Copper Ridge Nursing And Assisted Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #6) out of 30 residents reviewed during the facility's recertification/complaint survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. On 5/29/25 at 12:01PM in an interview with the Director of Nursing…

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

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to follow physician orders for a resident. This was evident for 2 (Residents #6 and #22) out of 30 residents reviewed during the facility's recertification/complaint survey. The findings include: 1) The surveyor reviewed Resident #6's medical record on 5/28/25 at 1:20 PM. The review revealed the resident had weight loss from 11/1/24 - 12/6/24. Further review of the medical record revealed Resident #6 was ordered weekly weights one time a day every Sunday for 4 weeks on 12/6/24. Per the order, the first weight should have been obtained on 12/8/24; however, there was no weight observed in the medical record for this date. Furthermore, there was no weight obtained on 12/22/24. Only half, 2 out of 4 weights were obtained for this order. The other 2 weights from the order were obtained but were not obtained on Sunday as ordered. Additionally, Resident #6 was ordered weekly weights one time a day every Sunday for 4 weeks on 2/4/25. The 4th weight from that order should have…

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 resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This was evident for 2 (Resident #29 and #165) out of 3 residents reviewed for administration of controlled medication during this recertification/complaint survey. The findings include: A controlled substance is a drug or chemical regulated by a government due to its potential for abuse, harm, or psychoactive effects. These substances are often classified into different schedules (or categories) based on their potential for abuse and accepted medical uses, including both illicitly used drugs and prescription medications designated by law. A controlled medication utilization record (known as a count sheet) is a form to record controlled medication dispense. It documents the details for each use of any controlled substance amount removed from its original containers, including date, time, the dose given, the signature of the 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 interviews with facility staff, it was determined that the facility failed to document/respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #1) out of 5 residents reviewed for unnecessary medication use during this recertification/complaint survey. The findings include: During an interview with the Director of Nursing (DON) on 5/29/2025, at 9:16 AM, she explained the procedures for obtaining medication orders for residents. She stated, When we get a new admission, the admitting nurse enters the medications. Supervisors review the medications, and the pharmacist reviews them within 2-4 hours. A report is then sent through their website. If drug interactions are noted, they are sent via email to the provider and DON. Then, I print and give them to the provider for review and sign-off. I hand it to the provider, and the provider reviews it. They agree, disagree, or note 'other,' then sign/date and provide a rationale for disagreement. The surveyor asked how the facility staff documented these…

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

Based on clinical record review and staff interview, it was determined that the facility nursing staff failed to ensure medications were administered or withheld according to physician's orders. This was evident for 2 (Resident #3 and #28) out of 30 residents in the survey sample. The findings include: 1) A review of Resident #3's clinical record on 6/4/25 revealed the resident's primary physician ordered Metoprolol (cardiac medication) 50 mg (milligrams) to be administered twice a day and to hold for a systolic blood pressure (top number) of less than 110 or a heart rate less than 60. A review of the resident's medication administration record (MAR) on 5/14/25 revealed the nursing staff took the resident's blood pressure, and it was 109/76 which meant the medication was to be held but the nurse administered the medication. On 5/24/25, the nursing staff did not take the resident's blood pressure in the morning but still administered the medication despite the physician having ordered parameters that instructed the nurse whether to hold the medication. Further review of the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, and staff interview, it was determined that the facility staff failed to ensure a resident received routine dental services. This was evident for 1 (Resident #3) out of 30 residents in the survey sample. The findings include: Resident #3 was interviewed on 5/28/25 at 9:11 AM. The resident was asked if they have been seen by a dentist since admission and if they are having any dental issues such as a suspected cavity, tooth pain, or a cracked tooth. The resident said they have never been to a dentist, and they have issues with their teeth and would like someone to take care of it. A review of Resident #3's clinical revealed that the resident was admitted on [DATE] and has never been seen by a dentist. The Director of Nursing was interviewed on 06/04/25 at 08:45 AM. This surveyor had requested all dental consults since Admission. She informed the surveyor that there were no dental consults in the clinical records because the resident did not have any problems.…

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

Based on observation and staff interview, it was determined that the facility staff failed to discard protein drinks past their use by date. This was evident for 2 out of 3 unit-based kitchens observed during the recertification/complaint survey. The findings include: During the tour of the kitchen on the Eastern Shore nursing unit on 6/4/25 at 10:08 AM two 4-ounce cartons of vanilla reduced sugar Mighty Shake (a fortified nutritional shake) were observed in the refrigerator. The cartons had a use by date of 5/30/25. Staff #21 was shown the shakes, and she said, I'll take care of it. She then appeared to put them back in the refrigerator. During the tour of the kitchen on the Baltimore nursing unit that served the lower numbered rooms on 6/4/25 at 10:14 AM one 4-ounce carton of vanilla reduced sugar Mighty Shake (a fortified nutritional shake) was observed in the refrigerator. The carton had a use by date of 5/30/25. Staff #22 was shown the shake, and he immediately threw it out. The Dietary Manager (Staff #20) was interviewed on 6/4/25 at 2:07 PM. This surveyor informed her 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 record review and staff interviews, the facility failed to adequately monitor and track residents receiving antibiotics. This deficiency was evident for 2 (Resident #22 and #166) out of 4 residents reviewed for antibiotic use and the facility's antibiotic stewardship program during the recertification/complaint survey. The findings include: Background on Antibiotic Stewardship: Effective antibiotic stewardship requires a facility to develop and implement robust policies, procedures, or protocols to ensure residents needing antibiotics are treated appropriately. This is crucial for minimizing the risk of adverse drug reactions, preventing unnecessary antibiotic administration, and mitigating the development of antibiotic-resistant organisms. A facility-wide process for monitoring antibiotic use is essential, with results and feedback consistently reported to nursing staff and prescribing clinicians. On 6/02/2025, at 12:04 PM, during an interview with the Director of Nursing (DON), who also serves as the Infection Control Preventionist, she stated that the facility had an…

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

Based on medical record review and staff interviews, the facility failed to adequately screen residents for eligibility and document their pneumococcal and influenza (Flu) vaccination status. This deficiency was evident for 2 (Resident #29 and #54) out of 5 residents whose immunization records were reviewed during this recertification/complaint survey. The findings include: Pneumococcal Vaccine: The pneumococcal vaccine helps prevent pneumococcal disease, an illness caused by Streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends this vaccine for individuals aged 65 years or older, and for adults aged 19 through 64 with certain medical conditions or risk factors. Influenza (Flu) Vaccine: Flu is a contagious respiratory disease that spreads annually, typically between October and May. While anyone can contract the flu, it poses a greater risk to certain populations, including infants and young children, individuals 65 years and older, pregnant individuals, and those with specific health conditions or weakened immune systems. Influenza…

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, staff employee file review, and staff interview, it was determined the facility failed to maintain document related to residents' and staff' COVID-19 vaccination status. This was evident for 2 (Resident #3 and #54) out of 5 residents, and 1 (Staff #16) out of 5 staff reviewed for COVID vaccination records during this recertification/complaint survey. The findings include: 1a) On 6/2/2025 at 10:00 AM, a review of 5 randomly selected resident immunization records revealed that Resident #54, admitted in May 2025, did not have his/her COVID-19 vaccination status in their medical chart. During an interview with the Director of Nursing (DON) on 6/2/2025 at 1:19 PM, the DON stated that the facility monitored resident immunization status through ImmuNet (Maryland's immunization information system), hospital records, and direct communication with residents or their family members. When questioned about Resident #54's COVID-19 vaccination status, the DON responded, I will look more. Subsequent review of Resident #54's medical record progress note on 6/5/2025 at…

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

Based on observation and interviews, it was determined that the facility failed to ensure that all residents were adequately equipped with the ability to call for assistance, if needed, through a communication system. This was evident for 1 (Resident #58) out of 4 resident rooms assessed for call light accessibility during the recertification/complaint survey. The findings include: On 5/28/25 at 8:47 AM, during the initial screening phase of the survey process, it was observed that Resident #58's call bell was on the floor in the resident's room and unreachable for the resident when laying in bed. On 6/3/25 at 10:26 AM, an observation of Resident #58's room revealed that the resident's call bell remained out of reach. The call bell was wedged under the resident's wardrobe. In an interview with Certified Medication Aide (CMA #25), she was made aware of Resident #58's call bell location. CMA #25 attempted to remove the call bell from the floor; however, she stated that she was unable to remove the wedged call bell, but would notify maintenance to address the concern. On 6/5/25 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 a review of facility investigative materials, resident medical records, and interviews with facility staff, it was determined the facility failed to ensure that a resident remained free of verbal abuse. This was evident for 1 (Resident #33) out of 4 residents reviewed for abuse during this recertification/complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and actions were verified during this survey, leading to a determination of past noncompliance, with a compliance date of 6/12/2024. The findings include: BIMS: Brief Interview for Mental Status score is a measure of cognitive function in individuals, typically used in long-term care facilities. It assesses orientation, recall, and the ability to perform simple tasks. The higher the score, the better the cognitive performance, with scores ranging from 0 to 15. Facility Reported Incident #MD00205893 was reviewed on 6/02/2025 at 9:25 AM. The facility's investigation revealed that on 5/16/2024, Licensed Practical…

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 the facility's investigation, the facility reported incident, and staff interview, it was determined that the facility failed to protect a resident from abuse. This was evident for 3 (#115 ,#116 #117) out of 9 residents selected for abuse review during the annual recertification survey. The findings include: 1) Review of facility reported incident MD00139229 on 09/15/2021 revealed an allegation that Resident #115 was verbally abused by staff member #30 on 04/09/2019 at 7:15 AM. The facility investigation indicated that Resident #115 was voicing concerns about staff member #30's care during the night shift. The facility investigation revealed documentation that staff member #30 overheard Resident #115 voicing his/her concerns to the day shift charge nurse that staff member #30 would not honor his/her request to get up out of bed. It was at this time that witnesses heard staff member #30 call Resident #115 a liar. In an interview on 09/20/2021 at 8:48 AM, staff member #14 stated that Resident #115 came to the nurses' station on the morning of 04/09/2019 and told…

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 the medical record, observation, and interviews with staff, it was determined that the facility staff failed to 1) develop a comprehensive care plan for a resident (#26) receiving an antidepressant medication, and 2) develop a plan of care for pain management that had included non-pharmacological interventions. This is evident for 2 (Resident #26, #263) of 46 resident's selected for investigative review in the annual survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicate to other health care professionals. A written care plan decreases the risk of incomplete, incorrect, or inaccurate care. A review of resident #26's medical record on 9/16//21 at 10 am revealed a physician order to administer Escitalopram Oxalate 20 mg (milligrams) by mouth once time a day for depression. Continued review of the medical record failed to review a care plan for the antidepressant medication. On 9/16/21 at 11:55…

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, review of daily staffing records, and staff interview, it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. It was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for the survey. The findings include. During observations on 09/13, 09/14, and 09/15/2021, the nurse surveyor did not observe the Federal requirements related to the posting of staff in the facility. The total number of and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift was not observed in any part of the facility. An interview was conducted with the facility Administrator and the assistant director of nurses (ADON) on 09/21/2021 at 2:15 PM during the sufficient and competent nurse staffing task review. 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.

Based on review of facility records and an interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was requested at the initiation of the survey on 09/13/21. Review of the Facility assessment on 09/14/21, revealed that the date of assessment or update was documented as September 2021. The initial creation of the Facility Assessment Tool dated August 2020 corresponded to the…

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

Based on observation and staff interview, it had been determined that the facility had not implemented infection control practices to prevent the spread of COVID 19 as evidenced by facility staff to wear mask that covered their mouth and nose at all time while in resident care area. The findings include: Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. On 5/4/2021 The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 5/4/21 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus (SARS-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals 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 observation rounds, it was determined the facility failed to maintain dignity for a resident when a staff member wrote the date and time on a pain patch after applying it. This was evident for 1 (#21) of 46 sampled residents. The findings included: During observation rounds on 9/20/21 at 10 am, LPN staff # 29 was observed applying a Lidoderm Patch to resident #21's right upper chest. After placing the patch to the upper chest, LPN staff #29 wrote the date and time applied on the patch. This surveyor asked staff #29, if this was his/her normal practice. S/he stated the patch should have been timed and dated before applying it. The DON (Director of Nursing) was made aware of the findings on 9/20/21 at 10:30 am.

Based on record review and interview, it was determined that the facility staff failed to ensure that residents were able to exercise their right of self-determination, as evidenced by denying a resident a food preference due to the resident's diagnosis. This was evident for 1 (#19) of 43 residents reviewed. The findings include: An interview with Resident #19 on 9/14/21 at 11:54 AM, revealed that Resident #19 had made several request for regular sugar for his/her coffee but had been denied this request due to his/her diagnosis of type 2 diabetes (a long-lasting condition in which the body doesn't regulate the sugars in the blood in order to get the sugar to the cells for energy). Resident #19 reported that he/she was aware that the artificial sweeteners would be a better choice, however, coffee tasted better when Resident #19 used regular sugar. During a record review for Resident #19 on 9/17/21 at 1:24 PM, it was revealed that Resident #19 had a diagnosis of Type 2 diabetes. A review of the physician's orders revealed that Resident #19 was ordered a carbohydrate controlled diet…

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 administrative documents and staff interview, it was determined that a facility staff member failed to 1) report an allegation of physical abuse immediately to the facility administrator and initiate an investigation into the allegation of abuse and 2) report an allegation of abuse to the State Agency within a timely manner. This was evident for 2 (Resident #115, #262) of 10 residents reviewed for abuse during an annual recertification survey. The findings include: 1) Review of facility reported incident MD00139229 on 09/15/2021 revealed an allegation that Resident #115 was verbally abused by staff member #30 on 04/09/2019 at 7:15 AM. In an interview on 09/20/2021 at 8:48 AM, staff member #14 stated that Resident #115 came to the nurses' station on the morning of 04/09/2019 and began telling staff member #44 that staff member #30 would not honor his/her request to assist them out of bed. At this time, staff member #14 heard staff member #30 call Resident #115 a liar. The facility investigation indicated that, prior to being admitted to the facility, Resident #115…

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 with residents and facility staff, it was determined that the facility failed to 1) give residents a list of their admission medications with a copy of their baseline care plans, and 2) develop and implement baseline care plans and 2) provide a summary of the baseline care plan to newly admitted residents. This was evident for 5 (#21, #26, #51, #261, #262) of 46 residents reviewed during the investigation phase of the survey. The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. The findings include: 1) Resident #21's medical record was reviewed on 9/20/21 at 9:10 AM for his/her admission in July of 2021. During a review of the medical record, a baseline care plan was found that was supposed to be given to 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, it was determined the facility failed to 1) update the care plans to reflect the removal of a Foley catheter for the residents (#26, #51), and 2) have a care plan meeting in August 2021 for resident #28. This was evident for 3 out 46 residents reviewed for the annual survey. The findings include: 1. Review of Resident #26's medical record on 9/21/21 at 9 am, revealed a care plan, initiated 8/24/21 for Resident has a continuous urinary Foley for urine retention and neurogenic bladder. Neurogenic Bladder-the nerves that carry messages back- and- forth between the brain and the spinal cord don't work the way they should. Urinary Retention is a condition in which you cannot empty all the urine from your bladder. A continued review of the medical record revealed that Resident #26's Foley Catheter was removed on 9/11/21; however, the care plan was not updated to reflect the removal of the Foley catheter. During an interview with the DON (Director of Nursing) on 9/21/21 at 11 am, she verified the Foley catheter was removed on 9/11/21. 2. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation of resident # 35, it was determined that facility failed to turn and reposition a resident who could not do so independently. This was evident for 1 (#35) out of 1 resident. Findings include: (Minimum Data Set (MDS) - Nursing Home Assessment The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs.) On 9/13/21 at 10:30 AM, an interview was held with resident # 35. Resident had a history of multiple sclerosis and a stage 3 pressure ulcer on sacrum. According to MDS dated [DATE], resident # 35 was a two person plus for bed mobility. Resident had a care plan for wounds and ADL care including turning and repositioning. On 9/13/21, resident was laying on her back in the same position as she was at 7:40 AM. On 9/13/21 during interview, resident # 35 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.

Based on complaint, a facility reported investigation, and interview with the ombudsman and facility staff, it was determined that 1) RN staff #11 failed to replace an empty oxygen tank for resident #213 that was empty, and 2) the nursing staff failed to administer an injectable anticoagulant timely. This was evident for 2 (Residents #213, #114) of 46 residents reviewed during an annual recertification survey. Findings include: 1) On 9/14/21 at 9 AM, an investigation was conducted for resident # 213, who stated to the ombudsman that on 7/20/19, his/ her O2 tank ran out of oxygen while she/he was in the dining room eating. Resident # 213 had an order for Oxygen 2 Liters continuous, written on 7/13/21. Resident reported to GNA staff # 12 that her oxygen had run out. GNA staff # 12 reported to nurse # 11 that resident # 213's oxygen had run out. Staff #11 stated to GNA that there is no need to replace oxygen at this time, and to monitor resident for SPO2 and let him know if it reaches below 84% on room air and then he/she will replace the oxygen. When SPO2 reached 84 % on room air, 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.

Based on observation and interview with GNA, facility failed to have sufficient staff on the Eastern Shore unit on 9/13/21 7-3 shift. This was evident for 34 out of 34 residents. Findings include: The Eastern Shore unit had 34 residents on the unit on 9/13/21. There were two GNAs assigned on 9/13/21 to work on the 7-3 PM shift on that floor. On 9/13/21 at 8:30 AM, during breakfast service on the Eastern shore unit, it was noted that residents were being dressed and sent to the dinning room to eat breakfast. Some of the residents were being fed by staff members. After residents were fed, the bedbound residents were served and fed their breakfast, which resulted in one resident # 35 getting his/ her tray at 10:50 AM. Resident # 35 stated that this happened all the time. No other care was provided to this resident until after she/he was fed. Resident # 35 was also not turned and repositioned or changed and had a history of pressure ulcer wound stage 3 on sacrum. Surveyor interviewed GNA #7 and he/she stated 'the nurses on the unit are giving out medications and do not help deliver…

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 administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on 2 (#40, # 43) out of 5 geriatric nursing assistant staff for the year of 2021, and 2) ensure that 2 (#40, # 43) out of 5 geriatric nursing assistants (GNA) staff completed a minimum of 12 hours of education per year. The findings include: During an interview on 09/22/2021 at 1:34 PM, the facility ADON stated that he/she was unable to produce documentation which indicated that 2 (#40, # 43) of 5 sampled GNA staff members had a performance review during the past year. (staff member #40, with a hire date of 11/11/2013 and staff member #43, with a hire date of 07/02/2000) or that staff member #40 and staff # 43 received at least 12 hours of training/education in the past 12 months as required.

Based on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to ensure that 5 ( GNAs #22, 40, 41, 42, 43) out of 5 geriatric nursing assistants (GNA) staff received and completed minimum training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. The findings include: During an interview on 09/22/2021 at 1:34 PM, the facility ADON stated that he/she was unable to produce documentation that indicated 5 sampled GNA staff members received training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. The following GNA staff did not receive residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, training for 2020-2021: 1) GNA #22 2) GNA #40 3) GNA #41 4) GNA #42 5) GNA #43 Cross reference F 838

Based on observation, staff interview, and facility documentation review, it was determined the facility failed to discard medications after the expiration date. This was evident for 1 of 2 nursing units observed. The findings include: Observation of the medication storage room on Baltimore-unit one on 9/20/21 at 2:59 PM revealed an IV (Intravenous) solution Bag labeled (D 5% Dextrose/0.9% Sodium Chloride injection USP 1000 ml bag) lying in an upper cabinet with other IV solutions. The IV solution was dated with an expiration date of August 2021. During an interview with the unit manager RN staff #28 on 9/20/21 at 3:15 PM, he/she stated the pharmacy had just been in to change the container. The DON was made aware of the findings on 9/20/21 at 3:30 PM.

Based on interviews of residents and facility staff, it was determined the facility failed to follow residents' meal tickets and provide foods that were consistent with the resident diet plan and provide meals on time. This was found to be evident for 2 (Resident #10, #261) out of 46 residents investigated for food concerns during the facility's annual survey. The findings include: An interview was conducted with resident # 10 on 9/13/21 at 10:30 am and s/he complained that the food was not correct when it was brought by the nursing staff. The resident went on to say that the dietary department staff were unable to read the dietary slips and stated that if they were reading the diet slips correctly, why was s/he not served items ordered on his/her menu slip. A review of the ticket on resident #10's tray read hot Tea, potatoes, waffles, and turkey sausage. The plated foods were 2 waffles and 3 turkey sausages which were cold per the resident. The resident also stated that breakfast was sometimes served as late as 11 am at times. According to the meal schedule, the trays were due on…

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

Based on complaint, observation, and staff interview, it was determined that the facility staff failed to provide a resident with a meal within the required time frame. This was evident for 2 (Resident #35, #114) of 2 residents who were totally dependent upon staff to feed them. This was observed during dining observations during an annual recertification survey. The findings include: 1) On 9/13/21 at 10:50 AM, an interview was being conducted with resident # 35, when GNA #20 brought in a breakfast tray. This surveyor asked GNA 20 why the tray was delivered so late, and she stated that there were only 2 GNAs here and we have a lot of residents that needed to be fed on the Eastern Shore Unit. GNA went on to say there were 6 residents that needed to be fed on the low side (rooms 1-18) and 3 residents that needed to be fed on High Side (rooms 19-36). On the day of the survey, (9/13/21) the census was 34 residents, which was 17 residents for each GNA. GNA stated that the nurse on the floor on 9/13/21 was giving out medications and that the Unit manager does not help feed residents or…

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.

4) On 9/21/21 at 10:56 AM, a review of Resident #263's medical records revealed on the Treatment Administration Record (TAR) for 5/2021, an order initiated on 5/3/21, that read, Sacrum: cleanse with wound cleaner then apply calcium alginate with silver and cover with foam dressing. Every day shift for wound healing. Further review of Resident #263's medical record revealed that staff had failed to document the assessment of this wound or a notification to the physician and resident representative regarding the wound. On 9/21/21 at 2:00 PM, an interview with the Assistant Director of Nursing (ADON) revealed that she was unable to locate any skin sheets or documentation regarding Resident #263's sacral wound. 3) On 9/22/21 at 12:05 PM, an investigation was conducted for resident # 28 who had a history of aggressive behavior towards other residents and staff. It was documented in resident # 28's progress notes that resident hit other residents with his/her cane, and wheelchair, He/she has also pushed residents causing them to fall, and cursed at staff and residents. He/she refused 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 record review and interview, it was determined that the facility staff had failed to conduct quality assurance meetings on a quarterly basis. This was evident for 2 of 4 Quality Assurance meetings. The findings include: On 9/21/21 at 3:01 PM, a review of the facility's Quality Assurance (QA) meeting notebook revealed that QA meetings had not occurred on a quarterly basis in the past 12 months [[DATE] - [DATE]]. The facility held meetings in 11/20, 12/20, 1/21, 6/21, 7/21, and 8/21. An interview with Nursing Home Administrator (NHA) on 9/22/21, revealed that he/she had started employment with this facility in 6/21, therefore had been unable to provide explanation of missed QA meetings.

Based on record review and staff interview, it had been determined that the facility failed to have a process in place to prevent the spread of infection by ensuring 1) that residents had been offered both pneumococcal vaccinations as recommended by the Centers for Disease Control and 2) that staff had provided immunization records in writing at the time of hire. This was evident for 3 (#19, #35, and #31) of 5 residents reviewed for immunizations and 5 (#40, #41, #42, #43, and #22) of 5 staff reviewed for immunization records. The findings include: 1) On 9/20/21 at 10:15 AM, review of Resident #19's immunization records revealed that the resident had not received a Pneumococcal 13 vaccination and facility staff failed to offer Resident #19 the vaccination. On 9/20/21 at 10:17 AM, review of Resident #35's immunization records revealed that Resident #35 had not received a Pneumococcal 23 vaccination following a Pneumococcal 13 vaccination on 11/22/19. Further review revealed that the facility staff had failed to offer Resident #35 a Pneumococcal 23 vaccination. On 9/20/21 at 10:30 AM,…

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

Based on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given 1) in-service training no less than 12 hours per year, 2) dementia management training and abuse prevention training, 3) a yearly performance review, and 4) training for GNA's that provided services to residents with cognitive impairments. This was evident for 5 of 5 GNA employee records (Staff #22, #40, #41, #42 and #43) that took place during the sufficient and competent nursing staffing task reviewed during an annual recertification survey. The findings include: During an interview with the facility assistant director of nurses (ADON) on 09/22/2021 at 1:34 PM, she/he stated that he/she was unable to produce documentation which indicated that 5 sampled GNA staff members received the following training: 1). Staff member #40, with a hire date of 11/11/2013 and Staff member #43, with a hire date of 07/02/2000 had not received 12 hours of training/education in the past 12 months 2) Staff member #40, with a…

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

Based on medical record review and interview it was determined that the facility failed to have a system in place to 1) ensure that required documentation regarding a resident's transfer and appeal rights were provided to residents when transferred to the hospital; and 2) to inform the Ombudsman of transfers and discharges. This was found to be evident for 1 out of 1 resident (Resident #61) reviewed for hospitalization but has the potential to affect any resident transferred out of the facility. The findings include: On 9/17/18 review of Resident #61's medical record revealed that the resident had been discharged to the hospital in August 2018 and re-admitted several days later. Further review of the medical record failed to reveal any documentation that the resident, or a resident representative, had been provided written notification of the reason for the transfer or a statement of the resident's appeal rights. On 9/17/18 at approximately 12 noon the Director of Nursing (DON) reported that they had devised a form to use for notification and were trying to figure out how to provide…

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

Based on medical record review and interview with staff it was determined that the facility failed to 1) ensure staff documented the reason why a resident did not attend the interdisciplinary team care plan meeting and 2) update and revise a care plan for a resident with identified changes in need related to mobility status. This was found to be evident for 2 out of 29 residents (Resident #61 and #17) reviewed for care plan participation and revision during the investigative stage of the 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) On 9/17/18 review of Resident #61's medical record revealed the resident was admitted in August 2018, was able to communicate without problem and was cognitively intact. Further review of the medical record revealed that a care plan meeting occurred on 8/28/18 but no documentation was found that the resident attended or was invited to the meeting. On 9/17/18 at 1:53 PM the social worker reported that letters are…

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 prevent the development of a pressure ulcer for a functionally and cognitively impaired resident (Resident #27). This was evident for 1 of 1 residents selected for pressure ulcer review in the investigative stage of the survey. The findings include: The Minimum Data Set (MDS) is an assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living and skin conditions.) On 9/14/18 Resident's #27's medical records were reviewed, this review revealed that the resident was admitted to the facility for long term care and with diagnoses which includes Dementia, osteoarthritis and hypothyroidism Review of the April 2018 MDS assessment reveals the following: the resident is cognitively impaired and is dependent on staff for all functional activities such as bed mobility, transfers, eating, turning and positioning. Review of the wound management documentation…

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 complete a physician ordered lab on a Resident (#21) This was evident in 1 of 5 residents reviewed for unnecessary medications. The findings include: Review of the medical record for Resident #21 on 9/14/18 at 11:43 AM, revealed diagnoses including Parkinson disease, dementia and hypertension. Further review of the medical record revealed an order on 8/30/18 for a basic metabolic panel (BMP test panel the kidneys, blood glucose level, and electrolyte and acid/base balance). Review of the medical record revealed that this lab was never completed. This concern was reviewed with the DON on 9/14/18 at 3:34 PM that the lab was not completed.

Based on medical record review and interview with staff it was determined that the facility failed to ensure laboratory test results were kept in the resident's medical record for review by medical practitioners. This deficient practice was found to be evident for 1 out of 29 residents (Resident #34) reviewed during the investigative stage of the survey and resulted in the re-ordering of a lab test. The findings include: On 9/14/18 review of Resident #34's medical record revealed an order, dated 7/12/18 for a CBC (complete blood count) and a CMP (comprehensive metabolic panel). Further review of the medical record failed to reveal any laboratory results for the CBC and CMP that were ordered on 7/12/18. Further review of the medical record revealed an order, dated 8/9/18, to: please track down labs ordered on 7/12 (CBC, CMP). There is another, separate order, written after the order to track down the labs but also dated 8/9/18 for a CBC and a CMP for the next morning. On 9/14/18 the Director of Nursing (DON) reported that lab results are kept on the resident's charts. Surveyor then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to ensure documentation of certifications of incapacity to make health care decisions were completed prior to allowing health care agents to make decisions for the resident. This was found to be evident for 1 out of the 29 residents (Resident #45) reviewed during the survey. The findings include: On [DATE] review of Resident #45's medical record revealed resident was admitted to the facility in [DATE] with diagnosis that included Alzheimer's disease and dementia. Review of the admission Minimum Data Set assessment revealed the resident had severe cognitive impairment but had clear speech and was usually able to make him/herself understood. Review of the Medical Orders for Life-Sustaining Treatment (MOLST) completed on [DATE], which was after the resident's admission to the facility, revealed the orders had been entered as a result of a discussion with and consent of the patient's health care agent as named in the…

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

Based on record review and staff interview it was determined that the facility failed to put a system in place to ensure proper infection surveillance policies and procedures are in place by not implementing a plan to monitor the duration/outcome of antibiotic therapy. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. Findings include: A line listing is a table in which important information is recorded on each person who is currently or potentially ill with an infection. The information recorded can be used to monitor unusual and expected outcomes to determine if current therapies or practices are effective or require changes. Review of the facility's Infection Prevention and Control Policies was conducted on 09/17/18 at 12:48 PM. Review of the residents' line listing revealed that there was no documentation of the duration of or the outcome of antibiotic treatments given to residents. During an interview with the Director of Nursing on 09/17/18 at 1:03 PM she acknowledged that since the line listing failed to outline this…

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

Based on record and staff interview it was determined that the facility failed to put a system in place to ensure that there is documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization (and the administration or the refusal of or medical contraindications to the vaccines.) This deficient practice has the potential to affect all residents, staff and visitors in the facility. Finding includes: Review of the residents' immunization records were conducted on 09/17/18 at 12:48 PM. It revealed that there was no documentation to support that these residents or their resident representatives had received education or information regarding immunization. During an interview with the Director of Nursing on 09/17/18 at 1:03 PM she acknowledged surveyor's findings.