Sligo Creek Healthcare

Based on observation, medical record review and interviews it was determined that the facility failed to develop comprehensive person-centered care plans for each resident and failed to provide a resident with a timely comprehensive care plan. This was found to be evident for 4 (Resident #66, #19, #2 and #352) out of 42 resident's reviewed during the survey. The findings include: 1) Review of Resident #66's Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date of 1/7/25, revealed the resident had functional limitations in range of motion for upper and lower extremities (arms and legs) on both sides, and the resident was dependant on staff for activities of daily living such as bathing, dressing and moving in bed. Observation of Resident #66 on 2/11/25 at 8:52 AM, 2/13/25 at 10:15 AM and 2/18/25 at 12:22 PM revealed quarter side rails were in the up position. On 2/18/25 review of the Proper Use of Side Rails policy revealed: An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. On 2/18/25…

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 pertinent documentation and interviews it was determined that the facility failed to have comprehensive care plan meetings at the required intervals and failed to update the care plan after a change in status. This was evident for 3 (Resident # 8, #2 and #337) out of 42 residents reviewed during a 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 2/17/25, the review of intake #MD00207198 revealed that Resident #8, a long-term resident of the facility, had a concern that the facility was not developing compressive care plans for the facility residents. On 2/18/25 at 9:29 AM Resident #8 was interviewed. During the interview s/he confirmed that s/he had made several complaints to the facility and to the Office of Healthcare Quality regarding the comprehensiveness of his/her care plan. Resident #8 reported that the concern with his/her care plan had not been resolved. On 02/18/25 11:18 AM the Director of Nursing (DON) and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and medical record reviews it was determined that the facility failed to safeguard resident's confidential medical records; failed to ensure medical records are kept accurate and current; and failed to ensure documentation of the certification of medical ineffectiveness before changing a resident's code status from a full code to Do Not Resuscitate (DNR). This was evident for 4 (Resident #55, #51, # 16 and #66) out of 42 residents reviewed during the survey. The findings include: 1)On [DATE] at 11:14 AM an observation of medication administration for Resident #55 was conducted. The facility Certified Medicine Aide (CMA #12) was observed at the medication cart in the hallway outside the resident's room. On [DATE] at 11:15 AM CMA #12 removed 2 bottles of stock medications, viewed the computer screen on top of the medication cart, which was open to Resident #55's clinical information, returned the bottles to the drawer, said that she needed to go get something, and she walked away…

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 staff and resident medical record review and interviews, it was determined that the facility failed to provide education and offer staff and residents the current COVID-19 vaccination. This was evident in four (Staff #28, #29, #30, and #31) out of four staff and two (Resident #66 and #48) out of five residents reviewed for immunization status. The findings include: On 2/13/25 at 12:00 PM the surveyor asked the Director of Nursing (DON) for Staff #28, #29, #30, and #31's employee health files to review. On 2/14/25 at approximately 1:00 PM the surveyor reviewed medical records for resident immunizations and noted no record of Resident #66 or #48 being offered or educated about the current COVID-19 immunization. The surveyor also reviewed four (Staff #28, #29, #30, #31) employee health files and could not find proof of current COVID-19 immunization acceptance, refusal, or education. On 2/14/25 at approximately 1:15 PM the surveyor notified the Assistant Director of Nursing (ADON) that the surveyor was unable to find records of current COVID-19 education or immunization for…

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

Based on medical record review, observation and interview it was determined that the facility failed to maintain a resident's dignity by failure to ensure a urinary catheter bag was maintained with a privacy cover. This was found to be evident during a random observation of Resident #49. The findings include: Review of Resident #49's medical record revealed the resident has had a urinary catheter for at least the past six months. On 2/14/25 at 9:58 AM Resident #49 was observed sitting in a wheelchair in the activity room while music was playing. Surveyor noted a partially filled urinary catheter drainage bag hanging on the side of the wheelchair. The catheter bag did not have a privacy cover. On 2/14/25 at 10:03 AM surveyor requested the nurse (Staff #10) observe Resident #49's catheter bag. On 2/14/25 at 10:06 AM nurse #10 was observed obtaining a privacy bag. Follow up observation of the resident at approximately 10:20 AM revealed Resident # 49's urinary drainage bag was now in a privacy bag. On 2/14/25 at 11:47 AM surveyor reviewed the dignity concern with the Assistant Director…

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 reviews and interviews, it was determined that the facility failed to ensure that information was provided to residents to formulate an advanced directive. This was evident for 2 (Resident #1, #10) of 7 residents reviewed for advanced directives during the survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A medical records review of several residents was conducted during the initial pool. The review identified residents that did not have credible evidence of an advanced directive. These residents include: a) On 2/11/25 at 9:37 AM, Resident #1 had a document in his/her hard chart titled Health Care Decision Making dated 12/19/2013. This document explained the resident's…

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

Based on review of pertinent documentation and interviews, it was determined that the facility failed to have a procedure in place to provide the residents with written notifications concerning resolution to grievances. This was evident for all residents' grievance forms reviewed during the survey. The findings include: On 2/18/25 at 10:30 AM a review of intake #MD00205216 revealed a concern regarding the facility's process of resolving residents' complaints and grievances. On 2/14/25 at 12:27 PM the Social Services Director (SSD Staff #13) provided the 2024 and 2025 grievance record book. On 2/14/25 review of 18 out of 18 grievance forms written between October 2024 through January 2025 failed to reveal documentation that the resident received and/or agreed to the resolution of the grievance. Further review revealed a space available for the signature and date for the Resident to sign that they were notified. Further review revealed that the Social Service Director signed in this space, or that it was left blank. On 2/14/25 at 12:08 PM The Director of Social Services (Staff #13),…

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

Based on record review and interview it was determined that the facility failed to ensure residents received bed hold notices when they were transferred to the hospital. This was evident for 1 (Resident #38) of 2 residents reviewed for hospitalizations. The findings include: A bed-hold notice describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 2/18/25 at 3:19 PM a review of Resident #38's electronic health records was conducted. The documentation revealed that the resident was transferred to a hospital on 2/04/25 at 6:37 PM for a change in condition. No bed hold notice was found in the electronic record. On 2/18/25 at 3:49 PM a review of Resident #38's closed paper chart failed to reveal a bed hold notice for the resident's hospital transfer on 2/04/25. On 2/18/25 at 3:52 PM an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) was conducted. They were asked if there was any evidence that Resident #38 was provided a transfer notice for…

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

Based on a review of resident medical records and staff interviews, it was determined that the facility failed to ensure an accurate Minimum Data Set (MDS) assessment when documenting pressure ulcers. This was evident in one (Resident #66) out of seven residents reviewed for pressure ulcers. The findings include: A review of Resident #66's medical record revealed the resident was re-admitted to the facility after a more than one-week hospitalization in late December 2024. A Minimum Data Set (MDS) is a standardized assessment tool that helps to evaluate the health status of residents in long-term care facilities. The information gathered helps facilities to develop patient-centered care plans based on the residents' unique needs. The MDS assessment is a mandated requirement for all residents. On 02/12/25 at 11:40 AM, the surveyor reviewed Resident #66's MDS assessment which had an assessment reference date of 1/7/25. A review of the skin assessment section of this MDS revealed documentation that the resident had two pressure ulcers that were present upon admission: one stage 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.

Based on observations, interviews, and record review it was determined that the facility failed to provide activities to meet the needs of the resident. This was found to be evident for 1 (Resident #2) out of 3 residents reviewed for activities during the survey. The findings include: Resident #2 has resided at the facility for approximately one year and has a history of stroke and dementia. A review of the admission Minimum Data Set assessment, with an assessment reference date of 2/22/24, revealed the Preferences for Customary Routine and Activities was conducted with the resident representative. This assessment revealed that music and getting fresh air were very important to the resident. The Minimum Data Set (MDS) is a standardized assessment tool that helps to evaluate the health status of residents in long-term care facilities. The information gathered helps facilities to develop patient-centered care plans based on the resident's unique needs. The MDS assessment is a mandated requirement for all residents. On 2/10/25 at 3:10 PM, the surveyor observed Resident #2 sleeping 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 record reviews, interview and observations it was determined that the facility failed to have an effective system in place to ensure physician orders were put in the electronic health record for implementation, and failed to ensure orders and a care plan were established for the use of safety equipment. This was found to be evident for 3 (Resident #12, #30 and #66) out of 42 residents reviewed during the survey. The findings include: 1)On 2/12/25 at 10:25 AM Resident #12, a Resident admitted to the facility for rehabilitation, medical records were reviewed. Further review revealed the residents had several orders for opioid medications. On 2/12/25 at 10:30 AM a review of a pharmacy review, dated 5/23/24 revealed a pharmacist recommendation for the resident to have an order for Naloxone in case of a opioid overdose. Further review revealed that a physician agreed with the recommendations and ordered Naloxone for Residents #12. On 2/12/25 at 10:39 AM the review of Resident #12 orders failed to reveal an order for Naloxone. On 2/14/25 at 1:42 PM interview with the unit 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 record review and staff interview, it was determined that the facility failed to ensure wound treatment recommendations were implemented in a timely manner. This was evident for one (Resident #66) out of four residents reviewed for pressure ulcers. The findings include: A review of Resident #66's medical record revealed the resident was re-admitted to the facility after a more than one-week hospitalization in late December 2024. On 02/12/25, a review of Resident #66's medical record revealed a 1/7/25 Minimum Data Set assessment, which indicated that the resident had one stage two pressure ulcer present on admission. A Pressure Ulcer (PU) is a skin injury caused by prolonged pressure on an area of the body. Pressure ulcers result from restricted blood flow to tissues resulting in skin breakdown, open sores, or ulcers. Review of the January 2025 Treatment Administration Record failed to reveal treatment orders for a pressure ulcer between 1/1- 1/7/25. Further review of the medical record revealed that on 1/7/24 the wound care specialist saw the resident and recommended 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 record review, staff interview, and observation, it was determined that the facility failed to have an effective system in place to ensure therapist recommendations were implemented. This was evident for one (Resident #19) out of three residents reviewed for activities of daily living. The findings include: Resident #19 had a history of a cerebral infarction (stroke) that resulted in contracture of the muscles in the left hand. A contracture is a shortening and hardening of the muscles and tendons that may lead to deformity or rigidity of the joints. On 2/10/25 at 2:44 PM, the Rehabilitation Director (Staff #6) reported that Resident #19 had previously received Occupational (OT). services The surveyor asked for a copy of the therapy discharge summary. Occupational therapists help people improve their ability to perform daily tasks. On 2/11/25 at 10:19 AM, review of the 12/11/24 OT discharge summary revealed that the resident was discharged from OT with recommendations for restorative range of motion (ROM) and restorative splint and brace program for [his/her] left hand 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 obtain a physician's order for oxygen use. This was evident for 1 (Resident #287) of 6 residents reviewed for respiratory care during the recertification survey. The findings include: On 2/10/25 at 12:15 PM Resident #287 was observed seated on the bed in his/her room. There was an oxygen nasal cannula tubing in his/her nose and the tubing was connected to an oxygen concentrator next to the resident's bed and the concentrator was set to deliver oxygen at 1 liter/minute. When the resident was asked how long he/she had used oxygen, the resident replied that he/she had used oxygen since his/her admission in January. On 2/13/25 at 3:16 PM a review of Resident #287's physicians orders failed to reveal any order to give the resident oxygen. On 2/13/25 at 3:46 PM Resident #287 was again observed in his/her bed with the oxygen nasal cannula in place and connected to an oxygen concentrator which was set at 1 liter/minute. On 2/13/25 at 3:47 PM the surveyor asked Registered Nurse (RN #4) to check…

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 providers accurately reviewed residents' medications. This was evident for 1 (Resident #74) of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: On 2/12/25 at 9:45 AM a review of Resident #74's prescribed medications was conducted and revealed that the resident had previously been prescribed quetiapine (an antipsychotic medication) for agitation, but it was discontinued on 12/26/24. On 2/12/25 at 11:12 AM a review of Resident #74's Nurse Practitioner (NP) notes revealed 2 clinical notes, one written on 1/31/25 and one written on 2/10/25 by NP #9. Both notes included documentation that quetiapine was an active and current medication. On 2/18/25 12:29 PM a telephone interview with NP #9 was conducted to review his documentation of Resident #74's medication evaluations on 1/31/25 and 2/10/25. During the interview, NP #9 reviewed his notes and the resident's medication order history. When asked why his documentation indicated that 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 interviews, it was determined that the facility failed to have a resident seen by a physician for more than 9 months. This was evident in one (Resident #2) out of three residents reviewed for nutrition. The findings include: On 02/18/25 at 11:30 AM, review of Resident #2's medical record failed to reveal documentation to indicate the resident was seen by a primary care physician, or a nurse practitioner, from August 2024 until 12/30/24. The Director of Nursing and Assistant Director of Nursing were made aware of this concern at this time. The ADON indicated she would check the medical record from her laptop computer. Further review of the medical record failed to reveal documentation to indicate the resident was seen by the primary care physician from March through November 2024. On 02/18/25 at 11:46 AM, the ADON presented with her computer and failed to find primary care provider notes for August through November via her laptop at this time. The surveyor also reviewed the concern that there was no documentation to support that Resident #2 was seen…

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

Based on record review and interviews it was determined that the facility failed to administer a resident's medication according to physicians ordered parameters. This was evident for 3 (Resident #51, #48 and #8) out of 5 residents reviewed for unnecessary medications during a survey. The findings include: Hypertension (HTN), also known as high blood pressure (BP), is a condition in which the force of blood against the walls of the arteries is consistently too high. It is defined as a systolic blood pressure (SBP top number) of 130 mmHg or higher, or a diastolic blood pressure (DBP bottom number) of 80 mmHg or higher, based on multiple blood pressure measurements. 1) Resident #51 had been residing in the facility since 2023. A review of Resident #51's medication orders was conducted on 2/13/25 at 11:44 AM. The review revealed an order for Amlodipine Besylate oral tablet 10 mg, with instructions that read Give 1 tablet by mouth one time a day for HTN Hold for SBP <110 or heart rate (HR) <60. Review of Resident #51's electronic Medication Administration Record (eMAR) for the month 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 observation and interview it was determined that the facility failed to ensure medications were kept in locked compartments and maintained under proper temperature controls. This was found to be evident during one out of four medication pass observations (Resident #55), one random observation (Resident #354); and for two out of two medication storage rooms observations. The findings include: 1) On 2/13/25 at 11:14 AM an observation of medication administration for Resident #55 was conducted. The facility Certified Medicine Aide (CMA #12) was observed at the medication cart in the hallway outside the resident's room. On 2/13/25 at 11:15 AM CMA #12 removed 2 bottles of stock medications, viewed the computer screen on top of the medication cart, and then returned the bottles to the drawer, and said that she needed to go get something, closed the medication drawer and walked away from the cart. On 2/13/25 at 11:17 AM an interview was conducted with the unit nurse manager (Staff #21) who was in the hallway a few feet away from the medication cart. The unit nurse manager #8 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 record reviews and interviews, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #1) of 1 resident reviewed for dental services during the survey. The findings include: Resident #1 had been residing in the facility for several years. In an interview with the resident on 2/11/25 at 9:25 AM, s/he reported having mouth pain coming from his/her gums and teeth. The resident also reported that the facility had been informed about this discomfort. A review of Resident #1's medical records on 2/18/25 at 1:43 PM, revealed that the resident was seen by a dentist on 2/2/24 for a periodic examination. A review of the treatment notes by the dentist indicated the examination revealed multiple retained roots, fractured teeth and carries that are non-restorable; patient has history of dental pain, referred to [NAME] Hospital Center where the…

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

Based on record review and interviews, it was determined that the facility failed to accurately assess the resident population's needs. This was evident during a review of the Facility Assessment during the recertification survey. The findings include: On 2/10/25, during the entrance conference, the Nursing Home Administrator (NHA #1) was asked to provide a copy of the Facility Assessment. On 2/14/25 at 8:20 AM a review of the Facility Assessment revealed that on page 2 there was a list titled Acuity which listed Special Treatments. Ostomy Care was listed but indicated N/A [not applicable] for Number/Average or Range of Residents, that needed that type of care. A review of the facility matrix revealed one resident who required ostomy care. On 2/14/25 at 9:38 AM an interview was conducted with NHA #1 regarding the facility assessment. He said that N/A listed on the list of Special Treatments indicated that the facility did not care for residents with those medical needs. The NHA was asked to review the entry which stated N/A for ostomy care, the NHA said it was incorrect, that there…

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

Based on observations and interviews, it was determined that the facility failed to ensure the walk-in freezer was kept in a safe operating condition. This was evident for 1 out of 1 walk in freezer in the kitchen. The findings include: A tour of the kitchen was conducted with the Food Service Director (FSD Staff #7) on 2/10/25 at 9:49 AM. During the tour, an inspection of the walk-in freezer was completed, and frost was observed that had built up around the door. It was also observed that it would not close and latch on its own. When the surveyor attempted to close the freezer door, a significant amount of force was applied to make it latch. The FSD stated, we are supposed to have a renovation soon and indicated that the facility was old. On 2/19/25 at 2:43 PM, the concern was discussed with the Director of Nursing (DON) that the walk-in freezer was not kept in a safe operating condition. The observation of frost build-up and the freezer door unable to latch and close on its own was discussed. The DON acknowledged the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical records, interviews with residents, resident's representatives and facility staff, it was determined that the facility failed to ensure timely interdisciplinary care conferences for residents. This finding was evident for 8 of 24 (#2, #3, #10, #11, #14, #48, #52, and #54) residents selected during the survey. The findings include: 1. On 11-19-2020 surveyor review of the clinical record for Resident #2 revealed the resident is his/her own responsible party with a total Brief Interview for Mental Status (BIMS) score of 13 documented in August 2020. BIMS is a test given by medical professionals that helps determine a resident's cognitive understanding. A BIMS score of 13 through 15 indicates cognitively intact. Further record review revealed Resident #2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05-08-2020, had been completed by staff. However, there was no documented evidence that an interdisciplinary care conference that included…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure that residents and/or responsible parties were provided with a summary of the baseline care plan. This finding was evident for 2 of the 8 new admission/readmission residents selected for review during the survey (Residents #125 and #126). The findings include: 1. On 11-18-2020 surveyor review of the clinical record for Resident #125 revealed that Baseline Care Plans were documented as completed by Licensed Practical Nurse (LPN) #4 on 11-09-2020. However, further review of the 11-09-2020 Baseline Care Plans document revealed, there was no evidence that Resident #125 nor the resident's representative had received the baseline care plan summary/information. According to the document, the signature section acknowledges that either the resident or the representative, receive[s] the above information and understand the content of this information. I understand any updated information will be communicated with me prior to, or at the care plan…

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

Based on surveyor review of the clinical records and facility staff interview it was determined that the facility staff failed to develop a comprehensive resident centered care plan to meet residents' medical conditions. This finding was evident in 4 of 24 residents selected for review during the survey (Residents #3, #10, #11, and #64 ). The findings include: 1. On 11-18-2020 surveyor review of the clinical records for Resident #10 revealed the resident was admitted with a suprapubic Foley catheter for the treatment of a neurogenic bladder. A suprapubic Foley catheter drains urine directly from the bladder. It is inserted into the bladder through a small hole in the abdomen. A neurogenic bladder is the name given to several urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem. Further review of the clinical records for Resident #10 revealed there was no care plan for the suprapubic Foley catheter. On 11-20-2020 at 9:00 AM, surveyor interview with the Director of Nursing (DON) and the Unit Manager for the first floor revealed no…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure nursing standards of practice for medication administration for Resident #126. This finding was evident for 1 of 24 residents selected for review during the survey. The findings include: On 11-19-2020 surveyor review of the clinical record for Resident #126 revealed 6:00 AM scheduled medications for thyroid, pain and muscle spasms treatment. However, review of the November 2020 Medication Administration Record (MAR) revealed no evidence that the 6:00 AM scheduled medications were administered to Resident #126 on 11-07-2020 by Registered Nurse (RN) #3. On 11-19-2020 at 5:30 PM surveyor interview with the Director of Nursing revealed that RN #3 had not documented on the MAR after the administration as is required. No additional information was provided. According to the Maryland Nurse Practice Act 10.27.09.02 E (1) (2), the RN shall implement the interventions identified in the plan of care. Interventions shall be implemented recognizing the rights 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 surveyor review of the clinical record, resident and facility staff interview, it was determined that the facility staff failed to provide the necessary services to residents who were unable to carry out activities of daily living (ADL). This finding was evident for 1 of 3 residents selected for review of ADL during the survey (Resident #14). The findings include: Activities of daily living (ADL) are the task we normally do in daily living including any activity we perform for self-care such as feeding, grooming, personal hygiene, oral hygiene, and dressing. On 11-16-2020 at 9:30 AM, surveyor observed Resident #14 in bed during initial tour of the facility. Additional observation revealed multiple facial hair under the resident's chin. When surveyor asked the resident whether the facial hair was left there per his/her preference he/she stated, No. On 11-16-2020 at 12:22 PM, surveyor observed Resident #14 out of bed sitting in a wheelchair, well-dressed but still had the facial hair. On 11-17-2020 at 10:30 AM, surveyor follow up observation revealed the resident in bed with…

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

Based on surveyor review of the clinical record and interview with the facility staff, it was determined that the facility staff failed to develop a comprehensive plan of care for resident #55's anxiety and behavior problems. This finding was evident for 1 of 1 resident selected for the Behavioral-Emotional review. The findings include: On 05-09-19, surveyor review of the clinical record for resident #55 revealed documentation by the attending physician on 04-05-19 regarding an evaluation for the resident's periodic agitation and possible use of of medication for agitation/combativeness and aggressive attitude. The attending physician on 04-05-19 ordered Lorazepam, a psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) to be administered via injection every 6 hours prn (as needed) for the treatment of agitation. On 04-08-19, an order for Lorazepam every 6 hours to be administered by mouth prn for agitation and anxiety was documented. Review of the April and May 2019 MAR (Medication Administration Record) revealed staff documentation of the…

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

Based on surveyor observation, interview with facility staff, and clinical record review, it was determined that the facility failed to revise the fall risk plan of care for resident #60 after multiple falls. This finding was evident for 1 of 6 residents selected for the Accidents review. The findings include: On 05-06-19 at 08:46 AM, surveyor observed resident #60 sleeping in his/her bed with the bed in low position and the call light and personal items within reach. On 05-09-19, record review revealed resident #60 had sustained falls on the following dates with no major injuries: 03-22-19 04-08-19 05-01-19 05-04-19 05-08-19 However, further review of the comprehensive plan of care for risk for falls revealed that the last revision documented by staff was 04-02-19. There was no evidence that the facility staff had revised the fall risk care plan after 04-02-19 to address interventions to minimize further falls. Staff conducted a comprehensive review assessment on 04-15-19 with no evidence that a review of the falls care plan was done. On 05-09-19 at 11:10 AM, interview with the…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that licensed staff failed to obtain physician clarification in medication administration via the gastrostomy tube (GT) for resident #45. This finding was evident for 1 of 2 residents selected for the Tube Feeding review. The findings include: On 05-09-19 surveyor review of resident #45's clinical record revealed that the attending physician ordered the administration of medications via the resident's GT( a tube placed directly into the stomach through the abdomen and used to administer nutrition, fluids and medicines). Further review revealed upon readmissions to the facility after hospitalizations in April 2019, the attending physician ordered Tamsulosin (Flomax) HCL 0.4 mg capsule ER (extended release) 24H via the GT to be administered once daily for benign prostate hypertrophy (enlargement of the prostate gland). Review of the 02-20-19 Pharmacy Consultation Report revealed that the pharmacist indicated a recommendation for the clarification of the order to administer Flomax via…

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

Based on surveyor review of the clinical record, review of the dialysis communication record and interview with facility staff, it was determined that the facility staff failed to ensure the monitoring of consistent and timely pre and post dialysis weights for resident #17. This finding was evident for 1 of 1 resident selected for the Dialysis review. The findings include: On 05-10-19, surveyor review of the clinical record for resident #17 revealed an initial order by the attending physician on 04-17-18 that the resident's pre and post dialysis weights were to be obtained by dialysis staff and that weights were to be recorded on the hemodialysis communication sheet. The resident's schedule for hemodialysis was scheduled for 3 days per week at an outside facility. Hemodialysis is the process of removing excess water, solutes, and toxins from the blood when the kidneys can no longer perform these functions naturally. The use of obtaining pre and post weights assists in the determination of the amount of fluid that is removed during dialysis treatment. Fluid build up in the body can…

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

Based on surveyor review of the clinical record and interview with the facility staff, it was determined that the facility staff failed to ensure that the use of a psychotrophic medication prn (as needed) was not extended beyond 14 days for resident #55. This finding was evident for 1 of 1 resident selected for the Behavioral-Emotional review. The findings include: On 05-09-19, surveyor review of the clinical record for resident #55 revealed documentation by the attending physician on 04-05-19 regarding an evaluation for the resident's periodic agitation and possible use of of medication for agitation/combativeness and aggressive attitude. The attending physician on 04-05-19 ordered Lorazepam, a psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) to be administered via injection every 6 hours prn (as needed) for the treatment of agitation. On 04-08-19, an order for Lorazepam every 6 hours prn to be administered by mouth for agitation and anxiety was documented. Further review revealed that staff obtained a physician clarification order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure accurate and complete clinical documentation in residents' clinical records. This finding was evident for 4 of 23 residents selected for review during the survey. (#41, #45, #62, #76) The findings include: 1. On 05-08-19, surveyor review of the clinical record for resident #41 revealed a Health Care Decision Making Worksheet, completed on on 12-10-18 with the resident and the facility's social service worker, regarding life sustaining treatment options. Further review revealed that the resident's decision was indicated as yes for whether blood transfusions or infusion of blood products should be given in case of bleeding. However, review of the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) completed by the attending physician certifiying that the orders were the result of a discussion with and the informed consent of resident #41 on 12-10-18 was left…

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.