Lorien Mays Chapel

Based on observation and staff interview, the facility failed to ensure medications were securely stored and controlled to prevent unauthorized access, and failed to ensure timely storage of medications upon delivery in accordance with accepted professional standards of practice. This deficient practice was identified in 1 (Resident #20) of 1 resident observed for medication storage during the annual recertification survey.Findings include:On 4/7/26 at 8:00 AM, during observation rounds, the surveyor observed a brown bag containing medications with a list of medications stapled to the outside. The bag was unattended on a bedside table next to the nurse's desk and was accessible to unauthorized individuals.On 4/7/26 at 8:15 AM, a Licensed Practical Nurse (LPN), Staff # 24, was interviewed regarding the medications. The LPN stated that the pharmacy had delivered the medications during the 11:00 PM-7:00 AM shift and that he did not have time to store them where they belong, indicating a failure to ensure timely and secure storage of medications upon delivery.Additionally, on 4/7/26 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 observations and interviews with facility staff it was determined the facility failed to ensure that dishes were cleaned and stored properly, dishwashing machine temperatures were consistently entered on the dishwasher log, and, foods were dated upon opening and stored in a sanitary environment. This was found to be evident during the initial tour of the kitchen during the facility's annual Medicare/Medicaid survey.Findings include:An initial tour of the kitchen was conducted on 4/6/26 at approximately 7:50AM with the Kitchen Supervisor (KS #17), and the following concerns were identified:On the counter in the area where the dishwashing machine is located, there were 2 stacks of dirty food trays, 2 dirty pitchers and a dirty bowl present. At this time Staff #17 was asked to provide the surveyor with dishwashing machine temperature logs and he accompanied the surveyor to the location of the logs. Upon review, it revealed missing temperature entries of the dishwasher; the last temperature entry was on 4/2/26. Staff #17 stated that the dishwashing machine is to be checked each…

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

Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form. This was evident for 1 (#46) out of 6 residents' medical records reviewed during the annual survey. The findings include: Review of Resident #46's medical record on 04/06/2026 at 9:54 AM revealed a physician's order dated 02/26/2026 stating the following: Oxygen: every shift O2 at 2 L/MIN CONTINUIOUS VIA N/C FOR >92 % every shift for MONITORING. Further review revealed a physician's order dated 02/10/2025 stating the following: OXYGEN PRN FOR O2 BELOW 90% AS NEEDED FOR HYPOXIA every 15 minutes as needed for HYPOXIA TITRATE OXYGEN AS NEEDED TO MAINTAIN 02 SATURATION - 90%.During an interview and review of Resident #46's oxygen orders on 04/08/2026 at 1:18 PM with the Director of Nursing (#2) stated, Resident #46's oxygen PRN order dated 02/10/2025 should have been discontinued and was an oversite. I will call the doctor and get the order discontinued. Resident should be on oxygen 2 L/min by nasal cannula continuous.

Based on observation and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication located in their designated treatment carts on nursing units. This practice was observed on both units of the facility involving 3 of 4 of the posted treatment carts. The findings include; During tour on the morning of 10/7/25 at approximately 8:00 AM on the 3rd floor, surveyor passed a treatment cart with a silver lock sticking out. This surveyor continued down the hall for the intended destination and noted that the resident was eating. This surveyor back tracked to the treatment cart and noted that it still had the silver lock protruding out. This surveyor attempted to open the top drawer, and it easily opened. Inside was hydrocortisone cream, bio freeze gel, nystatin powder all labeled with identifying resident names. While this surveyor was looking through the drawers, a staff member came out of the room adjacent to the treatment cart, looked at me and pushed the cart over so she could get out of the room with her linen carts, 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.

Based on observation, record review and interviews, it was determined that the facility failed to maintain residents' medical records in a secure location. This was evident for the 4 (Resident #s 8, 25, 53, and 56) of 4 residents' charts observed during the recertification/complaint survey on the 2nd floor nursing unit. Findings include: On 01/09/25 10:35 AM, an observation on the second floor revealed that residents' charts were located on top of a wide filing cabinet in the hallway. The surveyors noted that 4 charts with residents' name and physician orders were found unattended on top of the file cabinet with the physician's order pages flagged (sticking out of the chart) and visible. Resident # 8, # 25, # 53 and # 56's physician orders were visible to the public eye and were not securely stored to ensure confidentiality of the resident's medical records. On 01/09/25 at 10:35 AM, in an interview with Staff #17, Staff #17 was notified of the surveyor's concerns, and she removed the charts. When asked who was responsible for leaving the chart on top of the filing cabinet, she…

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

Based on interview and record review it was determined the facility failed to ensure the abuse, neglect, exploitation and misappropriation policy was developed to include the required necessary reporting and response timeframes. This was evident during the surveyor's review of 1 out of 1 policy the facility had in place to prohibit and prevent abuse, neglect, expolitation and misappropriation during the facility's recertification/complaint survey. The findings include: On 1/8/25 at 7:59AM the surveyor conducted an entrance conference with the facility's Administrator at which time the surveyor requested a copy of the facility's abuse prohibition policy and procedures. On 1/10/25 at 12:15PM the surveyor conducted a review of the facility's abuse prohibition policy and procedures and noted the following information present in the reporting requirements section of the policy which contained numerous statements and included innaccurate reporting timeframes: The administrator will direct that a report of an allegation of abuse, exploitation, neglect, or unknown injury be faxed or emailed…

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 failed to ensure that stored food items were labeled and were not expired. This was evident during the initial tour of the food service department during the recertification/complaint survey. Findings include: On 01/08/25 at 08:10 AM, an observation during the kitchen tour revealed that there were: a 3 lbs can of strawberry topping with a used by date of December 2024; a 6 lbs can of navy bean with unknown expiration date; 2 undated open bags cinnamon swirl bread with raisin and 2 undated open bags of hamburger buns. On 01/08/25 at 08:35 AM, an observation of the walk-in refrigerator revealed 2 open undated bags of mixed salad; an open undated bag of turkey breast deli meat, and a large open plastic container of cherry topping prepared on 12/31/24; however, there were no expiration dates on the above-mentioned items. On 01/08/25 at 08:35 AM, in an interview with Staff #15, he stated that the open, undated bread were usually used within the day and they don't usually have left overs. He was also unable 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 a facility reported incident MD00204294, observation, record review, and staff interviews, it was determined that the facility failed to protect a resident's right to be free from any type of abuse. This was evident for 1(#28) of 15 residents reviewed for abuse during the facility's recertification/complaint survey. The findings include: On 1/8/25 at 10:26 AM during the initial pool selection, Resident #28 was observed in room sitting in a wheelchair watching TV. Resident #28 is a Korean speaking resident but able to understand and respond with limited English. When asked if everything was ok and if he/she has any concerns, he/she said OK and no problem. On 1/13/25 at 8:09 AM, review of the facilities investigative report MD00204294 had that on 4/2/24 a nurse aide, Geriatric Nursing Assistant (GNA) #23, was screaming and calling Resident #28 stupid and was pushing the resident back into the wheelchair. A review of the video footage confirmed this allegation. The nurse aide, GNA#23, was initially suspended pending investigation, he was later terminated and reported 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 interview and record review it was determined the facility failed to ensure a thorough review of background check results during the hiring process for a geriatric nursing assistant who had been employed with the facility for approximately one year. This was evident for 1 (GNA #16) out of 1 previously employed geriatric nursing assistant which was reviewed during investigation of an allegation of abuse for facility reported incident #MD00206160 during the facility's recertification/complaint survey. The findings include: On 1/10/25 at approximately 10:29AM the surveyor conducted a review of the employment file of Geriatric Nursing Assistant (GNA) #16 which revealed there was no background check present within the file, at which time the surveyor requested from the facility Administrator that a copy be provided. On 1/10/25 at approximately 12:00PM the surveyor reviewed the results of the background check documented as completed on 12/11/23 for GNA #16 which revealed the following documented information: second degree assault offense, guilty disposition, and sentencing…

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 record review it was determined the facility failed to ensure: 1) timely reporting of a serious injury of unknown source (Residents #9, #82, #6 ), and 2) timely reporting of an allegation of abuse (Resident #81). This was evident for 4 (MD#00194057, MD#002044306, MD#00212835, #MD00181864) of 20 facility reported incidents reviewed during the facility's recertification/complaint survey. Findings Include: Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that helps healthcare professionals to share information about a patient's condition in a concise manner. 1) On 01/09/25 at 03:23 PM, a review of complaints MD#00193619 and #MD#00193826 submitted to the Office of Health Care Quality (OHCQ) alleged that on 5/31/23 Resident #9 was hit by a male aide, and the resident suffered blunt force head trauma to the entire left side of the forehead. A facility reported incident MD#00194057 alleged that the Resident #9 sustained an injury of unknown origin on 5/31/23.…

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

Based on interview and record review it was determined the facility failed to: 1) ensure measures were taken to protect a resident (Resident #81) during an investigation of an allegation of abuse and 2) thoroughly investigate an allegation of abuse. This was evident for 1 (#MD00181864) out of 20 facility reported incidents reviewed during the facility's recertification/complaint survey. The findings include: On 1/14/25 at 12:38PM the surveyor conducted a review of the facility's complete investigation file for MD#00181864 which revealed an allegation of staff to resident abuse was made by Resident #81 to Licensed Practical Nurse (LPN) #21 on 8/7/22 which was documented on a resident complaint form which included the allegation made by the resident to LPN #21 and the action taken by LPN#21 to notify the facility's Director of Nursing. On 1/14/25 at 2:22PM the surveyor conducted an interview with the facility Administrator and inquired as to if the physical appearance/description of the alleged perpetrator which was provided by Resident #81 to LPN #21 on 8/7/22 as documented on 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 notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing. This was evident for 1 (#55) of 2 residents reviewed for hospitalization during the recertification/complaint survey. Findings Include: On 1/21/25 at 8:41AM review of Resident #55's medical records revealed that s/he was hospitalization on 3 different dates in 2024 which were 1/16/24, 8/25/24 and 10/12/24. Further review did not show that the resident or their representatives were given a written notification of the transfer. In an interview with the Director of Nursing on 1/21/25 at 11:47 AM, she was asked about the notification process. She explained that the families are notified by phone calls or verbally to let them know that their loved ones are being sent out and that facility staff are required to document who they notified. When asked about sending written notifications, she indicated that there was no written notification and that the facility does not send…

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 interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#79) of 7 residents reviewed for baseline care plans during the recertification/complaint survey. The findings include: On 1/13/25 at 1:58 PM review of Resident #79 's progress notes did not reveal any notes referring to the resident's Baseline Care Plan (BLCP). On 1/13/25 at 2:19 PM review of the medical record revealed Baseline Care Plan v1.1 - V 1: 78 days overdue - 10/27/2024 documented in red letters. On 1/13/25 at 3:03 PM in an interview with the Director of Nursing (DON), she stated there was not a BLCP for Resident #79. During the interview, she stated she was not sure why it was missed. The resident did come on a Friday after we left for the day, but she stated she was not sure why it was not caught on Monday.

Based on record review and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and updated by the interdisciplinary team after the care plan meeting. This was evident for 1 (Resident #7) of 2 residents reviewed for the use of a feeding tube during the recertification/complaint survey. Findings Include: A gastrostomy tube (G-tube) is a tube that is surgically inserted through the abdomen and brings nutrition directly to the stomach. The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. On 01/09/25 09:20 AM, record review revealed that Resident #7 had 4 separate incidents of G-tube dislodgement between the months of July 2024 and October 2024. On 2 of 4 G-tube dislodgment, the resident was transferred to the emergency room for further evaluation. On 1/15/25 at 11:45 AM Interview with Staff #6, he stated that the unit manager is responsible for updating the care plan. He also stated that care plan updates are usually done quarterly with MDS assessment or as needed.…

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 facility report MD00205422, record review, and staff interviews, it was determined that the facility failed to provide and utilize an assistive device to transfer a resident as ordered. This was evident for 1(Resident #281) of 20 facility reported incidents reviewed during the recertification/complaint survey. The findings include: On 1/16/25 at 4:00PM review of MD00205422 had that on the night of 5/6/24, Resident #281 needed their air mattress installed. The aide was going to transfer resident from bed to wheelchair so that a new mattress could be placed. Resident stated that s/he was supposed to be transferred via Hoyer due to surgery but was not. Resident stated that the transfer was painful, their left leg jammed into the bed and their heel hit the floor hard. Resident stated they were having pain in their body during repositioning. Review of the resident's care plan on 1/17/25 at 10:50AM with initiation date of 5/6/24 documented that resident had a left leg fracture related to fall with interventions to follow orders for non-weight bearing to the affected leg.…

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 the facility failed to ensure the monitoring of a medication for a resident. This was evident for 1 (Resident #4) out of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include: On 1/16/25 at 12:12PM the surveyor reviewed the medical record for Resident #4 which revealed the January 2025 medication administration record (MAR) documented the following order dated as beginning on 7/27/24 was present: Metoprolol Succinate ER Tablet 25mg, give 1 tablet by mouth in the morning for HTN (Hypertension) hold medication if pulse <60 and/or systolic blood pressure <100mmhg. Further review of the documentation revealed various staff had signed off on daily administration of the medication from 1/1-1/16/25, however, the fields for blood pressure and pulse to be recorded and input were observed to not be completed. On 1/16/25 at 12:44PM the surveyor conducted an interview with Licensed Practical Nurse (LPN) #20 who was assigned to the care of Resident #4. When the surveyor inquired 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 record review and interview it was determined the facility failed to ensure the monitoring of a psychotropic medication. This was evident for 1 (Resident #4) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey. The findings include: On 1/16/25 at 9:16AM the surveyor reviewed the medical record for Resident #4 which revealed a recommendation was made upon completion of the resident's medication regimen review by pharmacy for the month of November, 2024, however, there was no documentation of what that recommendation was. At this time, the surveyor notified the facility's Director of Nursing (DON) that the recommendation was not located within the resident's medical record, and requested a copy of the recommendation. On 1/16/25 at 9:30AM the surveyor conducted an interview with the DON who confirmed with the surveyor that Resident #4 was not on the no recommendations made list for November 2024 and they were unable to locate what recommendation was made. The DON stated to the surveyor: I'll check with the pharmacy 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 a complaint incident #MD00191927, record review and interviews, it was determined that the facility failed to ensure that a resident was free from significant medication errors. This was evident for 1 (Resident #86) of 10 complaints reviewed during the facility's recertification/complaint survey. The findings include: On 1/17/25 at 8:43AM review of a complaint incident MD00191927 had that a resident's family member found a pill that did not belong to the resident on their bed when the resident got up to go to the bathroom. The resident also stated to the family member that he was given 14 pills the evening of 4/15/2023 and felt weak with numerous body aches. The family member took a picture of the pill, turned it in and reported to Staff #15, the evening shift supervisor. Further investigation revealed that the medication was one of the pills taken by the resident's roommate who was on multiple pills. Review of the resident medication for the month of April 2023 on 1/17/25 at 8:46 AM revealed that Resident #86 only takes 3 pills in the morning and 1 at night. The pill found…

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 facility reported incident, complaint, observation, record review and interview it was determined the facility failed to: 1) secure residents medication properly, evidenced by leaving medications unsupervised at the bedside, resulting in a foreign object accidental ingestion. 2) ensure a medication cart was locked while unattended. This was evident for: 1) 1 (Resident #282) of 30 intakes reviewed, and 2) 1 out of 4 medication carts located on the second floor of the facility, during the facility's recertification/complaint survey. The findings include: 1.) Gastro- Intestinal (GI) tract is the organ that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces. On 1/14/24 at 9:26 AM review of a facility reported incident MD00208443 and a complaint MD00208850 had that Resident #282 reported swallowing what looked like a horse-pill in his medicine cup. The nurse on duty verified she had left a lancet, a device used to obtain blood for testing blood sugar in the resident's medicine cup. The nurse turned around to get some water,…

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 the resident medical records provided during the survey process contained sufficient information to identify the care provided to each resident. This was true for 2 (Resident #7 and Resident #82) of 18 resident medical records reviewed in the survey sample during the recertification/complaint survey. Findings Include: A gastrostomy tube (G-tube) is a tube that is surgically inserted through the abdomen and brings nutrition directly to the stomach. Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that helps healthcare professionals to share information about a patient's condition in a concise manner. 1) On 01/09/25 at 09:20 AM, a review of Resident #7's progress notes written on 10/4/24 at 8:45 AM, stated that the resident's G-tube was dislodged, and the nurse received an order to transfer resident to the emergency room; however, there was no additional documentation to suggest that the nurse conducted a thorough assessment of the resident following 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, interview and medical record review it was determined the facility failed to: 1) ensure the accuracy of infection control signage, and 2) ensure all employees' required immunizations were up to date, as it relates to infection prevention and control. This was evident for: 1) 5 of 83 resident occupied rooms at the time of the surveyor's initial tour, and 2) 3 (GNA #22, GNA#23, GNA#24) of 5 employees reviewed, during the facility's recertification/complaint survey. The findings include: 1.) On 1/8/25 at approximately 7:30AM surveyors observed signage present at the front reception desk indicating the facility was currently in outbreak status. On 1/8/25 at 7:59AM the surveyor conducted an entrance conference with the facility Administrator, at which time they informed the surveyor of positive resident cases of Covid 19 infection within the building which included Residents #64, #41, #8, and #69. On 1/8/25 at 9:40AM the surveyor observed the following infection control precaution signage: Room of Residents #64 and #41: special droplet/contact precautions, Room 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 review of resident records and facility policy and interview with facility staff, it was determined that the facility failed to ensure that each resident was offered a pneumococcal vaccine. This was evident for 1 (Resident #19) of 5 residents sampled for review of influenza and pneumococcal vaccination. The findings include: On 1/15/25 at 11:48 AM 5 residents' (Residents #13, #43, #18, #19, #14) electronic medical records were reviewed for influenza and pneumococcal immunizations. There was no evidence that Resident #19 was offered, received, or refused the influenza and/or pneumococcal vaccine. On 1/17/25 at 9:06 AM the Director of Nursing (DON) was asked to provided evidence of Resident #19's being offered and/or receiving the influenza and/or pneumococcal vaccine. On 1/17/25 at 11:57 AM the DON provided documentation that Resident #19 had received an influenza vaccine on 9/19/24, however did not provide the survey team with any evidence of Resident #19's pneumococcal vaccine. During the interview the DON stated that any immunization documentation that was not provided,…

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 policy review, it was determined that the facility failed to provide education to residents regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine and the opportunity to accept or refuse a COVID-19 vaccine. This was evident for 1 (Resident #13) of 5 residents sampled for review of COVID-19 immunizations during the recertification/complaint. The findings include: On 1/15/25 at 11:48 AM 5 residents' (Residents #13, #43, #18, #19, #14) electronic medical records were reviewed for COVID-19 immunizations. There was no evidence that Resident #13 had been offered and/or educated about the risk and benefits and potential side effects of the COVID 19 vaccination. On 1/17/25 at 9:06 AM the Director of Nursing (DON) was asked to provided evidence of Resident #13 had been offered and/or educated about the risk and benefits and potential side effects of the COVID 19 vaccination. On 1/17/25 at 11:57 AM the DON was unable to provide any of the requested documentation for Resident #13. During the interview 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 interview with members of the Resident Council and a tour of the facility it was determined that the facility staff failed to ensure signage was posted to inform the residents of the location of the state survey results. This was evident for 2 out of 2 resident units. The findings are: Members of the Resident Council were interviewed on 2/21/20 at 10:52 AM. They stated that they were unaware of where to find the state survey results. They said they were not told, and they have never seen any signs posted. This surveyor toured the facility on 2/21/20 at 12:16 PM. I did not observe any signage on either the second-floor nursing unit or the third-floor nursing unit. Another surveyor asked the Administrator on 2/21/20 to show her the signage near the receptionist desk. The sign was not present. The Administrator asked the receptionist where the sign was located. The receptionist replied, Here it is and picked it up off of her desk and put it on the counter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications and 1 (#28) of 1 residents reviewed for activities. 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 [DATE] at 12:09 PM, review of Resident #16's medical record revealed the resident's most recent quarterly assessment had a reference date of [DATE]. Review of Resident #16's care plans revealed multiple care plans, including a care plan I use antidepressant medication (Sertraline) r/t (related to depression), with the goal I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Continued review of the medical record failed to reveal evidence that Resident #16's care plans had…

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 ensure staffing information was posted as required. This was evident for 2 out 2 nursing units. This surveyor toured both nursing units on 2/21/20 at 12:17 PM. Other surveyors toured on 2/21/20 but at different times. The team did not observe postings for either floor. The Director of Nursing was interviewed on 2/21/20 at 2:00 PM. The findings were shared with her. The Administrator was informed of the finding on 2/24/20 at 2:30 PM.

Based on resident interviews, surveyor observation and staff interview, it was determined that the facility failed to serve food at a preferable/palatable temperature. This was evident for 3 (#54, #87, #83) of 22 initial pool residents and 4 of 4 food items tested for temperature. The findings include: On 2/18/20 at 10:09 AM, during an interview, when asked if the hot foods were served hot and the cold foods served cold, Resident #54 stated that the food is usually warm. On 2/18/20 at 10:39 AM, during an interview, Resident #87 stated that the food was cold. On 2/19/20 at 8:44 AM, during an interview, Resident #83 stated that the food was not bad but warm, could be hotter. On 2/21/20 at 11:45 AM, a test tray was requested from the Dietary Director. On 2/21/20 at 12:35 PM, on Unit 2, the test tray, which was the last tray on a mobile, metal food cart, was removed from the food cart and the Dietary Manager was observed checking the food temperatures with the facility's thermometer. The temperature of the Salmon was 125 degrees F (Fahrenheit), the pasta noodles were 125 degrees F, 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 and staff interview, it was determined that the facility staff failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen. The findings include: On 2/18/20 at 8:30 AM, accompanied by the Dietary Director, Staff #11, an initial tour of the kitchen was conducted. Observation of the kitchen's main refrigerator revealed the following concerns: on the left side of the refrigerator, observation was made of a metal cart that held metal trays. There were two trays that each had 45 small juice filled glasses that were covered with a plastic lids which were not labeled with the date they were prepared, there was one tray that had 7 cups containing grapes and 4 cups containing peach puree that were not covered and not labeled with the date they were prepared. The tray also had several small beverage glasses filled with milk shake and several small glasses filled with water that were covered with a plastic lid and not labeled with the date they were prepared. On the top of the metal cart was a…

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

Based on medical record review and interview, it was determined the facility staff failed to notify the physician when Resident (#75) had refused medication for 7 days. This was evident for 1 of 45 residents selected for review during the survey process. The findings include: Medical record review on 2/19/20 at 12:00 PM for Resident #75 revealed on 1/31/20 the physician ordered: MiraLAX powder, 17 grams by mouth once a day. MiraLAX is a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements. MiraLAX is used as a laxative to treat occasional constipation or irregular bowel movements. Review of the Medication Administration Record revealed the resident had refused the medication for 7 days, from 2/15/20 to 2/21/20 at 9:00 AM; however, there is no evidence the facility staff notified the physician or Certified Registered Nurse Practitioner (CRNP) that Resident #75 had refused a medication for 7 days. Interview with the Director of Nursing on 2/24/20 at 3:00 PM confirmed the facility staff failed to notify the physician or CRNP that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident for 1 of 13 resident bathrooms observed on the 2nd floor. The findings include: On 2/18/20 at 9:52 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed a strip of rubber on the right side of the walk-in shower was peeling. Towards the outer edge of the shower floor, there was a gouge in the shower floor with an area of floor missing, approximately 1-inch X 0.5-inch X 0.25-inches deep, that had sharp edges. These findings were observed again on 2/24/10 at 1:06 PM, and, at that time, the bathroom floor was observed to be noticeably dirty. On 2/24/20 at 1:10 PM, Staff #12 accompanied the surveyor to room [ROOM NUMBER]'s shared bathroom and confirmed the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to notify the resident and/or responsible party in writing of a Resident's (#43, #81) transfer to the hospital and the reason for transfer. This was evident for 2 of 2 residents reviewed for hospitalizations. The findings include: 1. Resident #81 was admitted to the facility on [DATE] and due to a change in condition that required hospital level care was transferred to the hospital on 2-7-2020. On 2-21-2020 at 8:30 AM the Administrator confirmed that the facility did not notify Resident #81 and/or the responsible party in writing and in a language and manner that they understand of the reason for the transfer to the hospital. 2. A review of Resident #43's clinical record revealed that the resident was discharged on 2/20/20. Further review revealed that a written notification of the reasons for discharge was not provided to the resident. The Administrator was interviewed on 2/21/20 at 8:45 AM. The Administrator confirmed that…

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

Based on medical record review and staff interview it was determined the facility 1) failed to develop and implement comprehensive, person-centered care plans with non-pharmacological approaches to care for a resident receiving psychotropic medication, and, 2) failed to follow a resident's care plan related to administering oxygen. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications and 1 (#28) of 1 resident 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) On 2/19/20 at 12:09 PM, Resident #16's medical record was reviewed. Review of Resident #16's February 2020 MAR (medication administration record) documented that Resident #16 received Seroquel (Quetiapine) (antipsychotic) by mouth every day for dementia with behavioral disturbance. Review of Resident #16's care plans failed to reveal evidence that a comprehensive, resident centered care plan with measurable goals and non-pharmaceutical…

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 failed to implement an ongoing resident centered activities program to meet the interests and support the physical, mental and psychosocial well-being of each resident. This was evident for 1 (#28) of 1 resident reviewed for activities. The findings include: During the day, on 2/18/20, 2/19/20, 2/20/20 and 2/21/20, multiple, intermittent surveyor observations were made of Resident #28. On each of these observations, Resident #28 was observed in his/her room, lying in bed. The resident was never observed out of bed and continued surveyor observations failed to reveal evidence that Resident #28 received one to one activity staff visits, attended activity programs or that the resident was offered the opportunity to observe or participate in an activity program. Review of Resident #28's admission assessment with an ARD (assessment reference date) of 9/24/19, Section F, Preferences for Customary Routine and Activities, F0500, Interview for Activity Preferences, revealed documentation that…

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

Based on medical record review and interviews with facility staff, it was determined that the facility staff failed to follow a written physician order (Resident #81). This is evident for 1 of 2 resident's reviewed for discharge to the community during the annual survey. The findings include: Resident #81 was admitted to the facility from the hospital on 1-29-2020. During hospitalization Resident #81 experienced delirium. The hospital physician started Resident #81 on Seroquel, an antipsychotic medication, to control the delirium. The resident was then discharged to the facility. On 1-30-2020, after medication review, the facility physician ordered a psychiatric physician consult to assist with a gradual dose reduction of the Seroquel medication. Unable to locate the psychiatric consult in the medical record on 2-20-2020 at 12:36 PM this surveyor asked the Director of Nursing (DON) for the consult. On 2-20-2020 at 1:00 PM the DON confirmed that the ordered for a psychiatric consult was followed and the consult was not obtained.

Based on medical record review, observation and interview, it was determined the facility failed to maintain the environment for Resident (#19) free from potential accidents. This was evident for 1 of 1 resident selected for review of accidents and 1 of 45 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments contain standardized questions about several elements of functional and cognitive status and mobility, Behavioral symptoms - a number of items about behavioral symptoms common in dementia, Psychosocial functioning - resident participation in activities and resident preferences, Symptoms and geriatric syndromes - for example pain, continence, falls, nutritional status, activities of daily living and many others and Diagnoses 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, medical record review and staff interview, it was determined the facility staff failed to ensure oxygen was administered at the rate ordered by the physician, failed to accurately document the resident's oxygen rate in the treatment record, failed to ensure the resident's oxygen tubing was changed per the physician's order, failed to ensure a physician's order addressed the resident's use of oxygen humidification and failed to follow the resident's oxygen therapy care plan. This was evident for 1 (#28) of 1 resident reviewed for respiratory care. The findings include: On 2/18/20 at 9:47 AM, observation of Resident #28 revealed the resident was wearing an oxygen nasal cannula (NC) tubing connected to a humidification water bottle which was connected to an oxygen concentrator that was set at 2 LPM (liters per minute). The oxygen tubing was labeled with the date 2/4/20 and the humidification bottle was dated 2/3/20. On 2/19/20 at 10:09 AM, an observation was made of Resident #28 wearing oxygen NC tubing connected to a humidification water bottle which 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 the facility staff failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 2 (#28, #63) of 5 residents reviewed for position, mobility. The findings include: 1) On 2/21/20 at 1:53 PM, Resident #28's medical record was reviewed. Review of Resident #28's physician and NP (nurse practitioner) progress notes in the resident's EMR (electronic medical record) revealed that the practitioner's progress notes were not in the resident's medical record on the day of the practitioner's visit. Resident #28's EMR indicated that a 11/25/19 physician consult note was uploaded (attached) to the EMR on 12/5/19, a 12/20/19 NP progress note was uploaded to the EMR on 12/23/19, and a 12/27/19 NP progress note was uploaded to Resident #28's EMR on 1/9/20. 2) On 2/24/20 at 9:30 AM, Resident #63's medical record was reviewed. Review of Resident #63's physician and NP progress notes in the resident's EMR revealed that the practitioner's progress notes were…

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 employee files and staff interview, it was determined that the facility failed to have evidence of skills competencies for 2 geriatric nursing assistants (GNA #3, #4). This was identified for 2 of 4 GNA's reviewed during the annual survey. The findings include: Skills competencies on GNA's are usually completed during orientation to determine if the GNA has the skills to care for residents in a safe and accurate manner. A nurse or preceptor GNA observes the new GNA completing a list of skills, such as bathing a bedbound resident, and determines if the GNA is qualified to complete the task. A review of GNA #3 and GNA #4's employee file did not contain evidence that skill competencies were completed. On 2-21-2020 at 12:00 PM the Administrator confirmed the facility did not have skills competencies for the two GNA's.

Based on review of employee files and staff interview, it was determined that the facility failed to have a Geriatric Nursing Assistant (GNA #3) complete the annual required 12 hours of education based on the annual performance review. This was identified for 1 of 4 GNA staff members reviewed during an annual recertification survey. The findings include: Review of GNA #3's employee file on 2-21-2020 at 10:50 AM revealed a hiring date of 8-29-18 and no evidence of the required 12 hours of continuing education for 2019. Interview with the Administrator on 2-21-2020 at 12:00 AM confirmed that GNA #3 did not complete any continuing education for 2019.

Based on record review, observation and interview it was determined the facility staff failed ensure Resident (#48) was free from unnecessary medication. This was evident for 1 opportunity out of 28 for error and 1 out of 4 residents observed for medication pass. The findings include: When observing medication pass, the surveyor asks the facility staff as to what medications are to be administered to the resident in question at that time. The Surveyor will write the medications that are to be administered as noted by the facility staff. Then the surveyor will review the blister pack or unit-dose pack to ensure the correct medication is being administered. When the facility staff is finished administering medications to the observed resident, the surveyor will ask for the discarded-empty unit dose packages to verify the administration of the ordered medications. Surveyor observation of medication pass on 2/19/20 at 9:09 AM revealed LPN #5 indicated that she was administering Resident #48 a Mucinex Extended Release (ER) tablet, 600 milligrams. Mucinex is an expectorant. It helps…

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 administered anti-psychotic medication without adequate indication of need. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications. The findings include: On 2/19/20 at 12:09 PM, Resident #16's medical record was reviewed. Resident #16's February 2020 MAR (medication administration record) documented that Resident #16 received Seroquel (Quetiapine) (antipsychotic) by mouth every day for dementia with behavioral disturbance. On 12/18/19, in behavioral health progress note, the CRNP (certified registered nurse practitioner) indicated that the reason for the psychiatric consult was the resident had increased restlessness and multiple falls and the resident's treatment plan included Resident #16 was to start Seroquel by mouth for dementia with behavioral disturbance. The CRNP did not identify the resident's behaviors for which the Seroquel had been prescribed and there was no clear rationale documented for use of the antipsychotic. Continued review of Resident #16'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 record review, observation and interview it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 2 errors out of 28 opportunities and 1 out of 4 residents observed for medication pass (Resident #48) resulting in an error rate of 7.14%. The findings include: When observing medication pass, the surveyor asks the facility staff as to what medications are to be administered to the resident in question at that time. The Surveyor will write the medications that are to be administered as noted by the facility staff. Then the surveyor will review the blister pack or unit-dose pack to ensure the correct medication is being administered. When the facility staff is finished administering medications to the observed resident, the surveyor will ask for the discarded-empty unit dose packages to verify the administration of the ordered medications. Error 1. The facility staff failed to administer a Vitamin D supplement to Resident #48. Medical record review for Resident #48 on 2/19/20 at 12:00 PM revealed on 12/25/19 the physician…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimen on Resident (#5) as ordered by the physician. This 1 of 45 residents selected for review during the annual survey process. The finding includes: Medical record review on 2/21/10 at 1:00 PM revealed on 10/30/19 the physician ordered: Free Dilantin, BMP (Basic Metabolic Panel), Mg (Magnesium) and Dilantin level in the morning. Dilantin (phenytoin) is an anti-epileptic drug, also called an anticonvulsant. It works by slowing down impulses in the brain that cause seizures. Dilantin is used to control seizures. Dilantin doses are often adjusted to find the optimal dose based on measurement of blood levels. Free Dilantin: free phenytoin level is the best indicator of adequate therapy. BMP: The basic metabolic panel (BMP) is a frequently ordered panel of 8 tests that gives a healthcare practitioner important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Resident (#19) in the most accurate and complete form. This was evident for 1 of 45 residents selected for review during the annual survey. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review on [DATE] at 12:00 PM for Resident #19 revealed the a MOLST form dated [DATE]. Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. Review of the MOLST revealed the orders for Resident #19 were based on the following: Or, I hereby certify that these orders are based on: ____X____ other legal authority in accordance with all provisions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of medication pass it was determined the facility staff failed to administer medications in a manner which promoted the most infection control for Resident (#48) and failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to label and store resident care equipment in a manner to prevent development and transmission of disease and infection. This was evident for 1 of 4 residents observed for medication pass with 1 out of 28 opportunities for error and this was evident in 3 of 13 resident bathrooms observed on the 2nd floor during the survey. The findings include: 1. Medical record review on 2/19/20 at 10:30 AM for Resident # 48 revealed on 12/25/19 the physician ordered: Tylenol extra strength 500 milligrams, 2 tablets by mouth every day. Tylenol (acetaminophen) is a pain reliever and a fever reducer. Observation of medication pass on 2/19/20 at 9:09 AM revealed LPN (Licensed Practical Nurse) #5 obtained a multi-dose bottle…

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.