Holly Hill Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interviews, it was determined that the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. This was evident for 3 (#9, #49, #68) of 43 residents, reviewed during the survey. Maryland MOLST (Maryland Orders for Life Sustaining Treatment) 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. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the…

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

Based on observation and staff interviews, it was determined that the facility failed to maintain the residents' dignity, by staff standing over residents while assisting them to eat. This was evident for 2 Residents (Resident #38 and #42) observed in one dining area out of the three dining areas in the facility. The findings include: On 02/20/24 at 12:49 PM, the surveyor observed Staff #7 (Occupational therapist) feeding resident # 38 while standing and Staff #8 ( Staffing Coordinator) feeding resident # 42 while standing. On 02/29/24 at 01:22 PM, during the surveyor's interview with staff # 8, they confirmed that they were feeding the resident on 02/20/24 while standing. When asked if she/he was ever instructed to sit with a Resident while feeding, they indicated that the educational course/ training offered to them did not cover the topic. Staff # 8 then stated, I'm a stander. On 03/04/24 at 03:30 PM, during an interview with the Director of Nursing (DON): When asked about expectations of where staff should be when feeding residents, DON indicated that staff should be sitting…

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

Based on record review and interviews, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (#51, #57) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The notices include: Notice of Medicare Non-Coverage (NOMNC): This must be issued at least two calendar days before the last day of Medicare coverage. Skilled Nursing Facility Advance Beneficiary Notice (SNFABN): This notice must be issued far enough before delivering potentially…

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 thoroughly investigate an allegation of abuse.This was evident for 3 (Resident #68, # 23, and # 53) of 12 residents reviewed for abuse during a survey. The findings include: 1) On 2/28/24 at 10:37 AM, a review of the facility's investigation for the self-report, MD00201824, was conducted. The facility's initial self-report documented that, when Resident #68 was transferred to the hospital due to a fall, EMS (emergency medical systems) personnel alleged the resident appeared to be abused or neglected by the facility. Continued review of the documents included with the facility's investigation failed to reveal evidence that staff interviews had been completed during the facility's investigation, and there were no interviews of staff assigned to the resident at the time of the alleged event. On 2/29/24 at 1:50 PM, during an interview, the Nursing Home Administrator (NHA) was made aware there were no staff interviews included with documentation of the facility's investigation of the self-reported…

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 in record review and interview, it was determined that the facility failed to communicate the residents comprehensive care plan goal to the receiving healthcare institution to ensure safe and effective transition of care. This was evident for 1 (Resident #33) of 4 residents reviewed for hospitalization. The findings include: Resident #33 has been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency department in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form, with a reference date of 1/21/24, completed by Licensed Practical Nurse (LPN Staff #21) was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist were as follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Face sheet g) Other info h) Bed Hold i) Notice of Transfer, with an instruction to print these documents in this order and include with the transfer form to send with the patient 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 review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #27) of 4 residents reviewed for hospitalization. The findings include: On 2/27/24 at 11:00 AM, a review of Resident #27's electronic health record (EHR) revealed that Resident #27 was transferred to an acute care facility on 2/2/24. In a SBAR Summary for Providers note, on 2/2/24 at 12:24 PM, the nurse documented Resident #27 had a change in condition, the primary care provider was notified, and recommended that Resident #27 be sent to the hospital. Continued review of the medical record failed to reveal any documentation to indicate that Resident #27 was oriented and prepared for the transfer or received an explanation as to why s/he was being transferred to the hospital, in a manner that the resident could understand and there was no documentation of the resident's potential response or understanding of the transfer. The above concerns were discussed with the…

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

Based on observation, medical record review and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#15, #33, #6) of 44 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. A Discharge-return anticipated MDS assessment is completed when a resident is temporarily admitted for acute care in the hospital, or a hospital observation stay lasts more than 24 hours, but the resident is expected to return to the nursing facility. 1) On 2/20/24 at 1:12 PM during an initial rounding of the facility, Resident #15 was observed sitting in his/her room receiving oxygen at 2 Liters (L)per minute via nasal cannula. A record review completed for Resident #15 on 2/21/24 at 10:00 AM…

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

Based on record review and staff interview, it was determined that the facility failed to ensure that the Level II Preadmission screening and resident review (PASARR) screen was completed by Adult Evaluation and Review Services (AERS) before the resident's admission. This was evident for 1 (Resident #9) of 1 resident reviewed for PASARR compliance. The findings include: On 02/21/24 at 11:53 AM, the medical record review of Resident #9, revealed that a scanned copy of PASARR level one, dated 05/06/2020, was available from electronic medical records. PASARR form page 2 indicated that If questions 1.2.or three checked yes or if all answers in part D are No the individual must be referred to AERS for level two evaluation. Page 2, Part D, questions 1,2,3,4, and 5 had answers checked as No. Thus indicating a referral to AERS was required. Further review of the medical record failed to reveal the evidence that PASARR, dated 5/6/2020, was referred to AERS for level two evaluation. The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for…

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

Based on the review of medical records, and staff interviews, it was determined that the facility failed to provide the resident and or their representative with a summary of the baseline care plan. This was evident for 1 (Resident # 119 ) of 33 residents reviewed for baseline care plans. The findings include: On 02/28/24 at 04:17 PM, a review of Resident #119's medical record revealed that the resident was initially admitted to the facility in February 2024. Further review of medical records failed to reveal that a copy of the baseline care plan was offered to the resident or the resident's representative. On 3/4/24 at 11:10 AM, facility provided a copy of the Interdisciplinary Care Conference attendance record for an initial care conference held on 2/6/24 that revealed neither the resident nor the Resident Representative attended the meeting. Further review of the Interdisciplinary Care Conference Attendance Record form revealed the following statement Resident and/or Resident Representative will be invited to all Interdisciplinary Care Conferences. In instances where the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and observation, it was determined that the facility failed to 1) provide a resident with the amount of assistance needed during meals, according to the facility's assessment of the resident ability to feed himself, and 2) ensure that a resident who required assistance with activities of daily living (ADL) was assisted with putting his/her dentures in their mouth during meal times. This was evident for 1 (Resident #23) of 2 residents reviewed for Activities of Daily Living (ADLs) and for 1 (#15) of 5 residents reviewed for Dental. The findings include: 1) On 2/26/24 at 8:25 AM, Resident # 23, a long-term resident was interviewed. During the interview the resident reported s/he was unable to eat all their breakfast that morning. They reported that s/he had kept dropping their food and was only able eat a couple pieces of bacon. On 2/29/24, the GNA tasks documentation was reviewed. For the question regarding the Resident #23's ability to use suitable utensils to bring food and/or…

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

Based on record review and staff interview, it was determined that the facility failed to ensure the administration of a complete course of antibiotics as ordered. This was evidenced for 1 (Resident #118) out of 5 residents reviewed for un necessary medication. The findings include: On 02/29/24 at 4:00 PM, a record review for Resident #118 revealed that, on 02/06/2024 at 3:13 PM, a new order was placed for an antibiotic to be given every 12 hours for 7 days for Urinary Tract Infection (UTI). On 02/29/2024 at 11:10 AM, review of Resident #118's Medication Administration Record (MAR) indicated that the first two doses of the antibiotics, scheduled to be given on 02/06/2024 at 8 PM & 02/07/2024 at 8 AM were not administered, resulting in only 12 of 14 doses of the antibiotic being administered. A nurse's progress note with a date of 2/06/24 at 11:10 PM indicated, pending pharmacy delivery for Resident #118's antibiotic. A review of Resident #118 ' s medical record failed to reveal documentation indicating that Resident #118's physician was made aware, nor that there was any change 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, record review, and staff interview, it was determined that the facility failed to ensure and check the functionality of the wander guard, as ordered. This was evident for 1 (Resident # 119) of 1 Resident reviewed for potential elopement during the survey. The findings include: On 02/22/24 at 08:44 AM, Surveyor observed that Resident #119 had a wander guard on the resident's ankle. A Wander guard bracelet is a technology to safegurd residents at risk of wandering. It has a a sensor that monitors doors and a technology platform that sends safety alerts in real-time when residents get close to the doors. On 02/26/24 at 09:18 AM, a medical record review revealed that the physician ordered to monitor the wander guard device function and placement every shift, dated 02/05/24. Monitoring to ensure the placement of the wander guard and to check the function of the wander guard orders were combined and it was signed on the treatment administration record (TAR). A review of the February 2024 TAR revealed that monitoring and the function of the wander guard order was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to ensure that colostomy care was provided to a resident with a colostomy. This was evident for 1 (#15) of 1 resident reviewed with a colostomy. The findings include: The Minimum Data set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A medical record review done on 2/23/24 at 10:20 AM for Resident #15 revealed a care plan, initiated on 8/24/14 and revised on 3/9/22, that recorded that Resident #15 had a colostomy use status. A continued record review showed a progress note, dated 12/14/23,that the Resident had a diagnosis of cognitive impairment, completed by Resident #15's attending provider. A subsequent record review completed on 2/23/24 at 10:51 AM revealed an order summary report of January 2024 that revealed an attending provider's orders for 1) colostomy care…

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

Based on observation, record review and interview, it was determined that the facility failed to follow physicians' orders for the administration of oxygen. This was evident for 1 (Resident # 17) of 4 residents reviewed for respiratory care during a survey. The findings include: On 2/21/24, review of records revealed that Resident #17 was a long-term care resident of the facility. On 2/28/24 at 9:13 AM, a review of orders revealed an order with a start date of 2/20/24 for oxygen at 2 LPM (liters per minute) via NC (nasal cannula) as needed. May titrate to maintain O2 sats above 92% every 24 hours as needed for SOB, (Shortness of Breath). Supplemental Oxygen is a prescribed drug and is normally delivered by a nasal cannula. A nasal cannula is a thin, flexible tube that wraps around your head, typically hooking around your ears. On one end, it has two prongs that sit in your nostrils and deliver oxygen. The other end of the tube connects to an oxygen supply. There are several different types of oxygen supply delivery systems. The type of oxygen delivery system you use depends on your…

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 records review and interviews, it was determined that the facility failed to ensure that pain managementwas provided to the resident that was consistent with professional standards of practice. This was evident for 1 (Resident #16) of 3 residents reviewed for pain management. The findings include: Resident #16 was admitted to the facility in late 2023. On 2/21/24 at 1:12 PM, the resident was interviewed about pain management and reported that there had been several occasions where his/her pain medications were administered late or the dose was skipped. On 2/23/24 at 9:22 AM, a review of Resident #16's medical record indicated that the resident was sent to the hospital in November of 2023 due to a fall that resulted in a fractured hip and was readmitted in December 2023. On 2/26/23 at 10:38 AM, Resident #16's pain medication orders were reviewed. The review revealed an order for Oxycodone 10MG to be administered every 4 hours starting on 12/13/23 at 9 PM to 1/12/24 at 5 PM and restarted on 1/13/24 at 1 PM to 2/12/24 at 9 AM. On 2/13/24, the order for the 10MG Oxycodone 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 the surveyor's observation, record review, and interview with facility staff, it was determined that the facility failed to assess safety or obtain a physician's order before initiating the usage of side rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent. This was evident for 2 (Residents #6, and #9) of 2 residents reviewed for side rails. The findings include: 1) On 02/21/24, a record review revealed that Resident #6 had resided at the facility for more than a year. On 2/21/24 at 12:33 PM, observed the resident in bed with the bed rail up on the left side of the bed. On 2/21/24, medical record review failed to reveal a physician order, a safety screening, a consent either from the resident or from family, or a care plan reflecting the bed rail usage. The facility provided a copy of informed consent for the installation of a bed rail or assist bar not used as a restraint, dated 02/22/2024. A review of the policy # NS1293-01Safe use of bed rails procedure revealed that step VI a) physician order is…

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 records review, interviews, and observations, it was determined that the facility failed to develop a care plan that reflects an individualized, person-centered approach with measurable goals and specific interventions to care for and treat a resident with dementia. This was evident for 1 (Resident #38) of 1 resident reviewed for dementia care.The findings include: Resident #38 was admitted to the facility in late 2023. The resident's medical records indicated active diagnoses of, but not limited to, non-traumatic brain dysfunction, dementia, depression, impairment in both sides of the lower extremity, and sever cognitive impairment. During the survey, 3 of the 4 times Resident #38 was observed, no activity was being provided. On 3/01/24 at 3:33 PM, the residents care plan was reviewed and indicated that the resident had specific health practices, beliefs/values, cultural needs/preferences, and/or linguistic needs/preferences. On the same day at 4:16 PM, the activity preference interview signed by the Activities Director (AD Staff #27) on 12/29/23 was reviewed and revealed…

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 narcotic count sheets, and interviews, it was determined that the facility failed to keep an accurate record of controlled substances. This was found to be evident for 1 of 2 medication carts reviewed during a facility recertification survey. The findings include: On 3/04/24 at 11:30 AM, the narcotic count sheet binder for the ground floor was provided by the Registered nurse on duty (RN Staff #12). The narcotic count sheet revealed columns for the amount, date and time, amount used, amount wasted, administered by, and amount remaining. A count of all the narcotics in the ground floor medication cart was conducted with Staff #12, but before initiating the count, Staff #12 reported to the surveyor that there were medications that they had already administered to several residents but had not signed off from the narcotic count sheets. The count with Staff #12 revealed 1) Resident #1, had 6 Pregabalin capsules but the narcotic count sheet indicated 7; had 25 Oxycodone tablets but the narcotic count sheet indicated 26. 2) Resident #50 had 24…

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 pertinent documentation and interview, it was determined that the facility failed to implement the pharmacy and physician recommendations. This was evident for 1 (Resident # 17) out of 5 residents reviewed for unnecessary medication during a survey. On 2/21/24, review of records revealed that Resident #17 was a long-term care resident at the facility. On 2/23/24 at 12:26 PM, a review of the monthly pharmacy review, dated 1/1/24, for Resident #17 revealed the following pharmacist recommendation: Please consider monitoring a fasting lipid panel on the next convenient lab day and annually thereafter. On 2/23/24 at 12:30 PM, review of Resident # 17 physician orders failed to reveal an order for an annual lipid panel. On 2/23/24, the surveyor requested pharmacy reviews for Resident #17 and the physician or providers response to the recommendations. On 3/01/24 08:15 AM, a review of the physician prescriber/response to the pharmacist recommendation revealed a physician/prescriber signature, dated 2/5/24, and a handwritten OK. On 3/01/24 at 9:13 AM, a review of physician orders…

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 records review and interviews, it was determined that the facility failed to document adequate monitoring and indication after administering pain medication. This was evident for 1 (Resident #16) of 6 residents reviewed for unnecessary medications. The findings include: Resident #16 was admitted to the facility in late 2023. During the initial pool process interview, the resident raised some concerns about pain management. On 2/26/23 at 10:38 AM, a review of the resident's pain medication orders revealed the resident was on 10MG Oxycodone to be administered every 6 hours as needed for pain with a start date of 2/13/24. Oxycodone is used to relieve pain severe enough to require opioid treatment and when other pain medicines do not work well enough or cannot be tolerated. It belongs to the group of medicines called narcotic analgesics (pain medicines). Narcotic pain medications have significant side effects and the potential for abuse. As a result, it is a standard of nursing practice to administer narcotic medication only from sources that can be both accounted for 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 observations, records review, and interviews, it was determined that the facility failed to have a medication administration error of less than 5%. This was evident for 2 of 3 nurses observed for medication administration. The findings include: 1) An observation of the Registered Nurse (RN Staff #31) on 3/1/24 at 9:42 AM, of her preparation and administration of Resident #18's medications revealed several items on her computer that appeared bright pink. Staff #31 reported these items were the orders for the resident's lidocaine patches that were behind schedule. Staff #31 proceeded to pull Resident #18's medications one by one in a medicine cup as she verified each one from the computer on the medication cart. Included with the medications she prepared were, but not limited to, mucus relief DM guaifenesin and dextromethorphan HBr extended-release 600mg/30 Mg, and redness reliever eye drops (active ingredient tetrahydrozoline HCL 0.5%). After the medication administration observation of Staff #31, at 10:23 AM, she reported that she was done signing the electronic medication…

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

Based on observation and interview, it was determined that the facility failed to ensure expired medications were disposed of properly. This deficient practice was found to be evident for 1 of 1 medication storage room and 2 of 2 medication carts observed during medication storage and labeling inspection. The findings include: On 3/4/24 at 11 AM, an observation of the facility's medication storage room on the ground floor, in the presence of a Registered Nurse (RN Staff #12), revealed an unopened bottle of Vitamin C that expired on 1/24, on the shelf with other unexpired Vitamin C bottles. Staff #12 removed the bottle and indicated that it would be disposed of. On 3/04/24 at 1:31 PM, an observation of the medication cart on the 2nd floor, in the presence of an RN (Staff #5), revealed 1) a bottle of Vitamin B12 100mcg expired on 6/23, 2) Magnesium Chloride with Calcium expired on 11/23, 3) Zinc 50 MG expired on 1/24, and 4) Bisacodyl 5MG expired on 2/24. As the surveyor was inspecting the medication cart, at 1:42 PM, the Director of Nursing (DON) arrived and saw the bottles 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to provide full visual privacy for residents in non-private rooms. This was evident for 6 beds of the 2 floors observed during the recertification survey. The findings include: On 2/20/24 at 1:19 PM, an observation was made of room [ROOM NUMBER]. Bed A did not have suspended curtains to provide visual privacy and bed B had a curtain but only covered one side of the bed. On 2/28/24 at 2:43 PM, the resident's family member who occupied bed A in room [ROOM NUMBER] was interviewed and s/he indicated that there had not been a curtain to provide full visual privacy for several months. On 3/1/24 at 5:34 PM, a tour of the 1st and 2nd floor was conducted to identify other beds with the same concern. The observation revealed room [ROOM NUMBER] bed A and B; room [ROOM NUMBER] bed A and B; room [ROOM NUMBER] bed A; and room [ROOM NUMBER] bed B, did not have curtains that extended around the bed or in combination with adjacent walls and curtains…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the Office of Health Care Quality (OHCQ). This was evident for 4 (#25, #22, #7, #41) of 21 residents reviewed for incidents related to facility reported incidents during a complaint survey. The findings include: 1) On 12/11/23 at 10:02 AM a review of facility reported incident MD00194116 revealed on 7/5/23 Resident #25 alleged that geriatric nursing assistant (GNA) #30 was rough while providing care. Review of the facility's investigation revealed an email confirmation that documented the allegation was first reported to OHCQ on 7/6/23 at 5:50 PM and was not within the 2-hour timeframe for an allegation of abuse. Review of the facility staff interviews and statements documented that GNA #30 reported the allegation to licensed practical nurse (LPN) #14 on 7/5/23. On 12/11/23 at 2:46 PM Staff #12 was interviewed. Staff #12 confirmed that GNA #30 stated she reported 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 medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#44, #30, #38, #47) of 52 residents reviewed during a complaint survey. 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 those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 12/7/23 at 8:06 AM a review of Resident #44's medical record revealed the resident was admitted to the facility in October 2023 with diagnoses that included alcohol use disorder. A 10/17/23 care plan note documented that Resident #44 began to tell the police that he/she wanted to leave the facility.…

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

Based on medical record review and staff interview, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications if outside of physician ordered parameters. This was evident for 1 (#30) of 52 residents reviewed during a complaint survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). On 12/11/23 at 11:03 AM Resident #30's medical record was reviewed and revealed Resident #30 was admitted to the facility in July 2021 with diagnoses that included repeated falls, dementia, traumatic hemorrhage of cerebrum, and traumatic subdural hemorrhage. Review of physician's orders for Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation and interview, it was determined the facility failed to develop, implement and maintain an effective training program for all new and existing staff for the care of residents with a tracheostomy (Resident #46). This was evident for 1 of 1 residents with tracheostomies in the facility reviewed during a complaint survey. The findings include: Review of Resident #46's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include tracheostomy. A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. Observation of Resident #46 on 12/12/23 at 12:10 PM revealed the Resident to have a tracheostomy with a suction canister and suction tubing dated 12/4/23. Observation also at that time revealed the Resident's oxygen tubing and humidification bottle was not dated or initialed by staff. At that time the Assistant Director of Nursing (ADON) 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 observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was on 2 of 3 nursing units of the facility during a complaint survey. The findings include: On 12/12/23 at 8:30 AM observation was made of Resident #24 lying in bed. Resident #24's breakfast tray was sitting on the over the bed tray table. The laminate on the over the bed tray table was peeled off on the right side of the table approximately 8 to 10 inches. The back wall by the resident's bed was observed to have an area of white spackle on the wall. On 12/14/23 at 10:48 AM Resident #41 was lying in bed on top of a fitted sheet which was torn and had holes throughout the sheet. On 12/14/23 at 10:50 AM Resident #27 was observed sitting in a wheelchair in the common area. There was no armrest on the right side of the wheelchair. The vinyl on the left armrest was missing. Observation was then made in Resident #27's room. The laminate on the over the bed tray table was peeling on…

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

Based on review of complaint, medical record review, and interview with staff, it was determined that the facility failed to ensure that a care plan meeting was held at least quarterly and included the resident's representative. This was evident for 1 (#11) of 30 complaints reviewed during a complaint survey. The findings include. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 12/6/23 at 11:47 AM complaint MD00177360 was reviewed and alleged that Resident #11 had not had a care plan meeting in 2 years. On 12/6/23 at 11:47 AM Resident #11's medical record was reviewed and revealed Resident #11 was admitted to the facility in February 2019 and discharged from the facility in June 2023. Resident #11's medical record documented that the complainant was Resident #11's guardian. Review of Resident #11's medical record revealed documentation that care plan meetings were held on 3/25/19, 10/1/20, 1/22/21, 7/11/22, 8/9/22, 12/22/22, and 2/23/23. There were no care plan meetings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to administer medications as ordered by the physician (Resident #32). This was evident for 1 of 52 residents reviewed during a complaint survey. The findings include: Review of Resident #32's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. A. Further review of Resident's medical record revealed on 2/17/23 the physician ordered the Resident to have Prednisone 40 mg one time a day for 5 days with a start date of 2/18/23. Review of Resident #32's February 2023 Medication Administration Record (MAR) revealed the facility staff documented on 2/18/23 the medication was not available. On 2/19/23 and 2/20/23 the facility staff did not administer Prednisone. On 2/20/23 the physician reordered Prednisone 40 mg one time a day for 5 days with a start date of 2/21/23. Review of Resident #32's February 2023 MAR revealed the facility staff documented the facility administered Prednisone 40 mg on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers per the Wound Specialist recommendations (Resident #4 and #6). This is evident for 2 of 52 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure…

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

Based on medical record review, observation, and interview, the facility staff failed to supervise residents to prevent accidents (Resident #28 and #50) . This was evident for 2 of 25 residents on the 2nd floor of the facility. The findings include: Observation of 2nd floor staffing board on 12/13/23 at 8:07 AM revealed a census of 25 residents with 1 nurse and 2 geriatric nursing assistants (GNAs) for 7 AM - 3 PM shift with a floater GNA. Observation of staff on the unit at that time revealed 1 nurse (Staff #23) and 1 GNA (Staff #7). Observation of Resident #28 on 12/13/23 at 8:10 AM was walking down hallway and walked into Resident #50's room. The Surveyor followed Resident #28 into Resident #50's room and observed Resident #28 eating off Resident #50's breakfast tray. Staff #7 entered the room at 8:11 AM and intervened walking Resident #28 out of Resident #50's room. During interview with Staff #7 on 12/13/23 at 8:12 AM, Staff #7 was asked where the other GNA (Staff #3) was and she stated at that time Staff #3 is downstairs getting clothing. During interview of Staff #23 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy review, observation and staff interview, the facility staff failed to provide services for a resident receiving oxygen therapy (Resident #46). This was evident for 1 of 3 residents reviewed with oxygen therapy during a complaint survey. The findings include: Review of Resident #46's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include tracheostomy. A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. Observation of Resident #46 on 12/12/23 at 12:10 PM revealed the Resident to have a tracheostomy with a suction canister and suction tubing dated 12/4/23. Observation also at that time revealed the Resident's oxygen tubing and humidification bottle was not dated or initialed by staff. At that time the Assistant Director of Nursing (ADON) was called to the Resident room and confirmed the Surveyor'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey. The findings include: On 12/12/23 at 7:00 AM observation was made of an unlocked and unattended medication cart sitting in front of the nursing station on the 100-nursing unit. The surveyor was able to open all the drawers and go through the cart which contained insulin supplies and resident medications in the first drawer, and resident medication cards in the other drawers. On 12/12/23 at 7:02 AM Registered Nurse (RN) #19 came out of a door and asked the surveyor if she was done at the medication cart. The surveyor asked RN #19 if he realized he left the medication cart unlocked and unattended. RN #19 stated, yes, I know. I was only gone for a minute. I had to run upstairs. On 12/14/23 at 8:27 AM observation was made of an unlocked and unattended medication cart sitting…

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, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #16, #46) This was evident for 2 of 52 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. The facility staff failed to have a consultant report in Resident #16's medical record. Review of Resident #16's medical record on 12/13/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. During interview with the Resident's representative (RP) on 5/13/22 at 11:00 AM, the RP stated the Resident was taken out of the facility for an appointment in December 2022 by the…

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

Based on observation and interviews it was determined the facility staff failed to follow infection prevention and control practices. This was evident in the kitchen while preparing food for residents. The failure to follow effective infection prevention and control practices increased the risk for the spread of infection to all residents, staff, and visitors in the building during an active COVID-19 outbreak. The findings include: On 12/12/23 at 9:44 AM observation was made in the kitchen of dietary Staff #26 and Staff #27 at the food preparation table. The 2 staff members were preparing food. Both staff members were wearing a face mask that was positioned under their chins and not covering their nose and mouth. As the surveyor stood and observed the staff, their masks remained positioned under their chins. At the time of the observation there was an active COVID-19 outbreak in the facility where all staff were required to wear masks while in the building. On 12/12/23 at 10:30 AM an interview was conducted with the Infection Control Preventionist, Staff #10 and the Assistant…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#53) with the most dignified existence. This was evident for 1 of 37 residents selected for dignity during the annual survey process. The findings include: Medical record review for Resident #53 revealed on 11/23/18, the physician ordered: supervise at all meals and assist when he/she stops eating. Surveyor observation of Resident #53 on 4/12/19 at 12:30 PM revealed Resident #53 was served lunch, in the dining room with approximately 11 other residents. Further observation revealed the resident was served: breaded fish, noodles, peas, fruit cocktail and a carton of health shake. Further observation revealed the facility staff opened the health shake, of which the resident drank. Further observation revealed, Resident ate the fruit cocktail by putting the bowl to his/her mouth and consuming the food from the bowl. Further observation revealed the facility staff walking past Resident #53 and asking if Resident #53 was going to eat; however, there was no evidence…

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 ensure an advance directive was in place for Residents (#52 and #53). This was evident for 2 of 3 residents selected for review of advance directives and 2 of 37 residents selected for review during the annual survey process. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The (Medical Orders for Life-Sustaining Treatment) MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). DNR order, is a medical order…

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 guardian of person of a change of condition for Resident (#11) and failed to complete a change of condition form for Resident (#11). This was evident for 1 of 1 resident reviewed for change of condition and 1 of 37 residents selected for review during the survey process. The findings include: 1 A. The facility staff failed to notify the guardian of person of a change in condition for Resident #11. Medical record review for Resident #11 revealed the facility staff nurse #1 documented the resident's temperature of 102 approximately 4/15/19 at 8:30 AM. The resident was medicated with standing order of Tylenol and the physician notified. The physician assessed the resident at 12:30 PM and ordered laboratory blood tests and x-rays. Further record review revealed no evidence the facility staff notified the resident's guardian of person of the temperature and the ordered test. 1 B. The facility staff failed to complete a change in condition form for Resident #11. Medical record review…

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 and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: On 4/10/2019 at 9:59 AM during an initial tour of the facility the following observations were made: 1. room [ROOM NUMBER] had loose door handles on the hallway door and bathroom door 2. The bathroom in room [ROOM NUMBER] had a leaky faucet and brown stains on the ceiling tiles around the sprinkler. On 4/11/2019 during resident observation and interview the following observations were made: 1. The first-floor hand sink opposite the elevator had chipped surfaces that are not easily cleanable and may harbor bacteria. 2. A bariatric wheelchair was observed on the first floor to be in disrepair. The stitching was busted on the top of the chair exposing the foam cushioning underneath. This surface is no longer easily cleanable. The Director of Maintenance was informed of these findings…

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

Based on record review and staff interview it was determined that the facility failed to thoroughly investigate the allegation of abuse-misappropriation of property for a resident (#67). This was evident for 1 of 2 residents selected for review of misappropriation of property and 1 of 37 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse or misappropriation of property of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence being investigated by the facility. This investigation includes interviews with all direct care giver staff for a least 1-2 days prior to the reported allegation. Surveyor investigation of MD00130006 revealed Resident #67 was missing $100.00 from a locked drawer in his/her room. Further investigation revealed Resident #67 indicated $276.00 was in the inner drawer of the dresser. It was stated by the resident the inner drawer was locked and the key was kept around the resident's neck. It was stated 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 medical record review and interview with staff it was determined that the facility staff failed to have a system in place to ensure that the transfer of the resident's medical record and appropriate information is communicated to the receiving health care provider. This was found to be evident for 2 out of 3 (#55 and # 222) residents reviewed for hospitalization during the investigative portion of the survey. The findings include: The facility staff failed to meet the requirement for transfer information. If the resident is being transferred, and return is expected, the following information must be conveyed to the receiving provider: 1. Resident representative information, including contact information. 2. Advance directive information. 3. The resident's comprehensive care plan goals. 4. Medications (including when last received) 5. Most recent relevant labs, other diagnostic tests. The facility must ensure that the transfer or discharge is documented in the resident's medical record and, who is responsible for making the documentation. 1. A medical record review for…

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

Based on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #55 and #222) of 3 residents reviewed for hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #55 revealed the resident was transferred to an acute care facility on 3/11/2019. There was no documentation found in the medical record that the resident, the resident's responsible party, or the Ombudsman was given written notice of Resident #55 being transferred to the hospital and the reason for the transfer to the hospital. 2. Review of the medical record for Resident #222 revealed the resident was transferred to an acute care facility on 9/20/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given written notice of Resident #222 being transferred to the hospital and the reason…

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 the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 2 (Resident # 55 and #222) of 3 residents reviewed for Hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #55 revealed the resident was transferred to an acute care facility on 3/11/2019 and returned to the facility on 3/15/2019. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 2. Review of the medical record for Resident #222 revealed the resident was transferred to an acute care facility on 9/20/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 4/15/19 at 11:00 AM, 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 medical record review and interview, it was determined the facility staff failed to assess Resident (#67) for PASARR. This was evident for 1 out of 2 residents reviewed for PASARR's during the annual survey process. The findings include: The Level I Pre-admission Screening and Resident Review (PASARR) must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring a Level I screen is completed for everyone prior to admission. The PASRR determines whether an individual who has an active diagnosis of Mental Illness (MI) or Intellectual/Developmental Disability (ID/DD) meets the criteria for admission to a nursing facility and may require specialized services. PASARR is required for all persons seeking admission to Medicaid certified nursing facilities, regardless of whether their stay at the nursing facility will be paid for by Medicaid,…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide an environment which produced the highest level for practicable well-being for Residents (#1, #26 and #49). This was evident for 3 of 37 residents selected for review of during the annual survey for well-being. The findings are 1. The facility staff failed to clarify and correct a physician's order for Resident #1. Medical record review for Resident #1 revealed on 3/1/18 the physician ordered: Weigh patient monthly every day shift every 1 month(s) starting on the 1st for 28 day(s). Review of the Treatment Administration Record (TAR) revealed the facility staff transcribed the resident's weight to be obtained every day during the month; however, further record review revealed the last documented weight for Resident #1 was 11/11/18. Record review no evidence of Resident #1 refusing weights except on 4/15/19. Interview with the Director of Nursing on 4/15/19 at 12:00 PM revealed the facility staff failed to transcribe the physician's order correctly to reveal a weight to be…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to apply leg rest to the wheel chair of Resident (#53) as ordered and failed to apply fall mats to both sides of the bed as ordered for Resident (#53). This was evident for 1 of resident selected for review of accidents and 1 of 37 residents selected for review during the survey process. The findings include: 1. The facility staff failed to provide Resident #53 with leg rest for the wheelchair as ordered. Medical record review for Resident #53 revealed on 8/6/18 the physician ordered: high back wheelchair, pommel cushion, leg rest with foot board to prevent falls. A pommel cushion is a gel filled cushion designed to prevent the resident from sliding forward, promotes proper hip and knee alignment and the pommel helps keep residents in position. Surveyor observation of resident #53 on 4/ 12/19 at 12:26 PM and 4/15/19 at 12:00 PM revealed the resident out of bed, in a high back wheelchair with a pommel cushion; however, the facility staff failed to apply leg rest with foot board for…

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

Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and medicate Resident (#44). This was evident for 1 of 1 resident selected for review of pain assessment and 1 of 37 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review for Resident #44 revealed on 3/9/18 the physician ordered: Tylenol Arthritis Pain Tablet Extended Release 500 milligrams by mouth every 8 hours as needed for…

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

Based on medical record review and interview, it was determined the facility staff Social Worker (SW) failed to complete Preadmission Screening and Resident Review (PASARR) for Resident #67. This was evident for 1 of 2 residents reviewed for PASARR's during the annual survey process. The findings include: The Level I Pre-admission Screening and Resident Review (PASARR) must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring a Level I screen is completed for everyone prior to admission. The PASRR determines whether an individual who has an active diagnosis of Mental Illness (MI) or Intellectual/Developmental Disability (ID/DD) meets the criteria for admission to a nursing facility and may require specialized services. PASARR is required for all persons seeking admission to Medicaid certified nursing facilities, regardless of whether their…

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

Based on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated the medication was open. This was evident for 1 of 37 medication carts observed during the annual survey process. The findings include: Observation of the medication cart on 4/16/19 at 10:00 AM revealed the following observations: 1. The medication cart on the ground floor had a bottle of eye drops Timolol Maleate with no name on the bottle to determine which resident it was to be administered to. 2. The medication cart on the ground floor had a bottle of eye drops Dorzolamide with no open date. 3. The medication cart on the ground floor had a bottle of Nasacort nasal spray with no open date. 4. The medication cart on the 1st floor had the following insulin medications with no open dates, Lantus, Victoza, Humalog, Novolog and two Basaglar pens. 5. The medication cart on the 1st floor had the following bottles of eye drops with no open dates, Simbrinza, Bepreve, and Dorzolamide. Interview with the Director of Nursing on 4/16/19…

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 test as ordered for Residents (#44 and #52). This was evident for 2 of 37 residents selected for review of laboratory results in the survey sample. The findings include: 1. The facility staff failed to obtain laboratory blood specimen for Resident #44 as ordered. Medical record review for Resident #44 revealed on 2/11/19 the physician ordered: CBC, BMP, CRP and ESR every Thursday for 3 weeks. A complete blood count (CBC) is a test that measures the cells that make up the blood: red blood cells, white blood cells, and platelets. A complete blood count (CBC) is a blood test used to evaluate overall health and detect a wide range of disorders, including anemia, infection and leukemia. A basic metabolic panel is a blood test that measures the sugar (glucose) level, electrolyte and fluid balance, and kidney function, this panel measures the blood levels of blood urea nitrogen (BUN), calcium, carbon dioxide, chloride, creatinine, glucose, potassium, and sodium. 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 medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#52) with nectar thick water as ordered by the physician. This was evident for 1 of 1 resident selected for review of nutrition and 1 of 37 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #52 revealed on 2/28/19 the physician ordered: nectar thick liquids including bedside water. Nectar-thick liquids - are easily pourable and comparable to apricot nectar or thicker cream soups. Surveyor observation of Resident #52's room on 4/15/19 at 12:05 PM revealed the facility staff failed to provide nectar thick water at the bedside for Resident #52. Further observation revealed the resident had a thin water pitcher dated 4/15/19. The Director of Nursing was notified, and it was revealed that the water pitcher had come from the night shift. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to provide Resident #52 with nectar thick water at the bedside 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 interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#49). This was evident for 2 of 37 residents selected for review during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. The facility staff failed to maintain the medical record in the most complete form for resident #49 Medical record review for Resident #49 revealed: 1. Medical record review for Resident #49 revealed on 3/8/19 the physician ordered: ace bandage wrap apply in the morning and off at bedtime for edema and remove per schedule. On 4/11/19 and 4/12/19 a nurse's note revealed that the nurse signed the Treatment Assessment Record indicating that Resident # 49 had the ace wraps applied. Surveyor observation of the…

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

Based on medical record review, observations and interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Residents (#10, #52 and #65). This was evident for observations of dining in 2 of the 3 dining rooms and 3 out of 37 residents selected for infection control during the survey process. The findings include: 1. The facility staff failed to promote an environment free from the potential of transmission of communicable diseases or infections. Based on observation of lunch in the second-floor dining room on 4/15/19 at 12:34 PM revealed facility staff Geriatric Nursing Assistant #1 was noted to have bare hand food contact with Residents # 10's food. Further observations at that time revealed the resident was served a slice of ham. It was also noted a piece of white bread on the food tray. Facility staff GNA #1, using bare hands, placed the piece of ham on the bread and folded the bread to make a sandwich and provided to the resident. 2. The facility staff failed to promote…

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 staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident in 1 public bathroom accessible to residents and 1 resident bathroom. The findings include: 1. On 4/11/2019 at 09:21 AM and 4/15/2019 at 10:21 AM surveyors observed the call light system in the public/staff bathroom on the first floor. This door is not locked and can be accessed by residents. The chord for the call light system was wrapped around the toilet grab bar multiple times preventing the call light system from being activated by pulling the chord. Interview of the Maintenance Director revealed that residents may sometimes wrap the chord around the grab bar themselves. If this bathroom is accessible to residents the facility must ensure they have a means of directly contacting staff in the event of an emergency. 2. On 4/16/2019 at 10:00 AM during a Resident Council meeting, Resident #19 stated that the call light in their bathroom was not operable and had not been for months. At 11:01 AM the bathroom call…

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 and staff interview, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident for 2 resident bathrooms observed on the 1st floor of the facility. The findings include: Observation of resident rooms/bathrooms on 4/10/2019 at 10:35 AM revealed that exhaust fans were not operational in rooms [ROOM NUMBERS]. The bathrooms had a lingering smell of feces due to the lack of airflow. Interview with Staff #5 confirmed that the wall switches should trigger the bathroom fans when the lights come on. Staff #5 stated they would inform maintenance of the issue. At 1:09 PM the Director of Maintenance confirmed that the lack of airflow was caused by a broken exhaust motor on the roof and had been repaired. The Administrator was made aware of these findings on 4/16/2019 during the exit conference.

Based on interview, observation and medical record review the facility staff failed to provide all treatments and services as ordered by the physician (Resident #3, #45, #60, #65 and #70). This is evident for 5 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: 1. Review of Resident #3's medical record revealed an order on 7/9/16 for Mighty Shakes two times a day at lunch and dinner, document % consumed. Further review of the Resident's Administration Records revealed the facility staff failed to follow the physician order and document the % consumed. Interview with the Director of Nursing and Administrator on 12/12/17 at 9:30 AM confirmed the surveyor's findings. 2. Review of Resident #65's medical record revealed an order on 11/22/17 for fluid aspiration daily via pleurx catheter daily for recurrent pleural effusion. If CT drains less than 50ml/day for 3 consecutive days notify physician, every evening shift Document amount of drainage. Review of the Resident's Treatment Administration Record revealed the facility…

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

Based on observation and interview, it was determined the facility staff failed to provide the most dignified existence for Residents (# 28 and # 63). This was evident for 2 of 30 residents selected for investigation during the survey process. The findings include: Surveyor observation of Resident # 28 and Resident # 63 on 12/11/17 at 8:15 AM revealed the resident's breakfast tray was in the room. The tray was on the bedside table of both residents, to the side of the bed. The residents were not eating (the facility staff indicated both residents were to be fed). There was no facility staff in the room. It was noted the facility staff started collecting dirty trays from residents that had eaten their meal. It was noted that approximately 20 trays had been picked up and placed on the dietary cart. Further surveyor observation revealed no facility staff addressed the resident's breakfast until 8:30 AM; however, the facility staff was collecting dirty trays prior to addressing the breakfast tray for Residents # 28 and Resident # 63. Interview with the Director of Nursing on 12/11/17 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the December 12, 2017 observation of resident bedrooms and bathrooms, it was revealed that there was evidence of unattended maintenance needs in evidence. In addition, observation of the laundry area revealed multiple issues with disrepair. The findings included: 1. A tour of the environment of care was conducted on December 12, 2017 in response to team discussions of prior findings building during a tour on for this survey. Based on this tour, there was evidence of unattended maintenance needs. The following is a summation of those findings. a. room [ROOM NUMBER] was found with marred walls, a hole in the wall along the exterior wall of the room, the bedside table for the window side bed was missing a drawer handle, and the attached bathroom was found where the connected to mechanical ventilation at the ceiling was missing a grille or cover. b. Wall damage near entry to room where some effort of repair using wall compound was noted but application was rough and incomplete, plus the area of repair was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and review of the medical record it was determined the facility failed to initiate a care plan to manage a resident's incontinence (Resident #33). A comprehensive care plan outlines a resident's needs and drives the provision of care as required to meet those needs. Findings include: Review of the medical record on 12/12/17 at 9:10 AM revealed that resident #33 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) completed on 9/30/17 revealed that Resident #33 was frequently incontinent of bowel and bladder. A MDS is a complete resident assessment tool used to develop the resident plan of care on admission and then completed quarterly or with a significant change in condition. A second MDS was completed on 10/24/17 following a hospital admission and a change in condition. This MDS also revealed that Resident #33 was always incontinent of bowel and bladder. Further review of the medical record revealed that facility staff failed to initiate and implement a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for residents (# 30 and # 33). This was evident for 2 of 30 residents selected for investigation during the survey process. Findings include: Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. 1. Surveyor observation of Resident # 30 at lunch on [DATE] at 12:45 PM…

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

Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #46). This is evident for 1 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: During interview with Resident #46 on 12/7/17 at 11:55 AM, the Resident stated he/she is waiting for a follow up appointment with the eye doctor. Review of the Resident's medical record revealed the Resident did see the eye doctor on 7/31/17. The new orders for the Resident at that time were Refresh Tears oph. Solution apply 1 drop, Both eyes, twice daily for 60 days. Referral Ophthalmology Consult. Further review of the medical record revealed the Resident never received the eye drops as ordered and an Ophthalmology Consult was never scheduled. Interview with the Director of Nursing and Administrator on 12/12/17 at 11:00 AM confirmed the surveyor's findings.

Based on medical record review, observation and interview, it was determined the facility staff failed to provide a resident the food as indicated on the meal ticket (#30) or ordered by the dietitian (#61). This was evident for 2 of 30 residents selected for investigation during the survey process. The findings include: 1. Medical record review for Resident # 30 revealed the resident was ordered: CCD/NAS- Carbohydrate Controlled Diet/No Added Salt. A carbohydrate controlled diet is a diet in which carbohydrate intake is either limited or set at a value. Setting carbohydrate intake at set values or limits can be used by people with diabetes help stabilize blood glucose levels. A NAS diet is still a balanced diet. It includes grains, fruits, dairy products, meat and vegetables, but the choices made must be lower-sodium choices. The NAS diet allows all milk, all yogurt, all fruits and all breads without salted tops. Vegetables must be fresh or frozen and not canned or pickled. Surveyor observation of Resident # 30's meal ticket on 12/11/17 at 12:45 PM revealed the meal ticket indicated…

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 psychiatric consultations as ordered by the physician for residents (#45, #61, and #65). This is evident for 3 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: 1. Medical record review for Resident # 65 revealed on 11/1/17 the physician ordered: psychiatry consultation and treatment for diagnosis of cancer. Further record review revealed the facility staff failed to obtain that psychiatric consultation. Interview with the Director of Nursing and Administrator on 12/12/17 at 12:10 PM confirmed the facility staff failed to obtain the psychiatric consultation as ordered by the physician. 2. Medical record review for Resident # 61 revealed on 10/26/17 the physician ordered: psychiatry consultation for competency. Further record review revealed the facility staff failed to obtain that psychiatric consultation. Interview with the Director of Nursing and Administrator on 12/11/17 at 10:30 AM confirmed the facility staff failed…

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

Based on medical record review and staff interview the facility failed to ensure Consultant Pharmacist recommendations were acted upon accurately and as recommended for Resident (# 23), failed to ensure residents were free from unnecessary medications (# 47), and Consultant Pharmacist failed to identify labs were not done (Resident #9). This is evident for 3 of 30 residents selected for investigation during the survey process. The findings include: 1. Medical record review for Resident # 23 revealed on 10/17/13 the physician ordered: Calcium 600 milligrams/Vitamin D 400 milligrams (Mgs) by mouth 2 times day. Calcium is a mineral that is necessary for life. In addition to building bones and keeping them healthy, calcium helps our blood clot, nerves send messages and muscles contract. Vitamin D plays an important role in protecting your bones and your body requires it to absorb calcium. Review of the Medication Administration Record (MAR) revealed the facility staff documented the Calcium/Vitamin was administered at 8:00 AM and 4:00 PM. On 5/4/15 the physician ordered Iron Sulfate 325…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to ensure a resident was free from unnecessary medications (# 47). This was evident for 1 of 30 residents selected for review during the investigation stage of the survey process. The findings include: Review of Resident # 47's medical record revealed the resident had a daily order of aspirin. Low dose of aspirin reduces the risk of stroke and heart attack. On November 7, 2017 the Physician wrote an order to discontinue the aspirin. A reviewed of the medical record revealed that the Resident received aspirin in the month of November and up to December 12, 2017 until surveyor intervention. On 11/07/17 the aspirin should have been discontinued at that time to prevent the Resident from receiving the unnecessary medication. Interview with the Director of Nursing on 12/12/17 at 2:00 PM confirmed that the facility staff failed to ensure a resident's medication regimen was free from unnecessary medications. See F756

Based on record review, observation and interview it was determined that the facility staff failed to obtain a medication error rate less than 5 %. This was evident for 2 errors out of 25 opportunities for Residents (# 28) resulting in an error rate of 8%. The findings include: Error # 1: The facility staff failed to administer the correct dose of a medication to a resident. Medical record review of Resident # 28's record revealed on 8/17/16 the physician ordered: Aspirin 325 milligrams (mgs) by mouth every day for prevention of stroke. Aspirin is a pain reliever. It is used to treat mild pain and fever. This medicine is also used as directed by a doctor to prevent and to treat heart attacks, to prevent strokes, and to treat arthritis or inflammation. Review of Medication Administration pass on 12/11/17 at 8:23 AM revealed Certified Medication Aide # 1 attempted to administer Aspirin 81 mg instead of 325 mg. The CMA obtained Aspirin 81 mg from the bulk medication and placed in the medicine cup to administer to the resident. Prior to entering the room and after surveyor intervention,…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident received ordered laboratory services (# 9). This was true for 1 out of 30 residents selected for review during the investigation stage of the survey process. The evidence is as follows: A review of Resident # 9's clinical record revealed that the resident's primary physician ordered on 9/21/16 for a Liver Function Test (LFT) to be done every three months. Further review revealed that a LFT was done in April 2017 (one month late) but not in June or September 2017. The Director of Nursing was interviewed on 12/13/17 at 12:46 PM. She confirmed that the LFT's were not done as ordered.

Based on record review and staff interview, it was determined that the facility staff failed to obtain a physician's order prior to obtain laboratory blood specimen for a resident (# 63). This was evident for 1 of 30 residents selected for investigation during the survey process. The findings include: Medical record review of Resident # 63's record revealed on 5/31/17 the physician ordered: Liver Function Test (LFT) every 3 months. Liver function tests are blood tests used to help diagnose and monitor liver disease or damage. The tests measure the levels of certain enzymes and proteins in your blood. Some of these tests measure how well the liver is performing its normal functions of producing protein and clearing bilirubin, a blood waste product. Other liver function tests measure enzymes that liver cells release in response to damage or disease. Record review revealed the facility staff obtained the LFT 6/2/17, 8/24/17 and 11/6/17; however, the facility staff also obtained LFT on 7/3/17 and 10/2/17 without evidence of a physicians' order for those laboratory blood test. Interview…

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 provide a resident with the nectar thick water as ordered by Speech therapy (#70). This was evident for 1 of 30 residents selected for investigation during the survey process. The findings include: Medical record review for Resident # 70 revealed on 12/8/17 the Speech/Language Therapist ordered: discontinue thin liquids, begin nectar thick liquids by cup sips. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults. People who have trouble swallowing thin liquids often thicken liquids to help prevent choking and stop fluids from entering the lungs. Nectar-thick liquids are easily pourable and comparable to apricot nectar or thicker cream soup. Surveyor observation of Medication Administration pass on 12/11/17 at 8:30 AM revealed Certified Medication Aide (CMA) administered medications (Aspirin, Claritin for allergies, Cardizem for blood pressure,…

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 provide residents with assistive devices as ordered (# 28, # 30 and # 70). This was evident for 3 of 30 residents selected for investigation during the survey process. The findings include: 1. The facility staff failed to provide Resident # 28 a 3 compartment plate as ordered. Meal ticket review for Resident # 28 revealed: 3 compartment plate. The three compartments help keep foods divided so different foods can be prevented from mixing and is designed to increase the dining independence of those who can only use one hand, or those with limited flexibility or motor coordination. Surveyor observation of Resident # 28 on 12/7/17 at 12:45 PM, 12/8/17 at 1:00 PM and 12/11/17 at 12:45 PM revealed the facility staff failed to provide the resident with the 3 compartment plate as noted on the meal ticket. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 28 with a 3 compartment plate. 2. The facility staff failed to provide…

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

Based upon record review and staff interview it was determined that facility staff failed to ensure that the resident's medical record was accurate and complete (Resident # 61). This is evident for 1 of 30 residents selected for review during the investigation stage of the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Medical record review for Resident # 61 revealed a physician ordered dated 10/24/17 for cervical collar to be worn every shift. A cervical collar is an intervention to immobilize the cervical spine, the neck. It is also used for the treatment of neck pain. Surveyor observation of the resident on 12/07/17 at 10:45 AM and at 1:30PM, 12/08/17 at 8:00 AM and at 2:00 PM, revealed the resident in his room and in the hallway sitting in his wheelchair, however, facility staff failed to apply…

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.