Snow Hill Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined that the facility failed to 1) provide adequate supervision to prevent accidents as evidenced by a resident eating solid food while on nothing by mouth (NPO) diet restrictions and 2) ensure adequate supervision for a vulnerable, cognitively impaired resident which resulted in elopement. This was found to be evident in 2 (Resident #6 and #9) of 5 residents reviewed for accidents during the recertification survey. The facility implemented effective and thorough corrective measures following these incidents prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 4/25/2026. The findings include: NPO most commonly stands for the Latin phrase nil per os, meaning nothing by mouth. It is medical instruction requiring a patient to avoid eating or drinking. Someone with enteral feeding (tube feeding) is often placed on an NPO…

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

Based on record review and staff interview, it was determined that the facility failed to ensure a nurse aide completed required dementia training and competency evaluation within 120 days of employment. This is evident for 1 (Staff #22) of 5 employee records reviewed during the annual survey.The findings include:On 05/06/2026 at 2:00 PM, review of the employee file for Staff #22 revealed no documentation of completed dementia training or competency evaluation. Staff #22 had been employed by the facility for at least 9 months, with a hire date in July 2025.On 05/07/2026 at 8:29 AM, during an interview, Staff #8 was informed of the concern regarding the absence of dementia training and competency evaluation documentation for Staff #22. Staff #8 stated she would look in the former Director of Nursing's files for the documentation.On 05/07/2026 at 8:34 AM, the Director of Nursing (DON) stated that if the dementia training and competency evaluation program documentation was not in the employee folder, it was probably not completed for Staff #22.No further documentation was provided 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 observations and facility staff interview, it was determined that the facility failed to properly contain garbage and refuse. This was evident for 2 of 2 observations conducted during the recertification survey.The findings include: On 05/04/2026 at 7:35 AM the surveyor observed two blue dumpster containers located at the back of the facility. The two dumpsters were uncovered overflowing with bagged trash, and loose trash items on the ground between the two containers. On 05/04/2026 at 8:14 AM, the surveyor observed that the loose trash was removed from the ground between the two dumpsters, however, the trash remained uncovered, overflowing at the top of both dumpsters.On 05/04/2026 at 10 AM the Maintenance Director (MD) confirmed that trash pick up was to occur since Thursday 04/30/2026 and he placed a call to the trash removal company on 05/04/2026 to inquire about the missed service and to expedite removal on 05/04/2026.

Based on medical record review and interviews, it was determined that the facility failed to maintain documentation of Covid-19 vaccine administration. This was found to be evident in 1 (Resident #15) of 5 residents reviewed for immunizations during the recertification survey.The findings include:On 5/7/2026 at 9:15 AM, the facility's Covid-19 vaccination policy was reviewed. Section 21 subsection b. stated that The resident's medical record will include documentation of the following: b. Each dose of the vaccine administered to the resident.On 5/7/2026 at 1:15 PM, Resident #15's 2025 vaccine consent form was reviewed. It was signed by the resident on 10/16/2025 and stated yes to consent for the Covid-19 and flu vaccinations. Additional review of Resident #15's medical chart showed documentation that the flu vaccine was administered on 10/16/2026 but did not reveal documentation that the resident received the Covid-19 vaccine.On 5/8/2026 at 9:54 AM, the Director of Nursing (DON) provided the billing statement for Resident #15 for their flu vaccination. The DON stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interviews, it was determined the facility failed to ensure a functioning house wide call bell system. This was evident for all residents residing in the facility's 2 nursing units. The findings include: During an observation of the Cypress Unit on 02/02/26 at 4:08 pm, the nurse surveyor observed resident call bell lights lit above rooms but there was not an audible signal alerting the staff that a residents in rooms were requesting staff assistance. Closer observations of the call bell panel behind the nurse's station/desk, revealed tape covering the enunciator speaker and the enunciator was set to produce a low tone. After several seconds, the enunciator did elicit a sound, but the sound was not audible to this nurse surveyor, the staff or residents walking or sitting on the unit. Further observations of the Federal nursing unit on 02/02/26 revealed the resident call bell light above room [ROOM NUMBER] was light but there was not an audible signal alerting the staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a closed and active clinical record and administrative records, and staff interviews, it was determined that the facility nursing staff failed to follow the physician's specific pulse and blood pressure parameters before administering cardiac medications. This was evident for 2 (Resident #1, Resident #3) of 6 residents reviewed during a complaint survey, The findings include: 1) On 01/03/26 the Office of Health Care Quality received a complaint with concerns about resident safety and the quality of care being provided to Resident #1. Review of Resident #1's clinical record on 02/02/26 revealed that Resident #1 was admitted to the facility on [DATE] and had been deemed incapable of making all medical decisions by 2 physicians on 07/31/25 and 08/12/25. Further review of Resident #1's clinical record on 02/02/26 revealed a physician's order dated 01/16/26 instructing the nursing staff to administer the medication, Midodrine, 10 milligrams (mg), orally, three times a day for a systolic…

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 #3) of 6 residents reviewed during a complaint survey. The findings include: On 09/05/25 the Office of Health Care Quality received a facility reported incident concerning allegations that on Sunday 08/31/25 a nursing staff member (LPN#1) told Resident #3 nursing staff to not to provide care and that S/he was not going to administer any pain medication to Resident #3. 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 allegation of abuse on 02/03/26 revealed a 5-day follow-up investigation report that indicated Resident #3's responsible party…

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 facility reported incident, a closed medical record and staff interview, it was determined that the facility staff failed to obtain psychiatric consultation for Resident #3 after the facility concluded an abuse investigation and determined Resident #3 should be referred to the facility psychiatric services. This is evident for 1 (Resident #3) of 6 residents reviewed during a complaint survey. The findings include: On 09/05/25 the Office of Health Care Quality received a facility reported incident concerning allegations that on Sunday 08/31/25 a nursing staff member (LPN#1) told nursing staff providing care to Resident #3 to not to provide care and that S/he (LPN#1) was also not going to administer any pain medication to Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnoses that include: muscle atrophy, a lack of coordination, difficulty walking, depression, Gout and osteomyelitis of a wound. Resident #3 was deemed capable of making medical decisions by his/her…

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 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 (Resident #3) of 3 residents reviewed during a complaint survey.The findings include: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, interview, and record review, it was determined that the facility failed to meet proper internal cooking temperatures and failed to ensure beverages were served at an appropriate temperature. This was evident during the Kitchen Observation within the facility. This deficient practice has the potential to affect all residents who consume meals. The findings include: 1. On 02/19/25 at 11:59 AM, the surveyors observed the food line preparation for lunch. The Dietary Manager began taking the temperature for the food on the steam tray line. During the observation, the mashed potatoes temperature reached 120 degrees Fahrenheit (F). The appropriate temperature of hot foods on the steam table is 135 degrees or higher. Additionally, the mechanical ground chicken temperature was 120 degrees F and the fried chicken was 120 degrees F. These did not reach the proper final internal temperature of 165 degrees F. The Dietary Manager had asked Dietary [NAME] #41 to take the food and reheat it. The Dietary Manager further stated that she would have the Maintenance Director take…

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

Based on interviews and record reviews, it was determined that the facility failed to ensure its Infection Preventionist met the mandatory qualifications for the position. This deficient practice has the potential to affect all residents in the facility. The findings include: An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control. During an interview on 12/20/25 at 1:02 PM with the Assistant Director of Nursing (ADON). She confirmed she was the Infection Preventionist for the facility. The ADON reported she has a college degree in nursing but hasn't completed specialized training in infection control. During a review of a copy of an e-mail and a computer screenshot on 2/20/25 at 3:32 PM, it revealed the e-mail was dated as received on 2/20/25 at 1:13 PM. The email was a confirmation the ADON had registered for an Infection Prevention and Control course with Train Maryland - Maryland Department of Health. A review of the computer screenshot revealed she was currently…

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, clinical record review and interviews, it was determined that the facility failed to provide activities of daily living (ADL) care to dependent residents. This was evident for 4 (#12, #42, #47, #63) of 4 residents reviewed for ADL care during the annual survey. The findings include: 1. Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities. The Activities of Daily Living (ADL) care is a term used to collectively describe fundamental skills required to care for oneself, such as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence. On 02/18/25 at 3:43 PM, Resident #47 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 observations, interviews, and record reviews it was determined that the facility failed to ensure medications were properly labeled and stored. This was evident for 2 of 2 medication carts observed for medication storage during the annual survey. The findings include: During an observation of the Cypress Hall medication cart on 2/18/25 at 1:32 PM with nurse #31 and Consultant Pharmacist #32 it was discovered that there were expired medications and undated open medications. The expired medications and undated open medications were removed by the Consultant Pharmacist after being discovered. Expired medications include: Ondansetron 4mg tablets expired on 2/08/25 for Resident #45. [NAME] Milk of Magnesia Suspension 400/5mL, House stock expired on 2/09/25. Good Neighbor Pharmacy Cough Suppressant expired on 10/24. A Basaglar injection pen 100 units was labeled with the Date Opened as 1/16/25 for Resident #32. The instructions advise to Use a pen for up to 28 days after first use then throw away. 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 and interview, it was determined that the facility failed to store/prepare food under sanitary conditions. This was found to be evident during the Kitchen Observations. The findings include: During the initial brief tour of the kitchen on 02/18/25 at 08:43 AM, it was observed that [NAME] #4 and Dietary Aide #5 were not wearing hair nets while preparing food. On 02/18/25 at 08:43 AM an interview was conducted with the Dietary Manager. The surveyors made her aware of the staff that had not been wearing the hairnets. On 02/18/25 at 08:45 AM, an observation of the temperature logs for the reach-in fridge showed it was not filled out. For February 2025, only the 3rd, 5th, 7th, and 10th day had temperatures logged. Inside the reach-in fridge, it revealed multiple food items that were opened and unlabeled. There was sliced turkey, 4 packages of American cheese, corned beef, green peppers, 3 packages of mozzarella cheese, a gallon of lemon juice, stuffed cabbage, cottage cheese, and pureed fruit. There was also personal food, a Sunday brunch bake cheese, a small…

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

Based on observations and staff interviews, it was determined that the facility failed to 1) ensure that oxygen administration equipment and nebulization masks were stored in a sanitary manner when not in use and 2) ensure that the environment was maintained in a manner that minimized the potential spread of infection. This was evident for 1 (#42) out of 28 sampled residents and 1 random observation of the laundry room during the annual survey. The findings include: 1. A nebulization mask is a device that covers the nose and mouth to deliver medication directly into the lungs. A nasal cannula is a thin, flexible tube that delivers oxygen through the nose. An oxygen concentrator is a medical device that increases the amount of oxygen in the air. On 2/18/25 at 10:17 AM, the surveyor observed a nebulization mask placed on top of Resident #42's nightstand without any covering and label. On 2/18/25 at 11:07 AM, the surveyor requested Licensed Practical Nurse (LPN) inside Resident #42's room and was asked to verify the concern. LPN #1 acknowledged the concern and placed the mask inside 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 interview and record review, it was determined that the facility failed to provide the residents with the opportunity to choose their shower schedules. This was evident for 2 ( Resident #65 and #14) of 2 residents reviewed for choices during the recertification survey. The findings include: On 2/18/25 at 9:11 AM, in an interview with Resident #65, he/she revealed that he/she was not aware of his/her shower schedule. He/she added that he/she had been in the facility for several weeks and had inquired several times about his/her schedule from the staff but had not heard any updates. On 2/18/25 at 9:47 AM, Resident #14 stated that he/she had no idea when his/her shower schedule was and added that it would be good if he/she knew the schedule. On 2/19/25 at 8:35 AM, a review of the active physician orders for showers revealed that Resident #14 was scheduled every Tuesday and Friday 3-11 shift, however, Resident #65 had no order in place. On 2/19/25 at 8:57 AM, in an interview with Geriatric Nurse Assistant (GNA #12), she described that at the beginning of the shift, the charge…

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

Based on interviews and facility record reviews it was determined that the facility failed to ensure that facility records for abuse and neglect were maintained for correction of alleged violations and completed investigations. This was found to be evident for 3 (Resident #18, #28 and #219) out of 5 Residents reviewed for investigation and correction of alleged violations of abuse and neglect. The findings include: 1. On 2/19/25 a review of the Facility Reported Incident (FRI) MD00189291 revealed that on 2/21/23, Resident #170 was observed in the room of Resident #18 with their hand on the clothed thigh of Resident #18. The incident was reported to Office of Health Care Quality on 02/23/23. The summary of the incident stated that Resident #18 was assessed and was not negatively impacted by the incident. Resident #170, had a diagnosis of Dementia and was adjusting to a new environment. Him/her had medication changes and the facility worked to find the correct medications for him/her. After the incident, Resident #170 was placed on 1:1 sitter observation until a psychiatric evaluation…

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 develop a baseline care plan. This was evident for 1 (Resident #65) of 28 residents reviewed for baseline care plans during the recertification survey. The findings include: The baseline care plan is a document that outlines how to provide care for a new nursing home resident. It's created within 48 hours of admission. The plan's purpose is to reduce the risk of adverse events and ensure the resident receives quality care. On 2/19/25 at 12:47 PM, a review of Resident #65's medical record revealed an admission date of 1/31/25. Further review of the medical record revealed no evidence that a baseline care plan was developed, and a copy of the document was given to the resident. On 2/19/25 at 1:20 PM, in an interview with Licensed Practical Nurse (LPN #7), he/she revealed that normally, the Director of Nursing (DON)/ Assistant Director of Nursing (ADON) took care of the baseline care plans and nurses just added interventions by clicking the care plan tab in the electronic health record. On 2/19/25 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 observation, record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for the use of oxygen. This was evident for 1 (Resident #42) of 28 residents reviewed care plans during the recertification survey. The findings include: A nasal cannula is a thin, flexible tube that delivers oxygen through the nose. 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. On 2/18/25 at 10:17 AM, Resident #42 was observed lying in bed and oxygen was noted in use via nasal cannula at 2 liters/minute. On 2/19/25 at 10:39 AM, a review of Resident #42's care plan did not show any evidence that a care plan for oxygen use was developed. On 2/19/25 at 12:14 PM, in an interview with the Director of Nursing (DON), she revealed that care plans were initiated upon admission and as needed. She stated that the Resident Assessment Coordinator (RAC) would initiate resident care plans based on medical diagnoses, Activities of Daily Living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to develop/revise care plans to meet residents' needs. This was evident for 1 (Resident #63) of 28 residents reviewed for care planning The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. The Minimum Data Set (MDS) is a federally mandated assessment tool used to evaluate the health status of residents in nursing homes. The information collected helps nursing home staff identify health problems and develop individual care plans for residents. Resident # 63 was admitted to the facility on [DATE] with diagnoses including Hypotension, Diabetes, Dementia and Muscle Weakness. On 02/19/25 at 07:25 AM a review of…

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

Based on record review, interviews, and observations, it was determined that the facility failed to ensure 1) that physician laboratory orders were performed as ordered, 2) medications were administered as ordered and 3) a resident received proper cardiac monitoring. This was found to be evident for 3 (Resident #65, #45, and #12) out of 3 residents reviewed for quality of care during the annual survey. The findings include: 1. Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) are two common blood tests used to assess overall health and detect potential medical conditions. On 2/19/25 at 12:47 PM, a review of the active physician orders of Resident #65 indicated a laboratory order of CBC, CMP one time a day every Tuesday for monitoring for 4 Weeks. The order started on 2/04/2025 and would end on 3/04/2025. However, after further review of the medical records, it revealed that CBC and CMP were not performed for 3 consecutive Tuesdays, 2/4/2025, 2/11/2025 and 2/18/2025 as ordered. On 2/19/25 at 1:20 PM, in an interview with the Licensed Practical Nurse (LPN#7), he/she…

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

Based on interview, observation and record review, it was determined that the facility failed to 1) ensure that a resident with a pressure ulcer received the necessary treatment to promote healing and 2) implement the recommendations made by the wound clinic to the resident with pressure ulcer. This was evident for 2 (Resident #12 and #42) of 4 residents reviewed for pressure ulcers during the recertification survey. The findings include: 1. According to the Centers of Medicare & Medicaid Services (CMS), the definition of a pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). These lesions typically occur in areas of the body that have a lot of pressure applied. Pressure ulcers most often arise on skin that covers bony areas of the body, such as heels, ankles, hips and tailbone (coccyx). Measures to help prevent or promote healing for pressure ulcers include using devices that help elevate or float heels off of the bed to prevent pressure on the bottom of heels. Also, changing a resident ' s position every 2 hours helps keep…

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 medical record review, it was determined that the facility failed to ensure that drinking water was provided to the residents at the bedside for hydration. This was evident for 1(Resident #5) of 1 resident reviewed for hydration. The findings include: On 02/02/18/25 at 01:54 PM the surveyor observed Resident #5 sitting up in bed eating lunch. The resident pointed to a glass, half-filled glass with a brown liquid on his/her lunch tray. Resident #5 stated I cannot drink this it is too sweet; they do not give me water. The surveyor did not observe any water on the resident's lunch tray nor at the bedside. On 02/18/25 at 02:17 PM the surveyor interviewed the Geriatric Nursing Assistant (GNA) Staff #17 regarding the availability of water to Resident #5. The GNA stated that water is not put on meal trays because residents have water pitchers at the bedside. Water pitchers are filled by the night shift and placed at the residents' bedside daily. Further, Resident #5 did not have any water because his/her water pitcher was not delivered. On 02/18/25 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 observation, interview and record review, it was determined that the facility failed to provide necessary respiratory care services for residents by failing to 1) label oxygen administration equipment 2) put a physician oxygen order in place and 3) place signage outside the entrance of residents' room to indicate oxygen in use. This was evident for 3 (Resident #5, #18 and #42) of 3 residents reviewed for respiratory care during the recertification survey. The findings include: 1. On 2/18/25 at 9:07AM the surveyor observed Resident #5, lying in bed, receiving oxygen through a tubing attached to a humidification bottle and a concentrator. The oxygen tubing and humidification bottle were not labelled as to when they were put in use or when they should be replaced. Further, there was no signage on Resident #5's door or on the doorframe indicating that oxygen was in use. On 02 /19/25 at 8:54 AM a review of Resident #5's clinic record revealed diagnoses including Acute Respiratory Failure with Hypoxia and Dementia. Also, a physician order dated 01/07/25 which stated that Resident…

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

Based on record review and interview, it was determined that the facility failed to ensure that pain medications were given consistent with the professional standards of practice. This was evident for 1 (Resident #42) of 1 resident reviewed for pain management during the recertification survey. The findings include: The medical abbreviation PRN stands for pro re nata, a Latin phrase that translates to as needed or as the situation arises. Oxycodone is a strong painkiller from a group of medicines called opiates, or narcotics used to treat moderate to severe pain. Pain parameters are the specific aspects of pain that are evaluated during an interview to understand a person's pain experience. On 2/20/25 at 3:58 PM, a record review of Resident #42's active and discontinued physician orders revealed that he/she was on PRN pain medications, however, the following orders did not specify the pain parameters: 1. Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. (Start date: 1/05/25) 2. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl)…

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

Based on interviews and employee record reviews it was determined that the facility failed to ensure that the required Geriatric Nursing Assistant (GNA) perform review - 12 hour/year in-service were completed. This was found to be evident in 2 ( #24 and #25) out of 2 GNA employee files reviewed for required perform review - 12 hour/year in-service. The findings include: On 02/20/2025 at 07:30 AM the surveyor reviewed 2 Geriatric Nursing Assistant (GNA) employee files #24 and #25. During the review of the 2 employee files the surveyor discovered that the facility did not have current perform review - 12 hour/year in-service in the employee files for the 2 GNAs #24 and #25. At 08:30 AM on 02/20/2025 the surveyor interviewed the Director of Human Resources (HRD) #11. During the interview the surveyor informed the HRD #11 that the 2 GNAs #24 and #25 employee files did not contain any perform review - 12 hour/year in-service. The HRD #11 confirmed that the 2 GNA employee files #24 and #25 did not have current perform review - 12 hour/year in-service. The HRD #11 stated that there was 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 observation, interviews and facility record review it was determined that the facility failed to ensure that the posted nurse staffing information contained all the required information. This was found to be evident on the posted staffing sheet on the nursing unit reviewed for sufficient and competent nurse staffing. The findings include: On 02/19/2025 at 2:10 PM the surveyor toured the nursing unit. The surveyor observed the daily staffing sheet posted on the nursing unit; however, the required information was not included on the staffing sheet. The staffing sheet included the facility name, the names of staff, the staff assignment, the date and shift. The posted staffing sheet did not include the Resident census, and the total number and the actual hours worked by the following categories of licensed (Registered Nurses and Licensed Practical Nurses) nursing staff and unlicensed (Geriatric Nursing Assistants) nursing staff directly responsible for Resident care per shift. The surveyor on 02/19/2025 at 2:40 pm interviewed Geriatric Nursing Assistant (GNA) #2 and asked GNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, it was determined that the facility failed to provide behavioral health care services. This was found to be evident for 1 resident (Resident #45) out of 1 resident reviewed for behavioral health. The findings include: During an interview conducted on 02/18/25 at 12:56 PM, Resident #45 stated that he/she had a history of trauma. The Resident advised that the facility had not provided behavioral services for the history of trauma. Post-traumatic stress disorder (PTSD) is a mental health condition that's caused by an extremely stressful or terrifying event — either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event. On 02/20/25 at 07:56 AM, a record review of Resident #45 ' s Social Service History & Initial assessment dated [DATE], stated that this resident is At risk for post-trauma syndrome AEB [as evidenced by] patient reported experienced or witnessed: natural disaster, serious…

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 implement the recommendations from the Medication Regimen Review (MRR) and conduct a monthly MRR. This was found evident for 1 (Resident #45) out of 1 resident, reviewed for Medication Regimen Review. The findings include: According to the Centers of Medicare & Medicaid, the definition of a Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. Hemoglobin A1C (A1C) is a blood test for diabetes. This test measures your average blood glucose level over the past 3 months. It can be an important indicator for your doctor to see how well a resident is managing their diabetes. On 02/21/25 at approximately 11:15 AM, this surveyor conducted a 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 record review and interview, it was determined that the facility failed to provide adequate behavior monitoring for residents on psychotropic medications. This was evident for 1 (Resident #65) of 4 residents reviewed for unnecessary medications during the recertification survey. The findings include: Abilify is an antipsychotic medication that helps treat several kinds of mental health condition. Lexapro is an antidepressant and is used to treat depression and anxiety. On 2/19/25 at 4:08 PM, a review of the active psychotropic medications of Resident #65 revealed the following: - Abilify Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth at bedtime for psychosis - Lexapro Oral Tablet 20 MG (Escitalopram Oxalate) Give 20 mg by mouth one time a day for depression Further review of Resident #65's medical record revealed a care plan to address the use of psychotropic medications with an intervention Discuss with my physician and family the ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per…

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

Based on record review and staff interviews, it was determined that the facility failed to screen and offer vaccinations to residents. This was evident for 3 (Residents #26, #51, #32) out of 5 residents screened for immunizations. The Findings include: During a medical record review on 2/20/25 at 2:43 PM it was discovered that Residents #26, #51, and #32 had no documentation of being screened for, offered, receiving, or refusing a pneumonia vaccine. During a facility policy review of the Pneumococcal Vaccine (Series) on 2/20/25 at 3:38 PM it was discovered that Each resident will be assessed for pneumococcal immunization upon admission and Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. During an interview on 2/20/25 at 4:40 PM the Assistant Director of Nursing (ADON) agreed the pneumonia vaccines should be offered and administered as appropriate to the residents. She doesn't know why residents #26, #51, and #32 were not offered pneumonia vaccinations. During an interview on 2/20/25 at 5:49…

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

Based on interviews and employee record reviews it was determined that the facility failed to ensure that the required in-service training for Geriatric Nursing Assistants (GNA) was completed. This was found to be evident in 5 (#24, 25, 26, 27 and #30) out of 5 Geriatric Nursing Assistants (GNA) employee files reviewed for required in-service training. The findings include: On 02/20/2025 at 07:30 AM the surveyor reviewed 5 Geriatric Nursing Assistants (GNA) employee files #24, 25, 26, 27 and #30. During the record review of the 5 GNA employee files the surveyor discovered that the facility had incomplete documentation of the required in-service training for all 5 of the Geriatric Nursing Assistants (GNA) #24, 25, 26, 27 and #30. At 08:30 AM on 02/20/2025 the surveyor interviewed the Director of Human Resources (HRD) #11. During this interview the surveyor conveyed to the HRD #11 that the employee files had incomplete documentation of the required in-service training for the 5 GNAs #24, 25, 26, 27 and #30. The Director of Human Resources #11 confirmed that there was incomplete…

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

Based on a review of facility investigations and interviews with facility staff, it was determined that the facility staff failed to maintain documentation that alleged violations of abuse were thoroughly investigated for residents (#9, #18, #30, #62, #63, #64, #65, #66, #67, #68, and #264) This was evident for 11 of 40 residents reviewed during the annual survey. The findings include: The purpose of a thorough investigation is first to determine if abuse of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence being investigated by the facility and be reported to the appropriate agency within 24 hours and the conclusion of the investigation to be reported within 5 days to the appropriate agency (OHCQ) and the Office of Aging (Ombudsman). The facility staff failed to thoroughly investigate the allegation of abuse by a resident. 1. Review of the Facility Reported incident MD00134776 for Resident #62 on 8/18/22 at 4:50 pm revealed on 12/21/18 at 7:30 am Resident #62 reported to RN (Registered Nurse) #30 that GNA (Geriatric…

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 the facility staff failed to have the most recent survey results in a place readily accessible to residents, family members, and legal representatives of residents. This has the potential to affect all the residents and visitors within the facility. The findings include: On 08/15/22 at 10:50 AM, during the Resident Council meeting all seven residents who attended the meeting reported they did not know where the previous survey results were located. On 08/17/22 at 11:14 AM, the surveyor made the Director of Nursing #2 aware during the resident council meeting the residents stated they did not know where the survey results were located. The surveyor asked DON #2 where the survey binder was located. Staff #16 took the surveyor to the Chesapeake Dining Hall; the surveyor observed the survey binder behind the door in the dining hall. On 08/17/22 at 11:48 AM the surveyor spoke with Administrator #1 about the residents not having access to the survey results. Administrator #1 reported the survey binder should have been on the table in…

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

Based on medical record review and interview it was determined the facility staff failed to notify the physician when a resident refused to wear a medical device for at least a month. This was evident in 1 of 2 resident (Resident #12) records reviewed for treatment plans. The findings include: On 08/15/22 at 10:14 AM a review of Resident #12's treatment administration record (TAR) revealed that on 05/16/22 at 23:00 (11 PM), the resident was ordered to wear a sling to the right right arm at all times; the order was discontinued on 08/09/22 at 12:52 AM. The TAR legend indicated to see nurse note for several entries on the 7 am - 3 pm shift on 8/2/22, 8/3/22, 8/6/22, and 8/7/22, in which the nurses documented the resident refused to wear the sling. Per TAR and nursing notes, the resident refused to wear the sling on 8/5/22 (7 am-3 pm) and 8/6/22, 8/7/22 during the 11 pm-7 am shift. On 8/9/22 at 12:52 AM, Staff #28 was made aware the resident was refusing to wear the sling and the order was discontinued. Further review of the TAR in July 2022 revealed the nurses documented the resident…

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

Based on medical record review and staff interview, the facility failed to timely report a violation of mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property to the state authority. This was evident for 3 of 14 residents (Resident #15, #30, #7) investigated for reportable incidents. Findings include: 1. On 8/19/22 at 1:12 PM, review of a facility self-report of an allegation of neglect involving Resident #15 the date of the self-report revealed that the facility reported the incident to the state authority on 8/15/22. The incident of alleged neglect occurred on 8/13/22 at approximately 4:00 PM. On 8/19/22 at 2:00 PM, the surveyor interviewed the Administrator regarding the time the alleged neglect incident was reported to the state authority. The Administrator confirmed that the alleged neglect incident was reported after the required 24 hour reporting time as noted on the report form. 2. On 08/12/22 at 2:38 PM, the surveyor reviewed MD00157914 which revealed that on 09/05/20 Resident #30 was discovered to have 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 it was determined the facility staff failed to complete a notice before transfer before a resident was transferred to the emergency room. This was evident in 2 of 4 residents (Resident #12 and #15) reviewed for transfer documentation. The findings include: 1. On 08/15/22 at 10:50 am a review of Resident #12's electronic medical record (EMR) revealed the resident was transferred to a local hospital in May 2022 for further medical evaluation. While reviewing the EMR the surveyor noticed the transfer notice was not in the medical record. On 08/18/22 at 11:45 am during an interview, the Administrator #1 made the surveyor aware a transfer notice was not done because the resident was gone for less than 24 hours.2. On 8/15/22 at 11:00 am, review of Resident #15's medical record revealed that the resident was readmitted to the facility on [DATE] with a diagnosis of cerebral infarction. Further review of Resident #15's medical record revealed that the resident had two…

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, the facility staff failed to verify a weight reading resulting in an inaccurate weight loss calculation which led to an inaccurate Minimum Data Set (MDS) assessment. This was evident in 1 (Resident #42) of 7 residents reviewed for accuracy of assessments. The findings include: The Minimum Data Set (MDS) is a tool for implementing standardized assessments and for facilitating care management in nursing homes and non-critical access hospital swing beds. The assessment is completed upon admission, annually, quarterly, during a significant change, and when a resident is discharged . On 08/16/22 at 12:44 pm, a review of Resident #42's electronic medical record (EMR) revealed the resident had a significant weight loss of 10% or greater in 6 months. On 12/01/21 the resident weighed 105.8 pounds. On 06/07/22 the resident weighed 94.1 pounds which is an 11.06 % weight loss. A review of Resident #42's MDS assessment dated [DATE] revealed Section J Nutrition item K0300 Weight…

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 facility staff failed to develop and then provide residents and/or their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 2 (Resident #43, #45) of 2 residents reviewed during a annual survey for baseline care plan. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of Resident #43's electronic and paper medical record on 8/15/22 at 8:00 AM revealed Resident #43 was admitted to the facility in 06/2022. Review of the medical record failed to reveal documentation that a baseline care plan was developed within 48 hours of admission and that a copy was provided to the resident/resident representative. The Director of Nursing (DON) was interviewed on 8/16/22 at 10:04 AM and confirmed that facility staff failed to initiate a baseline care plan for Resident #43 within 48 hours of admission. The DON stated, Baseline…

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 medical record review and staff interview, it was determined that the facility staff failed to: 1.) initiate a care plan for a resident receiving a hypnotic and an antidepressant medication (Resident #43); 2.) failed to initiate care plans for activities (Resident #56 and #52); 3. initiate a care plan for a new treatment for Resident #12; 4.) to initiate a care plan for vision loss (Resident #52). This was evident for 4 out of 8 residents (Resident #12, #43, #52, and #56) selected for review during the annual survey. The findings include: A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1. The facility failed to initiate a care plan for a Resident (#43) who was receiving melatonin and Trazadone for insomnia. A review of the medical records on 8/18/21 at 11:00 am, revealed that Resident #43 was admitted to the facility in June 2022 for long-term care and with a diagnosis that included insomnia. A review of Resident # 43's medical record on 8/18/22 am revealed 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, the facility failed to update the resident's care plan after a change in status. This was evident in 2 of 40 residents (Residents #5 and #63) reviewed during the facility's annual survey. The findings include: 1. On 8/19/22 at 10:10 am, review of Resident #5's medical record revealed that the resident was receiving tube feedings and eating by mouth. Further review of the medical record on 8/19/22 at 10:15 am revealed that the facility Dietitian #29 documented on 5/24/22 that Resident #5 was asked if he/she wanted to continue with tube feeding. Resident #5 stated that he/she did not want to make changes to the tube feeding plan at that time because he/she liked the option of being able to have both options of receiving nutrition. On 8/19/22 at 10:30 am, review of Resident #5's care plan found no evidence that interventions were being made to ask the resident about his/her preference for tube feeding continuation. On 8/19/22 at 11:10 am, interview with Dietitian #29 revealed that he/she is responsible for updating Resident #5's nutrition…

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 the facility failed to administer a bowel protocol as ordered by the physician (Resident #216) and failed to follow-up on nutritional supplements for Resident #24. This was evident for 2 of 8 residents reviewed for nutrition services during the annual survey. The findings include: A fleets enema is a saline laxative that provides relief from occasional constipation. 1. Review of complaint MD00180330 and Resident # 216's medical record on 8/19/22 at 1:17 pm revealed a physician order dated 3/9/20 to administer 8 ounces of prune juice by mouth or by g-tube every 24 hours as needed for day one of bowel protocol and if no bowel movement (BM) by day 3 and to administer a fleets enema for day 3 of no BM. Review of the BM report on 8/19/22 at 1:30 pm, revealed the resident did not have a BM on 7/4/22, 7/5/22, 7/6/22 and the prune juice and/or the Fleets Enema was not given. During an Interview with the DON on 8/19/22 at 2pm she confirmed the bowel protocol put in place for Resident #216 was not followed. 2.…

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 medical records and staff interviews, it was determined that the facility failed to monitor a resident's tube feeding program (Resident #5). This was evident for 1 of 1 residents being investigated for tube feeding during the annual survey. Findings include: On 8/19/22 at 10:10 am, review of Resident #5's medical record revealed that the resident was receiving tube feedings and eating by mouth. Further review of the medical record on 8/19/22 at 10:15 am revealed that the facility Dietitian #29 documented on 5/24/22 that Resident #5 was asked if he/she wanted to continue with tube feeding. Resident #5 stated that he/she did not want to make changes to the tube feeding plan at that time because he/she liked the option of being able to have both options of receiving nutrition. On 8/19/22 at 10:30 am, review of Resident #5's care plan found no evidence that interventions were being made to ask the resident about his/her preference for tube feeding continuation. On 8/19/22 at 11:10 am, interview with Dietitian #29 revealed that it was normal practice to ask Resident #…

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

Based on medical record review and interview it was determined the facility failed to follow up with the consultant pharmacist's recommendations for a resident. This was evident in 1 (Resident #52) of 3 residents reviewed for unnecessary medications. The findings are: On 08/16/22 at 12:35 pm, the surveyor reviewed copies of Resident #52's pharmacy recommendations for May and July 2022. The pharmacy recommendation for July 2022 was for the resident to have a Ferritin level, TSAT, and Occult blood and/or add iron supplementation. On 07/21/22 Nurse Practitioner #28 agreed to the pharmacy recommendation and added if not done in the last 6 months to do Iron/blood saturation. A review of Resident #52's electronic medical record (EMR) revealed an order was not written for the recommended blood work and the iron supplement. On 08/18/22 at 3:03 pm during an interview with Nurse Practitioner (NP) #28 about the pharmacy recommendations for Resident #52 in July 2022, NP #28 verified, that an order was not written for blood work and/or an iron supplement.

Based on medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in resident's drug regimen to the physician, facility's medical director and/or the director of nursing. This was evident for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. The findings include: Review of the medical record for Resident #43 on 8/18/22 at 11 am revealed a physician order dated 6/30/22 to administer Melatonin 6 mg (milligrams) and Trazadone 50 mg at bedtime for insomnia. Melatonin is a hormone released by the pineal gland in the brain at night and has been associated with control of the sleep-wake cycle. Trazadone is an antidepressant and a sedative. Pharmacy reviews dated 7/18/22, 8/16/22 documented that no irregularities were noted. During interview with the pharmacist on 8/18/22 at 1 pm, he stated the resident had a diagnosis for depression; however, he should have brought the duplicate medications of Melatonin and Trazadone to the attention of the facility staff.

Based on observation and interviews it was determined the facility's dietary staff failed to wear hair restraints while in the kitchen to prevent hair from contacting food. This was evident in 2 (Staff #5 and Staff #9) of 5 dietary staff observed in the kitchen during the annual survey. The findings include: On 08/12/22 at 8:55 am surveyor observed Staff #5 in the kitchen without a hair covering. The employee reported he/she usually had his/her hair tied up. On 08/12/22 at 1:05 pm the surveyor observed Staff #9 in the kitchen without a hair covering. The employee verbalized he/she just came to work, and he/she has been working at the facility for 4-5 years. On 08/12/22 at 9:03 am Staff #30 made the surveyor aware the facility was trying to find a suitable hair covering for Staff #5. He/she wears a hairnet according to his/her hairstyle and the staff are required to wear a hair covering.

Based on observations and interviews with facility staff it was determined the facility staff failed to adhere to infection control practices and guidelines by ensuring that the appropriate personal protective equipment (PPE) was worn before entering a resident room who was noted to be on transmission-based precautions (TBP). This was found to be evident during multiple observations made of 2 residents (Resident #164 and #165) during the facility's annual Medicare/ Medicaid survey. Findings include: Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. On 8/11/22 at approximately 9:15 AM Staff #10 was observed going into Resident #164 and Resident #165's room. Staff #10 crossed the entrance of the resident room and did not have on a gown, gloves, or eye protection. At this time this surveyor asked Staff #10 if she was aware of the sign that was posted…

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.