Woodside Rehab & Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of medical records and all pertinent documents, and staff interview, it was determined that the facility failed to immediately notify a resident's physician with the results of a swallowing evaluation. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey. The findings include: On 02/26/26 the Office of Health Care Quality received a complaint #2789783, concerning the facility staff notifying Resident #1's physician regarding the results of a swallowing test. Review of Resident #1's closed clinical record on 03/03/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate. At the time of admission to the facility Resident #1 was noted to have cognitive issues. On 12/30/25, the facility staff conducted a BIMS assessment. A Brief Interview for Mental Status (BIMS) is an assessment that assists staff…

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 reviews of facility reported incident and staff interview, it was determined the facility staff failed to immediately report an allegation of suspected resident abuse to the local police. This was evident for 1 (Resident #4) of 8 residents reviewed during a complaint survey. The findings include: On 02/03/26 the Office of Health Care Quality received a facility reported incident concerning allegations that Resident #4 was identified with a fractured left humerus. The incident was reported as an injury of unknown source on 02/03/2026. The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse are to be reported to the Office of Healthcare Quality and the local police in a timely manner. A review of the facility investigation into the injury of unknown source on 03/03/26 revealed a 5-day follow-up investigation report that an x-rayed identified Resident #4's fractured left humerus. At the time, Resident #4 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of all pertinent documents and a closed medical record and facility staff interview, it was determined that the facility failed to revise care plans to meet a resident's needs. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey. The findings include: On 02/26/26 the Office of Health Care Quality received a complaint #2789783, concerning the facility staff notifying Resident #1's physician regarding the results of a swallowing test. Review of Resident #1's closed clinical record on 03/03/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate. At the time of admission to the facility Resident #1 was noted to have cognitive issues. On 12/30/25, the facility staff conducted a BIMS assessment. A Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining 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 observation and interviews it was determined that the facility failed to ensure medications were kept in locked compartments. This was evident in 1 (100 hall) of 4 nursing units observed. The findings include: On 03/10/26 at 10:58 am surveyor observed a medication cart unlocked an unattended in the hallway outside room [ROOM NUMBER]. No staff were observed around the medication cart at the time of the observation. This observation was immediately brought to the attention of LPN#2 who closed and locked the medication cart. This observation was brought to the attention of the director of nurses on 03/11/26 at 3:45 pm.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #4) of 8 residents reviewed during a complaint survey.The findings include:1) 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 errors and more prone to changes in conditions 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…

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 with facility staff, it was determined the facility failed to: 1) Remove outdated nourishment from the refrigerator, 2) ensure a sanitary environment in cleaning food items, and 3) ensure the labeling, dating, and expiration of food items. This was found to be evident during the facility's recertification/complaint Medicare/Medicaid survey and has the potential to affect all residents who consume food prepared in the facility's kitchen. The findings include: During the initial tour of the kitchen conducted on 04/09/2025 08:08 AM, a quarter jar of yellow mustard with open date of 12/05/2024 was seen in the refrigerator. At 08:13 AM of the same day, a dual observation with the dietary aide staff #10 was done and he stated that the jar should have been removed from the refrigerator, and he took it out. On the same day at 8:19 AM, a tray containing celery, onions, and two green peppers was observed in the manual rinse compartment of the three-compartment dishwasher sink. When Staff #11 was asked why the vegetables were in the sink, she stated that she…

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

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 ensure that advance directives were discussed with and/or information regarding advance directives was provided to residents and/or their responsible representatives (RP). This was evident for 2 (Resident #8 and #41) of 4 selected residents reviewed for advance directives during the recertification/complaint survey. Findings included: 1) On [DATE] at 11:40 AM, a review of Resident's #41 record revealed that the resident had capacity to make one's own decision, however, there was no documented evidence to support that the facility provided education and/or obtained Resident #41's advance directive. On [DATE] at 08:52 AM, in an interview conducted with the Director of social services (Staff #8), She stated that residents were evaluated on admission and if capable, they were asked about their ADs and copies requested to be placed in their paper chart. If a resident was deemed incapable and incapacity certification signed by…

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.

Based on record review and interviews, it was determined the facility failed to ensure timely reporting of abuse allegations. This was evident for 2 (Resident #18 and #58) out of 6 residents reviewed for allegations of abuse during the complaint/recertification survey. Findings Included: 1) On 4/10/2025 at approximately 11:15 AM the surveyor notified Unit Manager Staff #16 that Resident #58 stated that a Geriatric Nursing Assistant (GNA), white lady with yellow big hair was very rough with him/her during care. The Resident added that when the GNA asked him/her to turn over, the GNA does not give him/her time to turn, and the GNA turns him/her very roughly. By 4/15/2025 at 2:00 PM the surveyor did not get any notification that this alleged incident was reported to the DON, the Administrator, or Office of Healthcare Quality (OHCQ). On 4/16/2025 at approximately 1:40 PM, the surveyor asked the DON if Staff #16 notified her of an alleged abuse incident. The DON stated that she did not get any information concerning this incident. The surveyor and the DON went to Resident #58's room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews it was determined that the facility failed to provide the bed hold policy on transfer out of the facility and/or mail it to the resident's responsible representative. This was found to be evident for 1(Resident #58) out of 2 residents selected for the recertification/complaint survey. The findings include: On 4/14/2025 at 10:31 AM review of Resident #58's medical record revealed that the Resident was admitted on [DATE] and transferred out to the hospital on multiple occasions with the most recent transfer to hospital with return anticipation on 4/4/2025 and a re-admission to facility on 4/8/2025. On 04/14/25 at 10:54 AM further medical record review revealed that Resident #58 had a change in condition which was documented on 4/4/25 at 1840, that the Resident had a fall and was transferred out of the facility via 911. On 04/14/25 11:20 AM surveyor conducted an interview with Nurse #23 and asked about the process for when a resident is sent to the hospital. 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.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #53) of 5 residents reviewed for antibiotic use during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. During an interview with Resident#53 on 04/10/25 09:51 AM, the resident denied having a UTI and was unsure if he/she was taking antibiotics (ABX). A review of the Facility 30-day admissions Matrix on 4/10/25 at 11:02 AM indicated that Resident #53 is taking an ABX for a Urinary Tract Infection. On 4/13/2025 at 1:30 PM, the surveyor completed a record review for Resident #53. The review revealed an MDS assessment, dated March 23, 2025, at 12:12 PM in Section N0415.…

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 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.

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.

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.

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.

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.

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.