Lorien Taneytown, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to follow proper infection control procedures. This was evident for 2 (Resident #25 and #67) of 12 residents reviewed for infection control during the recertification survey.The findings include: 1). Transmission-based precautions (TBP) are a set of practices, designed to reduce the risk of infection by breaking the chain of infection through specific modes of transmission, namely contact, droplet, or airborne transmission. These precautions involve specific measures such as proper patient placement, use of personal protective equipment (PPE), and dedicated patient care equipment to prevent the spread of known or suspected infections. Contact precautions are used for infections that spread by direct or indirect contact with the patient or their environment. This involves wearing gloves and gowns for all patient interactions, single-room placement, and using dedicated or disposable patient equipment. Droplet precautions…

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

Based on record review and interview, it was determined that the facility failed to develop a mandatory training course that included the facility's standards, policies, and procedures regarding their Infection Prevention and Control (IPC) program. This was evident during the review of the facility's training program and has the potential to affect all residents. The findings include: On 6/26/25 at 11:36 AM the printout for the Infection Control training course that was required for facility staff to review on hire and annually thereafter was conducted. The training was an overview of infection control and failed to include the standards, policies and procedures of the facility IPC program. An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had an online training program that was sent from the corporate office for the facility staff to complete on hire and annually thereafter. She reported there were no online training requirements for the contracted staff. The findings were reviewed with the Director of Nursing and Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview it was determined that the facility failed to ensure that they had competent staff on duty to provide care to their residents. This was evident for 1 (#2) of 3 residents reviewed for falls with serious injuries.The findings include:On [DATE] at 6:43 AM a review of the video recording from the facility's surveillance camera at the [NAME] wing nurses' station was conducted. The video was time stamped for [DATE] at 11:36 PM. Resident #2 was observed being pushed in a reclined Geri chair to the nurses' station by GNA #5 (agency staff) and GNA #6 (agency staff). At 11:56 PM GNA #6 left the resident unsupervised in the nurses' station. Then at 12:06 AM on [DATE], Resident #2 was attempting to get out of the chair unassisted and GNA #5 and #6 came back and repositioned the resident in the chair. Both GNAs left the nurses' station and Resident #2 was unsupervised in the reclined Geri chair after the resident was trying to get out of the chair unassisted. Immediately…

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

Based on record review and interview, it was determined that the facility failed to develop all the required training requirements and have a process in place to ensure that all staff received the required trainings. This was evident for 3 (#7, #9, and #15) of 4 facility staff reviewed training requirements and 2 (#5, #6) of 3 contracted staff reviewed for training requirements. The findings include:1) A review of Staff #7's employee file on 6/23/25 at 1:55 PM revealed she was hired in 2019. She had not received training on the facility specific Compliance and Ethics training, Quality Assurance Performance (QAPI) and Improvement training, and Infection Control and Prevention (ICP) training. 2) A review of Staff #9's employee file on 6/23/25 at 1:28 PM revealed she was employed by the facility in 2024. She had not received training on the facility specific Compliance and Ethics training, Quality Assurance Performance (QAPI) and Improvement training, and Infection Control and Prevention (ICP) training.3) A review of Staff #15's employee file on 6/23/25 at 1:20 PM revealed she had been…

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 all staff who worked directly with residents had communication training. This was evident for 1 (#5) out of 3 contracted staff. The findings include:A review of Staff #5's employee file on 6/23/25 at 1:48 PM revealed she was contracted through a staffing agency and started working at the facility in 10/2023. The facility failed to ensure that she had communication training as required.An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had no online training requirements for the contracted staff. She reported that the agency that employed them provided the required trainings. She reported that she does not review their training program when they start working at the facility. The findings were reviewed with the Director of Nursing and Nursing Home Administrator on 6/26/25 at 1:43 PM.Cross Reference F940

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that all staff received facility specific compliance and ethics training. This was evident for 2 (#5, #6) of 3 contracted staff reviewed for training requirements. The findings include:1) A review of Staff #5's employee file on 6/23/25 at 1:48 PM revealed she was contracted through a staffing agency and started working at the facility in 10/2023. The facility failed to ensure that she received the mandatory, facility specific compliance and ethics training. 2) The employee file for Staff #6 was reviewed on 6/23/25 at 1:28 PM and this review revealed she was employed by a staffing agency and started working at the facility in 3/2025. The facility failed to ensure that she received the mandatory, facility specific compliance and ethics training.An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had no online training requirements for the contracted staff. She reported that she does not review their training list prior to…

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

Based on observation, interview with staff, and medical record review, the facility failed to meet the requirement to provide a system to account for the reconciliation of all controlled medications and ensure that an account of all the controlled drugs was completed with two licensed nurses at the change of each shift. This was evident for 3 of 3 available narcotic count logs. Findings Include: Tour of the unit on 07/14/22 at 1:28 PM to check for compliance of Medication Storage and Labeling revealed the Controlled Drug Count Verification Sheets. Several empty spaces for signatures were observed in the shift to shift verification log noted from March 2022 through the present day July 2022. On 07/14/22 at 2:30 PM, Surveyor requested the schedule for specific days from March to June of 2022 that were noted on the narcotic log where there were missing signatures over multiple shifts to verify if staff worked over multiple shifts in a row. According to the schedules provided to the survey team, no staff worked multiple shifts on the days noted with missing signatures on the log. During…

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 contracted pharmacist failed to identify recommendations were followed up on. This was evident for 1 of 5 residents reviewed for unnecessary medications. Pharmacy reviews are to occur monthly at a minimum to determine any irregularities in a resident drug regimen and report to the physician. The findings include: Review of the medical record for Resident #20 on 7/12/2022 at 2:04 PM for unnecessary medications, specifically regarding the use of a psychotropic medication, trazadone an antidepressant and sleep aide, revealed a recommendation from the pharmacist completed on 2/26/2022 to change the medication from AM to PM secondary to the risk of falls. The consult was signed by the resident's attending physician # 27 and the change was notated as agreed upon. Further review of Resident #20's medication administration records (MAR) for March through June 2022, revealed Trazadone was ordered and administered with the morning medications. The medication was not ordered to be changed to…

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

Based on medical record reviews and interviews with facility staff, it was determined that the facility failed to 1) implement pharmacy recommendations that were agreed upon by the physician and ensure that they were followed up on (#20) and 2) ensure that orders for as-needed psychotropic medications were limited to 14 days for residents #25 and #56. This was evident for 3 out of 6 residents reviewed for unnecessary medications. The findings include: 1) Review of the medical record for Resident #20 on 7/12/2022 at 2:04 PM regarding the use of a psychotropic medication, Trazadone an antidepressant and sleep aide, revealed a recommendation from the pharmacist completed on 2/26/2022 to change the medication from AM to PM secondary to the risk of falls. The consult was signed by the resident's attending physician # 27 and the change was notated as agreed upon. Further review of Resident #20's medication administration records (MAR) for March through June 2022, revealed Trazadone was ordered and administered with the morning medications. The medication was not ordered to be changed to…

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

Based on interview and medical record review, it was determined that the facility failed to thoroughly investigate and report to the state agency when a resident eloped from the facility. This was evident during the review of 1 of 4 residents (#20) reviewed for accidents. The findings include: During the tour of the facility on 7/11/2022 and interview with facility staff, Unit manager LPN #3, Surveyor was alerted when staff reported there was an 'incident' regarding a resident that was identified as a wanderer/elopement risk. At 12:53 PM on 7/11/2022 the Surveyor requested from the DON any facility policy on elopement or wandering that the facility followed and any information regarding the alleged incident occurring with Resident #20. Review on 7/12/2022 at 8:38 AM of Resident #20's medical record review revealed diagnoses including dementia and a history of falls. According to the social work admission note completed in March of 2021, s/he was admitted to the Long Term Care (LTC) from the Assisted Living Facility (ALF) in March of 2021 with a wander guard bracelet in place…

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 reviews, interviews, and observations, it was determined that the facility failed to thoroughly investigate and implement interventions related to an elopement documented for Resident #20. This was found to be evident for 1 out 7 (Resident #20) residents reviewed for accidents. The findings include: A wander guard is a device worn by residents with dangerous wandering behaviors to alert staff with an alarm if the vulnerable resident attempts to elope (leave the facility unsupervised). The device is detected by sensors at alarmed exits or other dangerous areas that cause the system to alarm when the resident approaches or walks past the monitored areas. Activities of Daily Living (ADLs) assessment provides indicators of where residents lie on a spectrum between completely independent and completely dependent. ADLs include but are not limited to bed mobility, transfers, eating, locomotion on and off the unit, and personal hygiene. Periodically (at least quarterly) facilities conduct assessments of residents to track status and identify if the residents 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 observation and interview of staff, it was determined that the facility failed to ensure that the kitchen stored and prepared food in accordance with professional standards for food service safety. This practice had the potential to affect all residents. The findings include: During a tour of the kitchen that took place on 7/11/2022 at 9:15 AM, the surveyor observed ice buildup at the back of the dessert walk-in freezer. The ice was built up around the base of the overhead condenser and had formed a stalactite that came in contact with two containers of ice cream. The temperature of the freezer was appropriate. The Food Service Director (FSD) was present for the tour and stated that she would have the freezer inspected by maintenance. During a follow up tour that took place on 7/12/2022 at 11:49 AM, the surveyor reviewed the July temperature logs with the FSD. These temperatures logs documented the highest cooking temperature obtained by kitchen staff during the preparation of potentially hazardous foods (foods that should reach a certain temperature for a certain length 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, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#28) of 2 residents reviewed for respiratory care and 3 (#50, #2, #38) of 5 residents reviewed for unnecessary medications. 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) Resident #28 was observed receiving 3.5 liters (L) of oxygen via nasal cannula on 1/16/19 at 6:52 PM, on 1/17/19 at 2:50 PM, and 1/18/19 at 10:10 AM. Resident #28's medical record was reviewed on 1/18/19 along with care plans. A care plan for oxygen therapy was not found. On 1/18/19 at 1:48 PM, Staff #3 confirmed that there was no respiratory care plan. 2) Review of the medical record for Resident #50 on 1/18/19 revealed January 2019 physician's orders for Tramadol 50 mg. twice per day for moderate pain relief, Tylenol 325 mg. (2) every 8 hours when needed for mild pain and Tylenol…

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 that the facility staff failed to notify the physician of a resident's multiple refusal of a prescribed breathing treatment. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications. The findings include: On 1/18/19, a review of Resident #38's January 2019 MAR (medication administration record) revealed an order for DuoNeb (Ipratropium and Albuterol) (bronchodilators) solution via nebulizer inhalation (breathing treatment) two times a day for COPD (chronic obstructive pulmonary disease) (a lung disorder). The MAR revealed documentation that, on 12 of 18 days, Resident #38 refused his/her morning DuoNeb breathing treatment and on 5 of 17 days, the resident refused his/her evening breathing treatment. Continued review of the medical record failed to reveal documentation that the resident's physician had been notified of Resident #38's refusal of his/her prescribed DuoNeb breathing treatments. On 1/18/18 at 2:32 PM, Staff #3 was made aware of this finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, during facility environmental rounds, it was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 1 of 3 nursing units. The findings include: Observation was made, on 1/17/19 at 10:36 AM, in room [ROOM NUMBER] of the heating unit which was loose and appeared to be hanging off the wall. The resident stated, it has been loose since I came here. The wall behind the resident's chair was spackled and was not painted over. Observation was made in room [ROOM NUMBER] of the heating unit on the wall which was loose and the cover was cracked across the entire length. The wood door at the entrance of room [ROOM NUMBER] had a 2-inch chunk of wood missing from the edge of the door, midway up the door. An environmental tour was taken on 1/22/19 at 1:46 PM with the Maintenance Director. The Maintenance Director observed the areas of concern.

Based on medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident but not limited to for 2 (#12, #55) of 4 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #12 on 1/17/19 revealed documentation that Resident #12 had unplanned transfers to an acute care facility on 9/6/18, and 9/14/18. Review of nursing progress notes, dated 11/6/18 and 11/14/18, did not include any documentation related to preparation and/or orientation to the resident before transferring the resident to an acute care facility. An interview was conducted with the Director of Nursing (DON) on 1/18/19 at 10:09 AM. The DON acknowledged the facility staff were not educated on documenting the response and orientation of a resident prior to a facility-initiated transfer to an acute care facility. 2) On 1/22/19, a review of Resident #55's medical record revealed documentation that the resident 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.

Based on medical record review and staff interview, it was determined that the facility staff failed to complete a comprehensive assessment within the regulatory time frame for 1 (#55) of 5 residents reviewed for hospitalization. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 1/22/19, review of Resident #55's assessments revealed that an annual comprehensive MDS assessment was completed with an assessment reference date (ARD) of 12/26/18. The resident's previous annual comprehensive MDS assessment was completed with an ARD of 11/18/17. The annual comprehensive MDS was not completed timely and should have been completed within 366 days. On 1/22/19 at 1:35 PM, during 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 and interview with staff, it was determined that the facility staff failed to review and revise resident care plans. This was evident for 1 (#2) of 5 residents reviewed for unnecessary medications and 1 (#25) of 2 residents reviewed for respiratory care. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of the medical record for Resident #2 revealed a care plan, observation for adverse side effects of medication r/t psychotropic medication with the intervention GDR (gradual dose reduction)- routine bid (2 times per day) Ativan decreased, PRN (when necessary) Valium dc'd. Resident #2's January 2019 physician's orders were reviewed, and the medication Ativan was not listed as a current medication. Physician's orders, dated 11/13/18, documentation that the routine Ativan was discontinued, PRN Ativan was ordered for 14 additional days and then discontinued. The care plan was not updated to reflect the discontinuation of Ativan.…

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 family interview, observation, medical record review and staff interview, it was determined the facility failed to 1) apply a physician's ordered brace to the right elbow, 2) failed to accurately document the use of the brace 3) failed to document if the resident received insulin and what the blood glucose level was and 4) failed to follow the care plan for splinting and administering medications. This was evident for 1 (#2) of 5 residents reviewed for unnecessary medications. The findings include: An interview was conducted, on 1/17/19 at 9:53 AM, with Resident #2's family member. The family member was asked if Resident #2 had any problems with range of motion or mobility. The family member stated, he/she wears an arm splint, but I haven't seen it lately. Observation was made on 1/17/19 at 10:46 AM of the resident sitting in a wheelchair. There was nothing on either of the resident's arms. Further observations were made at 11:48 AM and 2:18 PM with a second surveyor and the resident was not wearing a brace on either arm. The resident was observed again on 1/18/19 at 9:30…

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

Based on observation, medical record review and staff interview, it was determined the facility 1) failed to ensure that a resident who was placed on oxygen was monitored for difficulty breathing, failed to develop a resident centered care plan for a resident receiving oxygen, and failed to document the use of oxygen in the resident's medical record and on the Treatment Administration Record. 2) Staff failed to label and date oxygen tubing for a resident. This was evident for 2 (#28, #309) of 3 residents reviewed for respiratory care. The findings include: 1) Resident #28 was observed receiving 3.5 liters (L) of oxygen via nasal cannula on 1/16/19 at 6:52 PM, on 1/17/19 at 2:50 PM and 1/18/19 at 10:10 AM through an oxygen concentrator. The oxygen tubing and the water humidification bottle was not dated and labeled. Resident #28's medical record was reviewed on 1/18/19 along with care plans. A care plan for oxygen therapy was not found. On 1/18/19 at 1:48 PM, Staff #3 confirmed that there was no respiratory care plan. There were no nursing notes related to the resident's use 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 medical record review and staff interview, it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure prescribed medications for constipation had a clear indication as to when to give which one. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications. The findings include: On 1/18/19, a review of Resident #38's January 2019 MAR (medication administration record) revealed an order for Fleet enema per rectum one time daily as needed for constipation, an order for Lactulose 20 gm/30 ml (grams/milliliters) by mouth every 8 hours as need for constipation and an order for Miralax powder 17 gm by mouth once daily as needed for constipation. There was no clear indication in the physician orders as to which medication to give first for constipation. Continued review of the MAR revealed an order for Milk of Magnesia 30 ml two times a day as needed if no BM (bowel movement) in 3 days, and an order for Bisacodyl (Dulcolax) 10 mg (milligram) suppository per rectum at bedtime as…

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 keep residents free from significant medication errors. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications. The findings include: On 1/18/19, a review of Resident #38's medical record revealed a 11/28/18 physician order for Amlodipine (Norvasc) 10 mg (milligrams) by mouth every day for hypertension (high blood pressure). Review of Resident #38 electronic medical record revealed the order was put in the MAR (medication administration record) with an interval of Sunday, Monday, Wednesday and Friday instead of every day as prescribed. Resident #38's December 2018 MAR documented that the resident received the Amlodipine on 18 of 31 days, and the January 2019 MAR documented that Resident #38 received Amlodipine on 10 of 18 days. On 1/18/19 at 2:32 PM, Staff #3 was made aware of the finding. On 1/22/19 at 11:24 AM, during an interview, Staff #3 stated the problem was mechanical related to how the order was put into the system and confirmed the medication error.

Based on observation, medical record review and staff interview, it was determined the facility failed to have accurate medical record documentation as evidenced by nursing staff signing off treatments when they were not done, and not documenting a resident's use of oxygen. This was evident for 2 (#25, #28) of 3 residents reviewed for respiratory and 1 (#2) of 5 residents reviewed for unnecessary medications. The findings include: 1) Observation was made of Resident #25 on 1/17/19 at 8:44 AM. The resident was receiving oxygen via nasal cannula at 3.5 liters per minute (L). Additional observations were made on 1/17/19 at 2:45 PM and on 1/18/19 at 10:00 AM, and the resident continued to receive oxygen 3.5 L. Review of Resident #25's medical record revealed the oxygen order was revised on 10/19/18 which stated, oxygen: every shift O2 @ 3L/min continuous via n/c for SOB. A 1/15/19 at 21:08 nursing note documented a change in resident condition in which it was documented the resident received oxygen at 2L/min via nasal cannula. Further review of the medical record revealed the January…

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 documentation and interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assessment and Assurance (QAA) Program with Staff #7, on 1/22/19 at 2:39 PM, revealed that effective processes were not put in place regarding repeat deficiencies. The development of comprehensive care plans and unnecessary medications (that medications have adequate indications for use) had been cited in the previous survey and were cited again during this annual survey. The facility's action plans did not resolve quality deficiencies identified during the last recertification survey which concluded on 9/14/17, with a plan of correction compliance date of 10/25/17.