident #232 resided in the facility for 20 days. An allegation of abuse on behalf of the resident was reported, related to a facility reported incident (FRI) with intake number MD00208964. A review of the investigation packet for the FRI was conducted on 9/20/24 at 9:09 AM. The review revealed the different steps the facility took to prevent further potential abuse of an alleged victim including a pain assessment conducted by the Director of Nursing (DON). The pain assessment with an effective date of 8/20/24 at 4:57 PM indicated the following: Pain presence: No pain in the last 5 days Pain frequency: Rarely or not at all Pain Interference with Therapy activities: Does not apply- have not received rehab in past 5 days Pain management: On a scheduled 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 record review and interview, it was determined that the facility failed to ensure that essential information was provided to emergency department staff when a resident went to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization during the recertification survey. The findings include: On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician's order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed a transfer form completed by Licensed Practical Nurse (LPN #34) dated 9/04/24, that contained clinical information regarding the resident's status. On 9/12/24 at 9:50 AM, Resident #10 was observed in bed but did not respond to the surveyor's spoken greeting. A sign on the wall above the resident's bed indicated that the resident had a device for ASL [American Sign Language] Interpreter. The device was not present in the room, and the resident refused further interaction at that time. On 9/12/24 at 11:10 AM, a review of Resident #10's clinical record revealed…

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

Based on record review and interview, it was determined that the facility failed to provide a resident with a notice of transfer when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization. The findings include: On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed no Notice of Transfer documents were present. On 9/17/24 at 11:47 AM, an interview with Licensed Practical Nurse (LPN #34) was conducted. During the interview, Staff #34 reviewed Resident #10's documents and confirmed that there was no transfer notice in the resident's record. On 9/17/24 at 1:03 PM, an interview with the Director of Nursing (DON) was conducted. She was informed that there was no evidence that a transfer notice was provided to the resident when the resident was transferred to the hospital on 9/04/24. She was asked to provide any additional evidence, but none was provided by the end of the survey.

Based on record review and interview, it was determined that the facility failed to provide a resident a bed hold notice when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization. The findings include: On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician's order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed no bed hold notice in the resident's chart. On 9/17/24 at 11:47 AM, an interview with Licensed Practical Nurse (LPN #34) was conducted. During the interview, Staff #34 reviewed Resident #10's documents related to the hospital transfer on 9/04/24 and Staff #34 confirmed that there was no bed hold notice in the resident's record. On 9/17/24 at 1:03 PM, an interview with the Director of Nursing (DON) was conducted. She was informed that there was no evidence that a bed hold notice was provided to the resident when the resident was transferred to the hospital on 9/04/24. She was asked to provide any additional evidence, but…

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 interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#107) of 1 resident reviewed for behavior. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. A record review on 9/16/24 at 11:13 AM found that Resident #107 was admitted to the facility in April 2024. The continued review contained four MDS assessments, dated 4/24/24, 5/23/24, 6/3/24, and 9/3/24, for Resident #107. All the MDS assessments documented in section GG that Resident #107 had an impairment in range of motion (ROM) to both sides of his/her lower extremities. Observation of Resident #107 on 9/16/24 at 1:16 PM showed the Resident lying supine in bed with knees bent. Staff #8, a licensed practical nurse, was at the Resident's bedside. She reported…

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 records review and interviews, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form was completed for a newly admitted resident. This was evident for 1 (Resident #50) of 2 residents reviewed for PASRR. The findings include: Preadmission Screening and Resident Review is federally mandated and must be completed for all applicants in nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions. Resident #50 was admitted in the facility in late 2024. A brief review of the resident's medical record on 9/11/24 at 12:41 PM revealed an incomplete PASRR form, dated 8/22/24. A subsequent review of the PASRR form 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 review of the medical record and interview with staff, it was determined that the facility staff 1) failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 1 (#380) of 4 residents reviewed for pain management. The findings include: On 9/11/24 at 10:24 AM, during an interview, when asked if the resident or his/her representative received a written summary of the resident's initial care plan along with a summary of the resident's medications since s/he was admitted to the facility, Resident #380 indicated s/he had not, and deferred to his/her family member representative who was present during the interview. At that time, Resident #380's representative stated they had not been given a copy of the baseline care plan, however after requesting a copy of the resident's medications, a copy of the resident's medication list was given to the representative. In addition, the resident and his/her representative stated that the resident's baseline care plan and medications had 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 medical record review and interview, it was determined that the facility failed to ensure that nursing staff did not document administration of g-tube feedings that they had not actually provided. This was found to be evident for one (Resident #23) out of one resident reviewed for g-tube feeding. The findings include: Review of Resident #23's medical record revealed that the resident was admitted in June 2024 after a hospitalization. The resident's diagnosis included dysphagia which is difficulty swallowing and the resident had a g-tube for the administration of nutrition. The resident was admitted with orders that nothing was to be given by mouth, and a g-tube with orders for bolus feedings of Jevity 1.5 four times a day. A bolus is when a large amount of feeding is given at one time. Further review of the medical record revealed there were two different enteral feed (g-tube) orders in effect from 6/6/24 until they were both discontinued on 7/26/24. The first order, placed on 6/6/24 at 4:22 AM, was for Jevity 1.5 425 ml bolus four times a day every 6 hours per protocol.…

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 ensure that residents' communication needs were met. This was evident for 1 complaint (#MD00209021) of 5 complaints reviewed during the recertification survey. This had the potential to affect all deaf residents. The findings include: On 9/10/24 at 12:14 PM Resident #10 was observed in bed with their eyes closed and appeared to be asleep. A sign above the resident's bed indicated to use an interpreter line IVR instructions and included a company name - o, which indicated to call a phone number and say the language and the call would be connected to an interpreter. A second sign on the wall indicated that to communicate using ASL [American Sign Language] to request a tablet from Admissions, go to the interpreter app, choose the video button, hit the call button and the app would search for a live interpreter. The bottom of the sign stated Staff, tablet must be returned to Admissions once patient discharges. No such tablet was observed in the resident's room. On 9/12/24 at 8:03 AM, 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 medical record review, and staff interviews, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinent care in a timely manner. This was evident for 1 (Resident #16) out of 132 residents reviewed during the survey process. The finding include: On 9/17/24 at 5:40 AM, an observation was made of the second-floor nursing units. On 9/17/24 at 5:44 AM, an observation revealed the call light flashing above Residents #16's room, along with an accompanying audible alarm. On 9/17/24 at 5:51 AM, an observation was made of the Assistant Director of Nursing (ADON) entering Residents #16's room. On 9/17/24 at 5:51AM, an observation was made of the call light turned off and the ADON exiting the room. On 9/17/24 at 5:52 AM, Resident #16 was interviewed. During the interview s/he reported that s/he had first put her call light on at 5:10 AM. Resident #16 stated that the nurse came in shortly after 5:10 AM and told her/him that he would get someone to come in and assist her/him. Resident #16 reported…

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, observations and interviews, it was determined the facility failed to accurately assess the presence of pressure injuries and implement pressure prevention therapies. This was evident for 2 (Resident #328, #109) out of 5 residents reviewed for pressure injuries. The findings include: 1.On 9/11/24 at 8:02 AM, a review of medical records revealed that Resident # 328 was admitted to the facility for rehabilitation following a hospital stay. On 9/11/24 at 2:59 PM, review of orders for Resident #328 failed to reveal any orders for pressure preventions. On 9/12/24 at 8:06 AM, a review of Resident # 328's hospital discharge summary revealed a list of discharge conditions. Review of the discharge instructions failed to reveal that Resident had a pressure injury. On 9/12/24 at 8:09 AM, a review of the medical records titled admission Nursing/readmission Collection Tool, with an effective date of 8/31/2024 6:10 PM, revealed a section to document a skin observation. Review of the skin observation section revealed that a head to toes skin assessment was completed 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 medical record review and interview, it was determined that the facility failed to develop a care plan to ensure that advances in mobility that were achieved during therapy were maintained. This was found to be evident for one (Resident #23) out of three residents reviewed for falls during the survey. The findings include: Review of Resident #23's medical record revealed that the resident was admitted in June 2024 after a hospitalization. Review of the 6/11/24 Minimum Data Set (MDS) assessment revealed that the resident had functional limitations in range of motion on both sides for upper extremities (arms) and impairment on one side for lower extremities (legs). The resident was dependent on staff for activities of daily living. The resident was receiving occupational, speech and physical therapy in June. On 9/17/24 at 1:58 PM, review of the medical record failed to reveal a Multidisciplinary Care Conference note that would indicate a care plan meeting had occurred during the resident's admission. 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 medical record review, observations, and interviews, it was determined that the facility failed to have a system in place for monitoring residents who have been identified as high risk for elopement. This was evident for 1 (#59) of 6 residents reviewed for accidents. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the resident, and modify the care plan based on the Resident's status. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. A medical record review for Resident #59 on 9/18/24 at 10:45 AM showed that Resident #59 had been residing in the facility since May 2020. Diagnoses included Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). The review also noted that Resident #59 was able to ambulate…

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 identify a resident with a critically low body mass index (BMI) and failed to have a policy and procedure in place to measure residents' height. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey and had the potential to affect all residents. The findings include: Body Mass Index (BMI) is a measurement of weight relative to height. It is used as a reliable screening measure for underweight, overweight, or obesity. On 9/11/24 at 9:34 AM, a review of Resident #17's weight and height documentation in the electronic record revealed: Weight 9/05/24 = 105.7 lbs Mechanical Lift 8/05/24 = 106.4 lbs Mechanical Lift 7/30/24 = 106.1 lbs Mechanical Lift 7/23/24 = 106.0 lbs Mechanical Lift Height 7/23/24 = 61.0 inches lying down 12/16/16 = 72.0 inches Standing 12/08/16 = 72.0 inches Standing On 9/16/24 at 3:41 PM in an interview with the Director of Nursing (DON), she was asked about the difference in Resident #17's height in 2024 and 2016 and…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that feedings via a g-tube were administered as ordered and failed to ensure a plan to try to restore oral eating was established. This was found to be evident for one (Resident #23) out of one resident reviewed for tube feeding. The findings include: Review of Resident #23's medical record revealed the resident was admitted in June 2024 after a hospitalization. The resident's diagnosis included dysphagia which is difficulty swallowing and the resident had a g-tube for the administration of nutrition. The resident was admitted with orders that nothing was to be given by mouth, and a g-tube with orders for bolus feedings of Jevity 1.5 four times a day. A bolus is when a large amount of feeding is given at one time. Further review of the medical record revealed there were two different enteral feed (g-tube) orders in effect from 6/6/24 until they were both discontinued on 7/26/24. The first order, placed on 6/6 at 4:22 AM, was for Jevity 1.5 425 ml bolus four times a day every 6 hours…

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, it was determined that the facility failed to provide behavioral health monitoring to ensure a resident's highest practicable mental and psychosocial well being.This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications. The findings include: Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. Review of the medical record revealed that the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36. 1) Review of the Psychiatric NP #36's note, dated 2/7/24, revealed the resident's current psychiatric medications included Seroquel (an antipsychotic) 25 mg two times a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff, it was determined that the facility failed to ensure that Irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon and documented in the resident's medical record. This was evident for 3 (#30, #78, 50 ) of 5 residents reviewed for unnecessary medications. The findings include: 1) Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. On 9/16/24, review of the medical record revealed a Consultant Pharmacist's Recommendation to Physician, dated 5/6/24, which stated: Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking Seroquel 25 mg…

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

Based on medical record review and interview, it was determined that the facility failed to ensure the resident was free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications. The findings include: Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. Review of the medical record revealed the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36. 1) Further review of the medical record revealed a change in condition note that, on 6/8/24, the resident was highly agitated and was observed being verbally abusive and throwing items at the resident's roommate. 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, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 3 errors identified out of 25 opportunities for error. The findings include: 1) On 9/13/24 at 9:45 AM, during an observation of medication administration, Staff 13, Licensed Practical Nurse (LPN) was observed dispensing 5 pills into a medication cup and administering the pills to Resident #383. One of the pills dispensed and administered to Resident #383 by mouth was Calcium 600 mg (milligram) tablet. Following the medication observation, a review of Resident #383's September 2024 Medication Administration Record (MAR) revealed an 8/30/24 order for Calcium 600 mg (milligram) + Vitamin D3 (Cholecalciferol) 20 mcg (microgram) give 0.5 tablet by mouth one time a day, that Staff #13 documented as given on 9/13/24. The medication ordered was a combination drug of Calcium 600 mg and Vitamin D3 20 mcg, which was different than the Calcium 600 mg tablet Staff #13 administered to Resident #383. Staff #13…

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 interview and review of relevant documentation, it was determined that the facility failed to have a full time clinically qualified Food Service Director and failed to ensure scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This was evident for 1 (Staff #62) of 1 Food Service Director reviewed for required credentialing. The findings include: On 9/14/24 at 12:30 PM, an interview was conducted with the current Food Service Director (FSD-Staff #62) who reported she had worked at the facility for 4 years but was not a Certified Dietary Manager. Surveyor requested the FSD's current credentials. The FSD confirmed that the facility's Registered Dietitian (RD) was not involved in the running of the kitchen, and indicated she thought the facility did not currently employ a full time RD. State regulations require in a nursing home with more than 50 beds, overall supervisory responsibilities for the food service department and food production shall be assigned to a full-time qualified dietetic service supervisor. The state…

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

Based on observation, and interview, it was determined that the facility failed to ensure clean dishes were stored and maintained in a manner to prevent contamination. This practice had the potential to affect all the residents in the facility. The findings include: On 9/10/24, an initial tour of the kitchen was conducted at 7:30 AM. During this tour, surveyor observed in the dishwashing room a cart with approximately 20 cups, in stacks of about 4-5 where the cups were inverted and stored open area down on a tray. Significant moisture was noted in all of these cups. The dietary aide (Staff #61) reported these cups were for lunch. Surveyor then asked the [NAME] (Staff 63) to observe the glasses; at first the [NAME] said that the staff will wipe them. When surveyor repeated this statement back, the [NAME] then said: will send them thru the washer again and let them air dry. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganism can grow. On 9/12/24 at 11:45 AM, during a revisit to the kitchen…

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 document clinical assessments. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey. The findings include: On 9/11/24 at 9:34 AM, a review of Resident #17's height and weight documentation was conducted. There were 3 entries in the Height Summary: 7/23/24 61.0 inches lying down 12/16/16 72.0 inches Standing 12/08/16 72.0 inches Standing On 9/19/24 at 2:12 PM, an interview with the Director of Nursing (DON) was conducted to review the discrepancy in the resident's documented heights., 72 inches, and 61 inches. When asked to confirm the resident's current height, the DON agreed to measure the resident's height. On 9/19/24 at 2:45 PM, the DON informed the surveyor that she measured the resident's height today and it was 70 inches. On 9/23/24 at 8:54 AM, an updated printout of Resident #17's height measurements was requested. When the DON provided the printed copy, there were no additional entries beyond 7/23/24. The record did not contain…

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, observation, and interview, it was determined the facility failed to maintain a resident's medical equipment in proper sanitary conditions and failed to process linens in a manner that prevents cross contamination. This was evident for 2 (Resident #88, #330) out of 2 residents, reviewed for urinary catheter or urinary tract infection during a survey and evident in 1 of 1 laundry room observations during the recertification survey and had the potential to affect all residents of the facility. .The findings include: 1. 0n 9/10/24 at 2:29 PM, review of medical records revealed that Resident #88 was a long-term resident of the facility. Further review revealed that Resident # 88 had a foley catheter in place and was being treated for a urinary tract infection. On 9/13/24 at 8:53 AM, an observation was made in Resident #88's room. The observation revealed the Foley tubing was attached to the lower bar on his/her bed and the drainage bag was resting on the floor. On 9/13/24 at 9:14 AM, an observation was made with the Unit Manager LPN, (Staff # 12) and the…

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

Based on family and staff interview, and observation, it was determined the facility failed to maintain electrical equipment in safe operating condition and failed to maintain a bathroom safety rail in a safe operating condition. This was evident for 1 of 1 microwave observed during the survey and evident for 1 residents room. 1) On 9/20/24 at approximately 10:00 AM, Resident #380's family member asked if the surveyor had seen the microwave in the 1st floor pantry where residents could have food reheated. The family member then stated that the interior of the microwave was rusty and s/he was concerned the microwave was not safe to use. 9/20/24 at 10:05 AM, observation of microwave revealed the white coating on the walls and floor of the microwave was peeling with areas of coating missing, exposing areas of rust. This included a larger, irregular area, approximately 7-inch x 1 inch, in the back floor of the microwave, where the coating was missing, and peeling, and the area in the microwave was rusted. Also, on the left interior wall of the microwave, there was an irregular area,…

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 interviews, it was determined that the Facility failed to have the call light within reach of a dependent resident. This was evident for 1 (#402) of 3 residents reviewed for Activity of Daily need (ADL) dependence during a revisit survey. The finding include: On 12/18/23 at 2:00 PM Resident #402 was observed lying in bed half asleep, further observation revealed that the call light could not be found. The resident was asked about their call light, and they stated that they did not know where it was. At 2:03 PM a Geriatric Nursing Assistant (GNA) #16 was called into the resident's room. She was asked how resident calls for assistance, and she said resident can use the call light. She was asked about the whereabouts of the call light. Staff #16 proceeded to look for the resident's call light. She searched around the room and underneath the resident's bed but could not find it. She asked the resident, and s/he said they did not know where it was. She searched some more and finally located it tucked inside the top drawer of the resident's nightstand; 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility. The findings include: 1) On 9/16/24 between 1:00 PM - 2:00 PM, surveyor and the Maintenance Director #25 toured several resident rooms on both floors of the facility. During this tour, five out of nine bathrooms observed failed to have a functioning air vent exhaust system. When it was discovered that the exhaust in room [ROOM NUMBER]'s bathroom was not functioning, the Maintenance Director removed the vent cover and examined the vent with a flashlight, and stated he was not sure why there was no exhaust. In addition to room [ROOM NUMBER], the exhaust vents were found not to be working in the bathrooms in rooms 123; 205; 207; or. 231. The concern regarding the ventilation system was addressed with the Nursing Home Administrator (NHA) on 9/18/24 at 4:20 PM. 2) On 9/10/24 at 12:27PM, Resident #55 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interview with staff it was determined the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 5 of 27 abuse allegations reviewed for Residents (#1, #2, #7, #62, #3 ). The findings include: 1. Facility Reported Incident (FRI) #MD00186593 related to an allegation of abuse involving Resident #1 was reviewed on 6/11/24 at 12:50 PM. The Date/Time of the incident in the facility's report was 12/9/22 11:45 AM and the police report was 12/9/22 at 11:45 AM. The facility's email containing the Initial self-report was dated 12/9/22 2:36 PM. It was not sent to the State Agency within 2 hours of the allegation. 2. The facility's investigation documentation for FRI #MD00196546 was reviewed on 6/13/24 at 11:13 AM. The report indicated that 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 review of facility documentation and interview with staff it was determined the facility staff failed to investigate, prevent, and correct alleged abuse violations. This was evident for 6 of 27 abuse allegations reviewed related to Residents (#1, #24, #29, #3, #61 and #17). The findings include: 1. Facility Reported Incident (FRI) #MD00186593 was reviewed on 6/11/24 at 12:50 PM. The report alleged that on 12/14/22 Staff #37, a Geriatric Nursing Assistant (GNA) photographed Resident #1 while he/she was sitting on the toilet. The facility's investigative documentation included a typed statement from Staff #37. It did not include the date and time the statement was written nor when the events described in the statement took place. The statement was not signed by the person providing the statement to indicate it was their statement. The facility's report indicated that the incident occurred on 12/9/22 at 11:45 AM and the police were notified on 12/9/22 at 11:45 AM. However, review of GNA #37's time punch record on 6/12/24 at 11:46 AM revealed that GNA #37 worked from 6:54 AM -…

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

Based on medical record review and interview with staff it was determined the facility staff failed to accurately complete resident assessments reflective of the resident's status. This was evident for 5 of the last 5 assessments for 1 (Resident #1) of 65 resident's reviewed for during the survey. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The Brief Interview for Mental Status (BIMS) is a 15-point cognitive screening test that evaluates memory and orientation. 0-7 points: Severe cognitive impairment, 8-12 points: Moderate cognitive impairment and 13-15: Intact cognition. A PHQ (Patient Health Questionnaire) is a nine-item questionnaire that can be…

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 the review of a complaint, medical record review and interview with staff, it was determined that staff failed to provide all treatment and care to residents in accordance with professional standards of practice by failing to follow practitioner orders and established care plans. This was evident for 4 of 65 (#43, #1, #25 and #20) residents reviewed during a complaint survey. 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 findings include: 1. Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after a short stay at home with 3 areas, the groin, the medial and the anterior areas of the right leg all noted as surgical incisions requiring wound care and treatment by the wound care nurse practitioner on admission. A review of the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to ensure Resident #35's responsible party (RP) was provided the opportunity to consent to the COVID-19 vaccine for Resident #35. This was evident for 1 of 81 residents selected for reviewed during the complaint survey. The findings include: Investigation of complaint MD00179248 on 6/13/24, at 11 AM revealed the facility staff failed to have a representative present when a resident signed documents. A Brief Interview for Mental Status (BIMS) score is a cognitive screening tool that evaluates memory and orientation in older adults. It's often used in nursing homes and other long-term care facilities to identify and treat changes in mental abilities. A BIMS score of 0 indicates severely impaired cognition. Review of Resident #35's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include blindness and a BIMS of 0. Further review of Resident #35's medical record…

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

Based on observations and interview with staff it was determined that the facility failed to assess a resident for capability to self-administer medications. This was identified during a resident interview where medications were randomly observed on the nightstand. (#43) The findings include: During interview with Resident #43 on 6/18/24 at 7:45 AM this surveyor noted multiple bottles of vitamin supplements piled up on the resident's nightstand. Surveyor interviewed the facility DON on 6/18/24 at 8:20 AM after leaving the residents room and asked what the process was to determine if a resident can self-administer medication. She stated that no residents here in the facility self-administer medications. I further asked what about supplements. She stated again that the facility is the one that provides the supplements to the residents. Concurrently during the interview, this surveyor had pulled up the electronic medical record for Resident #43. According to the physician orders, there were no orders in place or assessments completed that stated s/he could self-administer medications.…

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 random observations from tours and complaints that were placed with the Office of Health Care quality, it was determined that the facility failed to attend to and answer call bells timely for dependent residents. This was evident during tour of the first and second floor and the validated review of 1 of 49 complaints. (Resident #10) The findings include: 1. Tour of the facility on 6/12/24 at 7:09 AM to observe and interview residents, a call bell could be heard from the first-floor elevator. As this surveyor waited for the elevator to come, the call bell was heard continuing to go off. This surveyor proceeded down the hall towards unit one and 5 nursing staff, a mix of GNA's and nurses, were observed standing and or sitting at the desk. To the left a call light was observed flashing on. This surveyor proceeded down the hall towards the call light. Moments later a GNA appeared behind this surveyor and entered the room where the call light was on and was heard asking the resident if they needed anything.…

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 reviews of a closed electronic medical record and staff interview, it was determined that the facility medical staff failed to create a MOLST for a resident upon admission. This was evident for 1 (Resident #57) of 65 residents reviewed during a complaint survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must accurately and legibly complete the form and then sign and date it. This also includes correctly identifying the name of the resident at the top of the form. Voiding the Form: to void this medical order form, a physician or nurse…

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, reviews of a closed medical record, and staff interviews, it was determined that the facility staff failed to 1. Immediately notify a resident's physician when a resident had fallen. 2. Notify the surgeon per discharge instructions or 3. Notify a residents' representatives of a change in condition and hospitalization. This was evident for 3 (Resident #8, #58, #59) of 65 residents reviewed during a complaint survey. The findings include: 1. A review of complaint MD00198899 on 06/11/24 revealed an allegation that Resident #8 had fallen and was not assessed or treated. A review of the facility Falls Management Program policy on 06/11/24 revealed that: The nurse will notify the resident's provider, responsible party, and/or EMS if indicated, as well as the supervisor/administrative personnel as appropriate. A review of Resident #8's closed medical record on 06/11/24 at 11 AM revealed that Resident #8 had been admitted to the facility on [DATE] for rehab after being treated at the hospital for 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 the review of a complaint, staff and resident interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident during the review of 1 of 2 complaints regarding discharges. (Resident #5) The findings include: Review of the complaint #MD00203025 on 6/10/24 at 9:45 AM revealed concerns regarding his/her discharge planning and preparation as well as the actual day s/he left the facility and not receiving all their personal property. A closer review on 6/10/24 of the discharge that occurred on 2/23/24 and the completed paperwork revealed that Resident #5 had not signed any discharge paperwork, including the discharge instructions/post discharge plan review or the resident property list. The facility DON was interviewed on 6/10/24 at 11:49 AM. The facility process on discharge was reviewed. She stated that the staff are to review the discharge planning and have the resident sign it and then it is scanned into the computer. Additionally, this is the process for the resident property list. Neither 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 medical record review and interview with facility staff, it was determined that the facility failed to implement a care plan related to a resident's primary diagnosis and therefore implement a plan of care related to that diagnosis. This was evident for 1 of 65 residents (#43) reviewed during a complaint survey. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. The findings include: Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after s/he went home postoperatively from right lower extremity surgery on the circulatory system. At home s/he developed cellulitis and returned to the hospital for antibiotics and required further rehabilitation services at this nursing care facility. On admission to the nursing…

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

Based on medical record review and staff interview it was determined that the facility failed to ensure that residents had a discharge summary and it was complete and accurate (Resident #17, #25, #36 and #54). This was evident for 4 of 65 residents reviewed during a complaint survey. The findings include: 1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 from the hospital and went to a surgery appointment on 5/19/24 at 4:15 AM. Further review of the medical record revealed the Resident did not return to the facility following the appointment. Further review of the medical record revealed no final summary of the resident's status at the time of discharge. Interview with the Director of Nursing on 6/17/24 at 2:10 PM confirmed the facility staff failed to document a discharge summary in Resident #25's medical record. 2. Review of resident #21's medical record on 6/10/24 at 12:36pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/2/23 and failed 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 the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to implement wound care orders for a resident with a stage 3 pressure ulcer. This was evident during the review of 2 of 5 residents (#40 and #37) reviewed for wounds during a complaint survey The findings include: 1. Review of the complaint #MD00175703 on 6/10/24 at 11:25 revealed concerns related to the treatment of Resident #40's wounds that were identified as a stage 3 sacral ulcer. Further review at this time of Resident #40's medical record revealed that s/he had a re-hospitalization during their stay. Upon readmission to the facility, there were no wound care orders reinstated for the treatment of the sacral stage 3 ulcer until Resident #40 was seen by the wound care nurse practitioner 3 days later on 2/25/22. Prior to discharge the wound care regimen consisted of treatment 3 times a day. A review of Resident #40's physician orders and medication and treatment administration record confirmed that there were no orders or treatments implemented during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a closed medical record, and staff interviews, it was determined that the 1. facility staff failed to follow a resident's fall prevention care plan to ensure all nursing interventions were implemented. Resident #8 did not have the call light within reach and tried to walk to the restroom without assistance and fell. This was evident for 1 (Resident #8) of 65 residents reviewed during a complaint survey and 2. the facility failed to ensure that staff were using a mechanical lift to transfer residents based on the manufacturer's instructions to ensure resident's safety. This was evident for 1 of 1 observation of a resident transfer in a mechanical lift. The findings include: 1. A review of complaint MD00198899 on 06/11/24 revealed an allegation that Resident #8 had fallen and was not assessed or treated. A review of the facility Falls Management Program policy, on 06/11/24, listed a procedure that included but not limited to: Prevention, a Fall Risk Tool will be completed upon…

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, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to 1. discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 and 2. failed to accurately monitor and assess a resident's weights on admission. This was evident for 1 of 3 residents during a complaint survey (#60) The findings include: 1. A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on [DATE] and arrived without his/her upper dentures. A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom. A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's…

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

Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 65 (#4) Residents reviewed during a complaint survey. The findings include: When the medical record of Resident #4 was reviewed on 6/12/24 at 1:11 PM a physician discharge note with an effective date of 5/19/24 was the first note to appear. However, Resident #4 was discharged from the facility on 3/22/24 to the emergency room and had not returned. This physician discharge note said that it was completed on 3/14/24. However, according to the resident's census report, s/he had been in and out of the facility twice since the note was written. This identified concern of the delay to have the physician note in the chart timely was reviewed with the DON on 6/12/24. At approximately 1:30 PM on 6/12/24 the DON was asked what the expectation and process was to have physician notes in the resident medical records. She stated that the notes are to be completed and in the charts within…

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

Based on the review of a facility reported incident (FRI) #MD00204392 related to an allegation of abuse, a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 1 out of 5 employee files reviewed for competencies and skill sets. The findings include: Review of the FRI #MD00204392 on 6/11/24 at 9:07 AM revealed an allegation of abuse occurring with Resident #3 at the hands of GNA #7. A review of the facility investigation and concurrent review of the employee file for GNA #7 revealed that upon hire on 8/6/19 the Certified Nursing Assistant competency check off sheet was never completed. The DON was interviewed on 6/11/24 at 10:10AM. This concern was brought to her attention as she was present and had completed this investigation and investigation packet. She was not aware of the blank competency check list. She was asked at this time for anything further or any education or training that was completed with staff GNA #7 since her hire. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of a complaint, resident interview and interview with the facility staff, it was determined that the facility failed to timely provide a resident with an established psychiatric diagnosis with therapeutic treatment to maintain his/her highest practicable well-being. This was evident during the review of 1 of 65 residents (#33) reviewed during a complaint. The findings include: Review of the complaints for Resident #33 on 6/17/24 at 10:17 AM, #MD00174214 and #MD00180447 revealed concerns related to general care in the facility and the fact that s/he battles with severe depression and anxiety and with the lack of care and neglect that [s/he] is not receiving, the depressive and anxiety episodes are increasing. The complaints also noted that the individual was under [AGE] years old. Continued record review revealed that Resident #33 has been a resident of the facility since February 2020. Admitting diagnosis' included acute transvers myelitis (a rare neurological condition that causes…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 1 out 1 resident (#51) in the complaint sample. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually…

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, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 residents reviewed during a complaint survey. The findings include: A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on [DATE] and arrived without his/her upper dentures. A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom. A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's family member who requested that the nursing staff place Resident #53's dentures in his/her mouth during meals.…

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

Based on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #25 and #51). This was evident for 2 of 65 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 following crainiectomy surgery. A craniectomy is a major brain surgery that involves removing part of the skull to relieve pressure on the brain. Further review of the medical record revealed a physician note on 4/4/23 that stated: Patient getting ready for his/her neurologist appt today, states doing well. Further review of the medical record revealed no documentation from…

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 facility's Quality Assurance and Performance Improvement (QAPI) record review and interview, the facility failed to adequately monitor malfunctions in the facility's hot water heating system. QAPI Plan A written plan that contains the process that will guide a facility in their efforts to assure care and services are maintained at acceptable levels. QAPI Committee A group consisting of a facility's administration department and selected other facility staff that review the facility's process to ensure care and services are maintained at acceptable levels. Findings include: The State of Maryland's Department of Health Office of Health Care Quality received a complaint (MD00193286) from resident #17 which alleged that facility was having issues with providing hot water to resident's rooms. On 6/10/24 at 11:42am, the surveyor interviewed maintenance director #2 regarding resident #17's allegations of the facility failing to maintain hot water in resident's rooms in the month of 6/2023. Maintenance Director #2 stated that he/she was unaware of hot water issues in the summer…

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 ensure infection control practices to prevent development and transmission of communicable disease and infections for resident #221. This finding was evident for 1 of 3 residents reviewed for the respiratory care area. Additionally, based on surveyor observations and interview with facility staff, it was determined that the facility staff failed to ensure appropriate hand hygiene practices between residents' contacts during meal distribution. This finding was evident for 2 of the 2 floors within the facility of resident units. The findings include: 1. On 09-23-19 at 10:30 AM, surveyor tour to resident #221's room revealed oxygen tubing connected to an oxygen concentrator (a device which concentrates the oxygen from the surrounding air). The tubing was observed on the floor under the resident's bed. The tubing and the humidifier bottle were not dated. Additional observation revealed a nebulizer treatment (a drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility failed to develop comprehensive plans of care for residents. This finding was evident for 4 of 34 residents selected during the survey (#30, #61, #64, #99). The findings include: 1. a. On 09-23-19, surveyor review of the clinical record for resident #64 revealed the resident was alert and oriented and able to verbalize his/her own needs. Further review revealed that an admission smoking evaluation was completed on 07-23-19, and that the resident was assessed as safe to smoke with staff supervision. Surveyor observations on 09-23-19 at 10:15 AM, and on 09-24-19 at 2 PM, revealed resident #64 outside the facility, in the designated smoking area, smoking and conversing with staff and other residents. However, further record review revealed no documented evidence of a comprehensive plan of care that addressed resident #64's smoking behavior as well as the need for supervison…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observations, review of the facility's policy and procedure, interview with residents, maintenance contractors and facility staff, it was determined that the facility failed to ensure that water temperatures were maintained in residents' rooms at a safe temperature below 120 degrees Fahrenheit (F). The findings include: a. On 09-23-19 at 12:00PM, surveyor observation revealed the following initial hot water temperature results for residents' bathrooms sinks: room [ROOM NUMBER] = 123.8 F room [ROOM NUMBER] =127.9 F room [ROOM NUMBER]= 126.8 F room [ROOM NUMBER] =125.5 F room [ROOM NUMBER] = 128.8 F room [ROOM NUMBER] = 128.7. F b. Further observations on 09-23-19 at 12:30PM revealed the following hot water temperatures obtained at residents' bathroom sinks: room [ROOM NUMBER] = 123.8 F room [ROOM NUMBER] = 128 F room [ROOM NUMBER] = 126.5 F room [ROOM NUMBER] = 128.1 F room [ROOM NUMBER] = 128.1 F c. Observations of follow up hot water temperatures obtained at the following 2nd floor residents'…

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

Based on surveyor observations and interview with facility staff, it was determined that the facility failed to ensure the dignity of residents. This finding was evident for 3 of 4 residents selected for the Dignity review. (#26, #58, #219) The findings include: 1. On 09-23-19 at 10:30AM, surveyor observed signage posted on the wall over resident #58's bed that indicated Swallowing Precautions were in place for the resident. The sign detailed steps necessary to assist the resident during meals. The posted steps included: the resident taking small, single bites and sips, eating at a slow rate, every 1-2 bites a liquid wash was necessary, the resident should be in an upright position during eating as well as be maintained upright 20-30 minutes afterwards, and that the resident requires assistance with set up of meals (i.e. cutting food). Surveyor interview with resident #58 on 09-24-19 at 3:52PM revealed that the Swallow Precautions signage was posted by the facility's speech therapist some time ago without the resident's permission. On 09-25-19 at 1:30PM and 5PM, surveyor interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical records, and resident and facility staff interview, it was determined that the facility staff failed to prevent involuntary seclusion during the treatment of a resident's medical condition. This finding was identified in 1 of 5 residents with infections not UTI related during the survey. (#99). The findings include: On 09-23-18 at 09:10 AM, during initial tour of the facility, surveyor observed an isolation cart (One of several measures that can be taken to prevent contagious diseases from being spread from a patient to other patient, healthcare workers, visitors and outsiders) set up at the entrance of resident #99's room with a visible sign indicating that the resident was on an isolation. Per Center for Disease Control, (CDC) different measures are taken to prevent the spread of diseases: Examples include standard precautions and contact precautions. Surveyor review of the clinical records revealed that resident #99 was re-admitted to the facility on [DATE] 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 the clinical records and facility staff interview, it was determined that the facility staff failed to report an incident of suspected elopement of a resident from the facility to the State Survey Agency. This finding was identified in 1 of 2 residents reviewed for accidents. (#222). The findings include: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. This finding was identified during the investigation of complaint #MD00142298. On 09-23-19 at 09:30 AM, surveyor review of the closed clinical record revealed that resident #222 was admitted to the facility's rehabilitation unit on 07-01-19 after a brief hospital stay. Further record review revealed that the resident was alert and oriented to self, place and time and that the resident was self-represented. Further record review revealed the facility's elopement risk assessment which indicated that the resident was a low risk for elopement. Additional record review 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 surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to ensure that services provided by the facility met professional standards of quality. This finding was evident in 2 of 34 residents selected for review (#68 and #99). The findings include: 1. On 09-23-18 at 09:10 AM during initial tour of the facility, surveyor observed an isolation cart (One of several measures that can be taken to prevent contagious diseases from being spread from a patient to other patient, healthcare workers, visitors and outsiders) set up at the entrance of resident #99's room with a visible sign indicating that resident was on an isolation. Surveyor review of the clinical records revealed that resident #99 was re-admitted to the facility on [DATE] after a brief hospital stay after a medical procedure. Additional record review revealed that resident #99 was isolated for an infection MRSA (Methicillin-resistant staphylococcus aureus) in the wound. (MRSA is a bacterium 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.