Woodside Rehab & Nursing

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 that a PASARR screening (Preadmission Screening for Individuals with a Mental disorder and Individuals with Intellectual Disability) was re-evaluated as required. This was evident for 3 (Resident #9, #19, and #41) of 9 residents reviewed for PASARR screening during a recertification/complaint survey. The findings include: 1) Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals 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. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. The screening form only needs to be partly completed if a resident is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews with facility staff, it was determined that the facility failed to 1) Initiate a wound care plan for a resident with wounds, 2) initiate a care plan for a resident who was receiving hospice care, and 3) failed to develop a comprehensive care plan that included psychotropic and antidepressant medications. This was evident for 3 (Resident #6, #11 and #65) out of 19 residents reviewed for care plans during the Medicare/Medicaid recertification and complaint survey. The findings include: A care plan is an outline of nursing care showing all the residents' needs and the ways of meeting the needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. Terminal prognosis means a disease is expected to lead to death and is not expected to be cured or adequately treated. In essence, it indicates a life-limiting condition where death is anticipated, regardless of medical…

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: 1) conduct an interdisciplinary care plan meeting as required, 2) revise or update the care plan to reflect the needs of the resident, and 3) failed to review and revise the interdisciplinary care plan for discontinuation of Physical Therapy (PT) and Occupational Therapy (OT). This was evident for 2 ( Resident #18 and #60) of 19 resident care plans reviewed during the recertification/complaint survey. Findings included: The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents and is usually completed with on admission, quarterly, annually and with significant change of condition. A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team. A care plan meeting is where healthcare professionals, residents and/or their family members come together 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 observation, medical record review, and interview, it was determined the facility failed to 1) properly date label oxygen tubing when changed, 2) follow physician's orders for the administration of oxygen, and 3) develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 1 (#15) of 3 residents reviewed for respiratory care during a recertification/complaint survey. The findings include: Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. On 4/9/2025 at 9:05 AM, surveyor observed Resident #15 in bed awake, alert, and oriented to person and place. The resident was wearing a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) that was connected to a humidifier (water) bottle connected to an oxygen concentrator set at 4LPM (liters per minute). The LPM oxygen flow rate of 4 indicates that 4 liters…

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 document the use of nonpharmacological methods for pain management. This was evident in the review of 2 (Resident #58 and #65) of 5 reviewed for unnecessary medications during the recertification/complaint survey. The findings include: 1.On 4/15/25 at 11:51 AM during an unnecessary medication review for Resident #58, the surveyor found a physician order dated 3/12/2025 for Roxicodone Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for pain 6-10 or prior to physical therapy. The care plan review on 4/15/25 at 11:53 noted that the RN and LPN must use the nonpharmacological interventions for pain management: Turn and Reposition, music, television, low light, hot application, cold intervention, and reduce noise. On further medical record review on 4/15/25 at 11:55 AM, the surveyor noted that there was no documentation of the nonpharmacological pain interventions on the Treatment Administration Record (TAR) therefore, there was no way to validate 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 with facility staff, it was determined that the facility attending failed to follow up with the hospital discharge recommendations and her own physician notes related to a cardiac consult for a resident with a diagnosed cardiac condition. This was evident during the review of 1 (Resident #52) of 3 residents regarding coordination of care during a recertification/complaint survey. The findings include: Left ventricular thrombus is a blood clot (thrombus) in the left ventricle of the heart After meeting with Resident #52 in his/her room on 4/9/25 after an initial tour of the facility, his/her medical record was reviewed at 11:25 AM. Resident #52 was admitted to the facility in February of 2024 after a hospital admission related to increased confusion. During that hospitalization, Resident #52 was identified as having a cardiac ejection fraction of 20-25% (A normal ejection fraction (EF), which measures how much blood your heart pumps out with each beat, typically ranges from 55% to 70%), prior stroke, ischemia cardiomyopathy, coronary…

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 provide and show documentation that the attending physician reviewed any irregularities identified by the pharmacist. This was evident for 2 (Resident #52 and #19 ) of 5 residents that were reviewed for drug regimen reviews during the recertification/complaint survey. The findings include: 1) On 04/10/25 at 09:24 AM, Review of Resident #52's medical record revealed 4 dates (2/28/24, 7/30/24, 10/30/24, 12/31/24) with irregularities identified during drug regimen reviews (DRR) completed by the pharmacist. On 4/10/25 at 10:15 AM, after an interview with the Director of Nursing (DON), the surveyor asked her to provide documentation of the drug regimen reviews (DRR) from the dates identified with irregularities. The DON responded back to the surveyors at 10:41 AM that she was only able to locate one (2/28/24) of the requested DRR and she was not able to locate the other dates of documentation and that they were not able to provide proof that the reviews were completed and seen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to implement behavior monitoring for residents receiving antipsychotic medications. This was evident for 1 (Resident #65) out of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: Medical record review on 4/15/25 at 12:59 PM found that Resident #65 was admitted to the facility on [DATE] with diagnoses including bipolar disorder. Further review on 4/15/25 at 1:10 PM revealed a physician order dated 3/12/25 for Risperidone Tablet 0.25 MG Give 1 tablet by mouth at bedtime for bipolar disorder, give with 0.5 mg for total dose of 0.75mg. On 4/15/25 at 1:20 PM the surveyor noted the psychiatry initial consult notes dated 3/20/25 stating that, There are no reports of disturbances in his sleep, patterns or appetite, indicating stability in these areas. He also denies any suicidal ideation (SI) or homicidal ideation (HI), suggesting he does not have thoughts of wanting to harm…

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 employee file reviews and interviews with staff, it was determined that the facility failed to ensure that nursing staff had an active license. This was evident for 1 (LPN #24) of 5 licensed health care professionals reviewed during the recertification/complaint survey. The Findings include: The Maryland Board of Nursing (MBON) is the agency charged with the regulatory oversight of the practice of nursing in the State. The MBON's mission is to preserve the field of nursing by advancing safe, quality care in Maryland through licensure, certification, education, and accountability for public protection. All licensed practical nurses must have an active license in order to work. The primary source verification of certification status is found in the Look Up A License feature of the MBON website. This secure program is updated daily. On 4/14/25 at 12:15 PM 5 employee files were reviewed. During this review the surveyor was checking that the health care professionals had an active license. The employees were entered into the Look Up A License feature on the MBON website 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 record review and interviews with the staff, it was determined that the facility failed to provide outside services to a resident in a timely manner. This was evident for 1 (Resident # 52) out of 3 residents that were reviewed for coordination of care during the recertification/complaint survey. The Findings Include: Left ventricular (LV) thrombus is a blood clot (thrombus) in the left ventricle of the heart Resident #52's medical records were reviewed on 4/10/25 at 09:14 AM. There was a physicians note from 2/29/24 stating that the Resident was a new admission after being hospitalized for Cerebral Vascular Accident (CVA) caused by an LV thrombus, a blood clot that forms inside the left ventricle of the heart. Per the hospital's recommendations at time of discharge, resident was to continue taking an anticoagulant for 3 months minimum with reassessment for LV thrombus as outpatient with cardiology. It also stated that s/he would need repeat imaging to assess the LV thrombus in three months. All physician's notes were reviewed by the surveyor from 2/29/24 to 3/28/25. There…

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

Based on record review and interviews with facility staff, it was determined that the facility failed to obtain a hospice plan of care for resident receiving hospice services to ensure that the needs of the resident were addressed and met. This was evident for 1 resident (Resident #11) out of 1 resident reviewed for hospice plan of care notes during the Medicare/Medicaid recertification/complaint survey. The findings include: Terminal prognosis means a disease is expected to lead to death and is not expected to be cured or adequately treated. In essence, it indicates a life-limiting condition where death is anticipated, regardless of medical interventions. Hospice care is a specialized form of healthcare that provides comfort and support to terminally ill patients and their families. It focuses on managing pain, symptoms, and other physical, emotional, and spiritual needs during the end of life. On 04/10/2025 at 12:31 PM, Resident #11's paper medical record on the unit was reviewed for the hospice plan of care, communication process and related documentation, but none was found. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and staff interview, it was determined that the facility failed to have a Quality Assurance and Performance Improvement (QAPI) committee meeting at least quarterly and with enough frequency to conduct the required (QAPI) activities. This was evident during the recertification/complaint survey. The findings include: Review of the Quality Assurance Committee sign-in sheets for the last year (January 2024 to March 2025) revealed that the facility held meetings on 1/2/24, 2/27/24, 3/26/24, 4/30/24, 5/3/24, 7/24/24 and 12/24. There were no documented evidence that the Quality Assurance Committee meeting was held quarterly in June 2024 and from [DATE] to [DATE]. In an interview with the Director of Nursing (DON) on 4/17/25 at 11:22 AM, he/she stated that the facility's computer system was hacked, and she cannot provide the information. When the surveyor asked about paper documentation, the DON stated that there was none. The DON was made aware that this was a concern on…

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

Based on medical record review and interview with complainant and facility staff, it was determined that the facility failed to notify the Medical Director, the physician, or the resident's responsible party in a timely manner 1) when medication was not available from the pharmacy, and 2) when the resident had an inability to provide a urine sample for testing. This was evident during the review of 2 (Resident #76 and #78) of 3 complaints reviewed during this recertfication/complaint survey. The findings include: 1) Review on 4/15/25 at 8:22 AM of complaint MD #200018 regarding Resident #76 revealed concerns related to the availability of medication. Record review on 4/16/25 at 7:50 AM revealed that on 11/25/23 Benadryl anti-itch cream was entered into the orders, and to start on 11/26/23 at 9am and be administered again at 5PM, two times a day for five days. However, review of the MAR noted that on 11/26, 11/27, 11/28 a '0' was entered. According to the progress notes, on 11/26/23 at 1:55 PM, a nursing note stated that the medication was unavailable from the pharmacy. Another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, medical record review, and interview with staff it was determined that the facility failed to ensure that a resident who required assistance with activities of daily living (ADL) received showers twice per week. This was evident for 1 resident (Resident #74) out of 19 residents reviewed for complaints during the Medicare/Medicaid recertification/complaint survey. The findings include On 04/15/2025 at 8:33 AM, a review of complaint MD#00203224 revealed an allegation that Resident #74, was dirty during course of performing personal care by a hospital nurse when the resident was transferred out to the hospital on [DATE]. The complainant believed it was very likely that Resident #74 was not being cleaned properly while at the skilled nursing. On 04/15/2025 at 8:43 AM, medical record review of Resident #74 revealed an elderly resident with multiple co-morbidities that was dependent on staff for all ADL was admitted on [DATE]. On 04/15/2025 at 10:54 AM, review of the shower log…

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 the medical record and staff interviews, it was determined that the facility failed to 1) ensure accurate documentation of a resident's personal hygiene preference and 2) ensure that the staff who performed activities of daily living (ADL) care documented in the resident's electronic record. This was evident for 1 resident (Resident #74) out of 19 residents reviewed for complaints during the Medicare/Medicaid recertification/complaint survey. The findings include: On 04/15/2025 at 8:33 AM, a review of complaint MD#00203224 revealed an allegation that Resident #74, was dirty during course of performing personal care by a hospital nurse when the resident was transferred out to the hospital on [DATE]. The complainant believed it was very likely that Resident #74 was not being cleaned properly while at the skilled nursing. On 04/15/2025 at 10:54 AM, a review of Resident #74's paper shower log revealed that Geriatric Nursing Assistant (GNA) #25 had documented providing the resident with a complete…

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 the clinical records, observations made during the medication pass process, and interviews with facility staff, it was determined that the facility's pharmacist failed to identify drug irregularities for 1 of 2 residents that require tube feedings (Resident #25). The findings include: On 02-26-2021 at 9:26 AM surveyor observation revealed Rresident #25 had a functioning Gastrostomy tube (GT) in place. GT is a tube placed directly into the stomach through the abdomen and used to administer nutrition, fluids and medicines. Further observation revealed, Licensed Practical Nurse (LPN) #1 prepared the resident's medications for administration via the GT. LPN #1 opened the resident's Flomax 0.4 mg capsule, then mixed the granules from the capsule in 5 ml of water. LPN #1 administered the mixture of medication and water to Resident #25 using the resident's the GT. LPN#1 flushed the Resident's GT with an additional 5 ml of water after the medication was administrater. According to information 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's observations, interviews with staff, and the review of administrative policies, it was determined that the facility staff failed to ensure staff adhered to wearing and removing personal protective equipment (PPE) on the Yorktown (observation) unit as required to comply with infection control measures. The findings include: Coronavirus Disease 2019 (COVID-19), is a disease caused by the Coronavirus SARS -CoV-2. COVID-19 spreads from person to person, mainly through respiratory droplets produced when an infected person coughs or sneezes. According to the Centers for Disease Prevention and Control (CDC) guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 12-14-2020 revealed personnel are to put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen…

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, surveyor observations, review of the facility assessment and facility schedules and assignments, interviews with residents, residents' responsible parties and facility staff, it was determined that the facility failed to assure there is sufficient nursing staff available to provide personal care needs to residents in a timely manner. This finding was evident for 4 of 4 units. The findings include: a. Based on surveyor review of the clinical record, surveyor observations and interviews with resident #46's family member and facility staff, it was determined that the facility failed to ensure that resident #46 was provided with showers as scheduled secondary to an insufficiency of nursing staff. This finding was identified during the investigation of complaint MD00141134. On 06-10-19 at 3PM, surveyor interview with resident #46's family member revealed that visits are made to the resident almost daily by many of the resident's family members. During these visits,…

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

Based on surveyor review of the clinical record, surveyor observations and interviews with the resident's responsible party and facility staff, it was determined that the facility failed to ensure residents' rights of choice. This finding was evident for 2 of 2 residents selected for the Choice review. ( #72, #46) The findings include: 1. On 06-11-19, surveyor review of the clinical record for resident #72 revealed that, in April 2019, the resident was hospitalized for chronic anemia (low blood count). Further review revealed that the resident was a Jehovah Witness and the resident's responsible party/surrogate decision maker refused for the resident to receive any type of blood transfusions. However, review of resident #72's Maryland MOLST (Medical Orders for Life-Sustaining Treatment) revealed that on 02-28-19, the attending physician documented a medical order, under the category for Blood Transfusion, that the resident may receive any blood product (whole blood, packed red blood cells, plasma or platelets) that was medically indicated. Maryland MOLST is a portable and enduring…

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 and administrative record reviews and interviews with facility staff and residents, it was determined that the facility failed to notify local law enforcement of an alleged employee to resident abuse incident. This finding was evident for 1 of 2 residents reviewed for abuse during the survey. The findings included: On 06-10-19, surveyor review of facility reported incident #MD00138626 revealed that resident #47 reported to their family member on 03-29-19 that a staff member was allegedly rough with them while providing personal hygiene care and allegedly hit their hand and shoulder. The facility initiated an investigation on 03-29-19 and suspended the alleged staff member. However, there was no evidence that the facility notified the local law enforcement agency of the abuse allegation. On 06-10-19 at 03:20 PM, surveyor interview with the administrator revealed no new information.

Based on record and administrative policy reviews and interviews with facility staff, it was determined that the facility failed to thoroughly investigate facility reported incidents. This finding was evident for 2 of 2 residents reviewed for abuse during the survey. (#71 and #47) The findings include: 1. These findings were identified during the investigation of facility reported incident #MD00141556. On 06-11-19 at 09:47 AM, surveyor interview with resident #71 revealed that he/she was treated roughly during routine care by facility staff. Resident stated that he/she had a bowel movement during wound care and the staff slapped his/her buttocks. Resident #71 stated that this happened a week ago during the morning shift. On 06-11/19 at 10 AM, surveyor notified facility administrator about resident allegation. On 06-17-19 at 09:27 AM, surveyor review of the facility reported incident #MD00141556 record revealed that resident #71 was assessed and interviewed by the social worker and the administrator about the alleged abuse. Further review of the incident 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 surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan that addressed the resident's risk for falls. This finding was evident in 1 of 25 residents selected for review during the survey. (#20). The findings included: On 06-11-19 at 11:10 AM, surveyor interview with resident #20 revealed that he/she fell from the bed a couple of weeks ago. Review of the clinical record revealed that resident #20 was admitted to the facility with multiple diagnoses including, but not limited to, multiple falls. Further record review revealed that a fall risk assessment was done on 10-16-18 when the resident was admitted . The risk assessment result indicated that resident #20's risk for fall was very high. Additional record review revealed nursing documentation on 05-18-19 that indicated that the resident was observed lying face down beside his/her bed. However, there was no evidence that the facility developed a resident centered plan of care to address resident #20's high…

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

Based on surveyor review of the clinical record interview with facility staff, it was determined that the facility failed to ensure that residents' participated in their care plans and reviewed residents' care plans quarterly. This finding was evident in 2 of 32 residents selected for review during the survey. (#20 and #46). The findings include: 1. On 06-11-19 at 9:30 AM, surveyor interview with resident #20 revealed that he/she had not had a care plan meeting in a while. On 06-12-19 around 1 PM, surveyor review of the clinical record revealed that the last care plan meeting for resident #20 was in October 25, 2018. Further record review revealed that resident was his/her own responsible party for his/her health care decisions. There was no evidence that a quarterly review of resident #20's care plan was done by the interdisciplinary team as required. Resident #20 was not given the opportunity to participate in the review of his/her plan of care. On 06-12-18 at 2:10 PM, interview with social worker revealed he/she was newly hired and was unable to answer why quarterly care plan…

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

Based on clinical record review and interview with facility staff, it was determined that the facility failed to administer medication according to professional standards of practice. This finding was evident for 1 of 7 (#65) residents selected for medication regimen review during the survey. The findings included: According to the National Coordinating Council for Medication Error Reporting and Prevention, medication orders should include the drug name, exact metric weight or concentration, and dosage form (https://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing). On 06-13-19, surveyor review of resident #65's clinical record revealed that a physician's order was written on 05-18-19 for a bowel regimen medication to be given twice a day. There was no strength or dosage indicated on the physician's order. On 06-13-19 at 12:50 PM, surveyor interview with nurse #8 revealed that he/she administered the 100mg dosage of the medication, however, the order did not state what dosage should be given. Review of resident #65's medication administration 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 surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to provide services to ensure that residents attain or maintain the highest practical well-being. This finding was evident for 2 of 25 residents selected for review during the survey. (#183 and #72). The findings include: 1. The finding was identified during the investigation of complaint #MD00138454. On 06-18-19 at 08:20 AM, surveyor review of the clinical record revealed a physician's order for an antiviral viral medication used to treat HIV infection. Further review of the medication administration record (MAR) revealed that the antiviral medication was to be administered once a day at 9 AM. However, surveyor review of the 2019 March and April MAR revealed that the medication was not documented as administered on March 26, 28, 29, 30, 2019 and on April 1 and 2, 2019. There was no evidence in the clinical record to indicate that resident #183 received the antiviral medication as ordered. On 06-18-19 at 09:10 AM, surveyor interview with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record, review of the facility's policy and procedure and interview with facility staff, it was determined that the facility staff failed to provide appropriate care of a midline catheter intravenous (IV) line. This finding was evident for 2 of 5 residents selected for the Infection Control review. ( #48, #53) The findings include: 1. On 06-13-19, surveyor review of the clinical record for resident #48 revealed, after a hospitalization, the resident was readmitted on [DATE] to the facility with a midline catheter for the continuation of IV antibiotics. A midline catheter is inserted in a larger vein used for IV therapy greater than 5 days, and less than 28 days. The catheter, which is 8 inches long for adults, is advanced until the distal tip rests in the upper arm, at or below the axillary line. Further review revealed that, on 06-02-19, the attending physician ordered an IV antibiotic to be administered every 8 hours for 9 days. Surveyor interview, on 06-17-19 at 3PM,…

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

Based on review of administrative and clinical records and interviews with facility staff, it was determined that the facility failed to ensure that licensed nurses have the competency to perform suprapubic catheter replacement. This finding was evident for 1 of 3 (#2) residents reviewed for urinary tract infections/catheter use during the survey. The findings included: A suprapubic catheter is a hollow flexible tube that is inserted into the bladder through the abdominal wall to drain urine from the bladder. On 06-17-19, surveyor review of resident #2's clinical record revealed a physician's order, written on 04-05-18, for the facility staff to change resident #2's suprapubic catheter every 3 weeks. Review of the treatment administration record (TAR) revealed that the procedure was performed every 3 weeks by the facility's licensed nurses. On 06-17-19 at 12:17 PM, surveyor interview with the facility staff educator revealed that the facility does not allow licensed practical nurses (LPNs) to change suprapubic catheters. The staff educator further stated that there has been no…

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

Based on surveyor review of the clinical record interview with facility staff, it was determined that the facility failed to provide routine medication to resident#183. This finding was evident in 1 of 25 residents selected for review during the survey. (#183). The findings include: This finding was identified during the investigation of complaint #MD00138454. On 06-18-19 at 08:20 AM, surveyor review of the clinical record revealed a physician order for an antiviral viral medication used to treat HIV infection. Further review of the medication administration record (MAR) revealed that the antiviral medication was to be administered once a day at 9 AM. Surveyor review of the medication administration record (MAR) revealed a physician's order that stated, resident to provide medication to facility. On 06-18-19 at 10:10 AM, surveyor review of resident #183's admission contract with the facility revealed that, under pharmacy services, resident #183 consented and gave authority to the facility to provide all services provided by a skilled nursing facility. However, surveyor 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 surveyor review of clinical records and interviews with facility staff, it was determined that the facility failed to discontinue or reassess the need for the use of a PRN (as needed) psychotropic medication beyond the original 14 days. This finding was evident for 1 of 7 residents selected for the Unnecessary Medication Review (#15). The findings include: A psychotropic drug is any drug that affects the mind, emotions or behavior. On 06/13/2019 at 9:00 AM , surveyor review of resident #15's clinical records revealed a physician's order for anti-anxiety medication to be administered every 6 hours as needed on 04/11/2019. Further review revealed a pharmacist's recommendation to discontinue the medication on 05/01/2019. The physician accepted the recommendation on 05/21/2019. Surveyor review of physician's order sheet and medication administration record (MAR) for the months of April, May and June 2019 revealed that the anti-anxiety medication was not discontinued. Further review of the clinical record reveled nursing documentation on 06-12-19 that the anti-anxiety medication…

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.