Towson Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and residents and review of the medical record, it was determined that the facility failed to ensure medications were stored properly. This was evident for 1 (Resident #51) out of 41 residents reviewed during the facility's recertification survey.The findings include:On 2/10/26 at 11:10 AM in an interview with the Nursing Home Administrator (NHA), who had just finished speaking with Resident #51, she stated, He/she's a hoarder and he/she's an admitted hoarder. He/she has a safety inhaler in his/her pocket. He/she always has one. The surveyor asked, The resident always has an inhaler? for clarification. The NHA replied, He/she had one just now when I was down there. When asked if there was medication in the inhaler, the NHA stated, I didn't really look. I guess I should have, but I saw a blue inhaler in his hand. When asked if residents should have medications at the bedside, she stated, If they have an order. I don't even know if he has an order to keep meds at the…

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

Based on record observation and interviews, it was determined that the facility failed to serve food at an appetizing temperature. This was evident during the completion of the kitchen facility task during the recertification/complaint survey. Findings Included:On 02/09/2026 at 9:12 AM: Resident #10 reported hot foods were not hot. Resident #12 reported that food was sometimes served hot and sometimes not, and the taste was poor.On 02/09/2026 at 12:46 PM, another resident, Resident #4, reported that food was being served cold and sometimes it is due to the wait for assistance with feeding.On 02/13/2026 at 08:50 AM, the Food Service Director was informed to provide a test tray (sample tray) on the last food cart for delivery to the unit during the lunch time.On 02/13/2026 at 12:30 PM, observation of the last food cart delivery to the Terrace unit began. Lunch tray service started at 12:36 PM. The surveyor observed staff deliver all resident trays before removing the last tray (test tray) from the cart.On 02/13/2026 at 12:44 PM: The surveyor pulled the test tray/sample tray as served…

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 maintain the medical records on each resident that was accurately documented. This was evident for 2 behavioral monitoring assessments reviewed in the January 2026 Medication Administration Record (MAR) during the recertification/complaint survey.Findings included:On 02/09/2026 at 1:00 PM, Resident #64 was observed to be irritable and easily agitated (stating he/she wants to leave the facility immediately) during the initial interview.On 02/17/2026 at approximately 11:04 AM, a review of Resident #64's Psychiatric services progress notes on 1/12/2026 revealed Resident presented today as frustrated, irritable, and angry. yelled at therapist, I want to leave here ASAP! The resident complained of sleep difficulty and fatigue. A psychiatric evaluation on 12/30/2025 indicated depression and Anxiety and the treatment plan included continue current treatment plan and routine monitoring of mood and behavior. Follow-up as clinically indicated.On 02/17/2026 11:22 AM, a review of Resident #64 physician's 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 observation, interview, and medical record review it was determined the facility failed to: 1) ensure staff donned appropriate personal protective equipment (PPE) during wound care for resident who was on Enhanced Barrier Precautions and entering residents' room who was on Droplet Precaution, 2) use appropriate infection control practice when performing wound care. This was evident for 1 (GNA #5 ) out of 1 employee observed entering the Droplet Precautions room and 1 (LPN #26) out of 1 employee conducting wound care during the recertification survey. The findings include: Droplet Precautions are infection control measures designed to prevent the spread of germs (viruses/bacteria) transmitted through short-range, large-particle respiratory droplets (coughing, sneezing, talking). They require the following PPE: a surgical or procedure mask, eye protection, gown, and gloves. Enhanced Barrier Precautions (EBP) involve the use of gowns and gloves during high contact care activities. This practice is specifically aimed at residents with wounds or indwelling medical devices. 1) 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 medical record review, documentation review, and interview, it was determined the facility staff failed to notify the resident's responsible party of the addition of a medication and an increase in an anti-anxiety medication. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.The findings include: On 10/22/25 at 8:40 AM a review of Resident #3's medical record revealed that Resident #3 was admitted to the facility in September 2025 with diagnoses that included but were not limited to metabolic encephalopathy, unspecified dementia with other behavioral disturbances, anxiety disorder, depression, and altered mental status.Review of a 10/2/25 at 14:00 (2:00 PM) change in condition note documented that Resident #3 was noted with increased anxiety and restlessness and required frequent redirection due to impulsive behaviors, including repeated attempts to ambulate without assistance. Resident #3 was evaluated by psychiatry, and Buspar 5 mg. was ordered twice per day for management of anxiety. Resident #3's caregiver was notified and authorized…

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

Based on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.The findings include:On 10/23/25 at 7:30 AM a review of Resident #3's medical record was conducted and revealed the physician's notes were not in the electronic medical record on the day the resident was seen. There were physician visit notes dated 9/6/25, 9/11/25, 9/14/25, and 9/17/25, that were not signed until 9/24/25 and were not uploaded into the resident's medical record until 9/24/25. A 9/22/25 physician's note was not signed and uploaded until 9/27/25.On 10/23/25 at 9:32 AM Physician #12 was interviewed and stated that he typically got his notes in the system within 24 hours and that the notes that were referenced here were not his notes.On 10/23/25 at 11:27 AM the concern was discussed with the Nursing Home Administrator (NHA). The NHA confirmed the findings.

Based on medical record review and staff interview, it was determined the facility failed to ensure a resident's drug regimen was free from an unnecessary drug as evidenced by a PRN (when necessary) medication that was given routinely and lack of documented behavior monitoring. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey. The findings include: On 10/22/25 at 8:40 AM a review of Resident #3's medical record revealed that Resident #3 was admitted to the facility in September 2025 with diagnoses that included but were not limited to metabolic encephalopathy, unspecified dementia with other behavioral disturbances, anxiety disorder, depression, and altered mental status.Review of a 10/2/25 at 14:00 (2:00 PM) change in condition note documented that Resident #3 was noted with increased anxiety and restlessness and required frequent redirection due to impulsive behaviors, including repeated attempts to ambulate without assistance. Resident #3 was evaluated by psychiatry, and Buspar 5 mg. was ordered twice per day for management of anxiety.…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.The findings include. A medical record is the official documentation of 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. On 10/22/25 at 8:40 AM a review of Resident #3's medical record revealed Resident #3 had a fall on 9/26/25 at 20:12 (8:12) PM. The change in condition note documented the resident sustained a hematoma on the face with discoloration to the left side of the eye. The change in condition note documented that the writer was unable to notify the physician. There was no further documentation in the medical record that the physician had been notified.On 10/22/25 at 1:51 PM an interview was conducted 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 interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse to the state survey agency (SSA) for 1 (Resident #2) of 10 residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed/revised 07/21/2021, indicated, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #2's admission Record indicated the facility admitted the resident on 02/14/2025. According to the admission Record, the resident had a…

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

Based on interview, record review, and facility document and policy review, the facility failed to ensure an investigation into an allegation of abuse was submitted to the state survey agency (SSA) and failed to ensure documentation of the facility's investigation reflected a thorough investigation for 1 (Resident #2) of 10 residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed/revised 07/21/2021 indicated, V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur. The policy specified, B. Written procedures for investigations included, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations and 6. Providing complete and thorough documentation of the investigation. Resident #2's admission Record indicated the facility admitted the resident on 02/14/2025. According to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to 1.) complete wound care in a manner to prevent cross-contamination when they did not use proper barriers during wound care for three of three residents reviewed for wound care (Resident (R) 91, and R82, and R298), and 2.) ensure peripheral inserted central catheter (PICC) dressings were changed and/or remained intact for one of one resident (R298) reviewed for PICC lines out of total sample of 24. These failures had the potential to increase contamination and the spread of infection. Review of the facility policy titled, Wound Care, dated 10/01/23 revealed, . (5) use disposable cloth (paper towel is adequate) to establish a clean field. Place all items to be used during the procedure on a clean field. Arrange supplies so they can be easily reached . (7) Position resident. Place a disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites . Review of the facility policy…

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 all allegations of abuse were reported to the State Agency (SA) within the required timeframe. This was evident for 1 (MD00209677) of 2 facility reported incidents reviewed. The findings include: A review of the facility's investigation file for the facility reported incident #MD00209677 on 10/08/2024 at 1:03 PM revealed an incident report that was dated 9/10/24 at 12:44 PM. The report read that during Resident #1's care plan meeting s/he reported an allegation of abuse that occurred on 9/7/24. Review of the facility's initial report to the SA the facility documented that Registered Nursed (RN) #2 was made aware of the allegation of abuse on 9/10/24 at 12:45 PM and it was reported to the Administrator at 12:50 PM. Review of the email confirmation for the initial report to the SA revealed it had not been sent until 9/10/24 at 3:15 PM. The Nursing Home Administrator and Director of Nursing were made aware at the time of exit 10/10/24 at 1:40 PM. They offered no rationale for the late…

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 turn and reposition a resident who was at risk for pressure injury. This was evident for 1 (#72) of 4 residents reviewed for pressure ulcers. The findings include: An observation on 10/9/24 at 8:45 AM of Resident #72, revealed s/he was sitting up in the bed for breakfast. When the geriatric nursing assistant (GNA) left the room, the resident remained laying on his/her back. The resident was observed to have a few inches on each side of the mattress. A second observation on 10/9/24 at 11:21 AM revealed the resident was laying on his/her back. An interview on 10/9/24 at 9:07 AM with GNA #1, who was Resident #72's assigned GNA, revealed she was aware that s/he was to be turned and repositioned every 2 hours. On 10/10/24 at 7:58 AM an observation was made of Resident #72 laying on his/her back. The resident was in the same position 10/10/24 at 8:12 AM, and 10/10/24 at 10:13 AM. On 10/10/24 at 10:26 AM an interview with the resident's assigned GNA #2 revealed she reportedly turned 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the cleanliness of the ice machine filter and drip pan for one of two ice machines at the facility. This failure had the potential to cause contamination of the ice which could have a negative impact on all 104 residents currently residing at the facility. Findings include: During an observation on 10/10/24 at 4:15 PM in the kitchen, the [NAME] Symphony Plus' (a small ice machine) filter grate on the right side of the machine was noted to be covered in yellow tinged dust, and the drain pan was covered with rust and white colored substances. During an observation and interview on 10/11/24 at 10:00 AM, the Kitchen Dietary Manager (DM) confirmed that the filter grate was dusty and that the drain pan was covered with rust and white colored substances. The DM stated the maintenance department was responsible for the ice machine's filter management, and the kitchen staff was responsible for cleaning the drain pan. The DM could not…

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

Based on interview and medical record review, it was determined the facility staff failed to provide a resident a copy of the resident's medical record in a timely manner (Resident #15). This was evident for 1 of 36 residents reviewed during a complaint survey. The findings include: The Surveyor began on 5/17/24 a review of a complaint regarding a delay in obtaining a copy of the medical records for Resident #15 that was requested on 3/28/24 and still had not been received as of 5/17/24. Review of Resident #15's medical record on 5/17/24 revealed the Resident was discharged from the facility on 2/6/23. The Resident's representative provided to the Surveyor on 5/17/24 the request that was sent to medical records on 3/28/24 signed by the Resident for a copy of all the medical records during the Resident's stay at the facility. On 5/20/24 at 8:00 AM the Director of Nursing provided the Surveyor the closed record for Resident #15. During interview with Medical Records, Staff #22, on 5/20/24 at 9:18 AM, Staff #22 stated she did receive the request dated 3/28/24 for Resident #15's medical…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to notify the resident representative and physician of a change in condition. This was evident during the review of a complaint for 1 of 3 residents (#4). The findings include: Review of the complaint #MD00169562 on 5/14/24 at 11:39 revealed concerns related to the notification of a significant weight loss that occurred with a family member that was residing in the facility. Review of the medical record for Resident #4 on 5/14/24 at 11:39 AM revealed medical diagnosis including congestive heart failure and atrial fibrillation. Further record review revealed an initial order to notify the physician for weight gain of 5 lbs or more related to the congestive heart failure. On 6/8/21 the resident physician ordered Metolazone, a diuretic, (used to treat conditions like high blood pressure, edema, and heart failure, help the body get rid of extra fluid and salt by making the kidneys remove water and salt through urine. This lowers the amount of fluid flowing through the veins 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 record review and interview it was determined that the facility failed to have a process in place to ensure that allegations of abuse were reported to the State Agency within the required 2-hour time frame and to ensure that the final report was sent to the State Agency within 5 business days. This was evident for 3 of 3 allegations of abuse reviewed. The findings include: 1) On 5/20/24 at 11:45 AM a review of the facility's investigation file for the facility reported incident #MD00205616 revealed an initial report form that read a police officer had come to the facility on 5/12/24 at approximately 7:30 PM and reported that they suspected sexual assault due to the findings of the physician's exam at the hospital. Further review revealed an email confirmation for the report sent to the state agency (SA) which read it had not been sent until 5/13/24 at 1:15 AM, 5 hours and 45 minutes after the facility was made aware of the allegation. There was no evidence of when the final investigation report had been sent to the SA. On 5/20/24 at 2:10 PM reviewed the findings 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 record review and interview it was determined that the facility failed to conduct a thorough investigation of allegations of abuse. This was evident for 3 of 3 allegations of abuse reviewed. The findings include: 1) A review of Resident #19's medical record on 5/17/24 at 9:25 AM revealed a quarterly MDS (minimum data set) with an assessment reference date of 7/14/23 that documented the resident had no cognitive impairment and the resident required extensive assist of 2 staff to provide care. On 5/17/24 at 10:28 AM a review of the facility's investigation file that was supposed to be for the facility reported incident #MD00198055. The file had the self-report form for the incident that occurred on 10/1/23, however the remainder of the content was for an allegation of abuse that occurred on 5/26/23. Registered Nurse (RN) Staff #24 completed a concern form on 5/26/23 at 11:14 AM that documented Resident #19 reported to him that last night (5/25/23) on night shift the resident was eating a pack of crackers, which were dry and started coughing. When the resident put on his/her…

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 staff failed to 1.) follow physician orders for a resident in a timely manner (Resident #15); and 2.) failed to administer care to a resident when in distress (Resident #30). This was evident for 2 of 36 residents reviewed during a complaint survey. The findings include: 1a) Review of Resident #15's medical record on 12/17/22 revealed the Resident was admitted to the facility for rehabilitation on 11/23/22 following a spinal surgery. Further review of Resident #15's medical record revealed the Resident went to a follow up infectious disease and orthopedic appointment on 12/8/22. Review of the Consultation Report dated 12/8/22 revealed the physician ordered the Resident to start Clindamycin 300 mg three times a day. Clindamycin is an antibiotic used to treat infections. Review of Resident #15's December 2022 Medication Administration Record revealed Clindamycin was not started until 12/10/22, 2 days after the consult. 1b) Further review of Resident #15's medical record revealed the Resident went a follow up infectious disease…

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 staff failed to provide siderails as ordered by the consulting physician (Resident #15). This was evident for 1 of 36 residents reviewed during a complaint survey. The findings include: Review of Resident #15's medical record on 5/17/24 revealed the Resident was admitted to the facility following a spinal surgery for rehabilitation. Review of the hospital's Occupational Therapy (OT) note on 11/21/22 prior to discharge, the OT note stated the Resident was practicing rolling using bed rail. Further review of the Resident's medical record revealed the Resident went to a follow up orthopedic appointment on 12/8/22. Review of the Consultation Report dated 12/8/22 stated, Please apply bed rails so patient can work on pulling up or rolling. Interview with the Director of Rehabilitation (DOR) on 5/20/24 at 11:40 AM, the DOR stated the facility does not use siderails and thinks the facility gave the Resident a trapeze. Asked if the facility had any evidence of placing a trapeze and stated it would have been in old TELs system 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 with facility staff, it was determined that the facility staff failed to appropriately order and administer a medication. This was evident for 1 of 36 (#4) residents reviewed during a complaint survey. The findings include: Review of the complaint #MD00169562 on 5/14/24 at 11:39 revealed concerns related to the notification of a significant weight loss that occurred with a family member that was residing in the facility. Review of the medical record for Resident #4 revealed medical diagnosis including congestive heart failure and atrial fibrillation. Further record review revealed an initial order to notify the physician for weight gain of 5 lbs or more related to the congestive heart failure. On 6/8/21 the resident physician ordered Metolazone, a diuretic, (used to treat conditions like high blood pressure, edema, and heart failure, help the body get rid of extra fluid and salt by making the kidneys remove water and salt through urine. This lowers the amount of fluid flowing through the veins and arteries) to be administered concurrently…

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

Based on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have an updated annual facility assessment. The findings include: Review of the facility assessment for the 2024 year that would be reflective of 2023 on 5/21/24 at 11:40 AM during the extended survey revealed paperwork only for the year 2020-2021. This was brought to the attention of the facility corporate nurse and corporate operations representative at 11:45 AM. There were signed reviews in the front of the facility assessment binder showing the current Nursing Home Administrator and the facility governing body representative. The Corporate Operations representative stated that he has signed as the governing body representative. The signature page was not dated and a concurrent review of the facility assessment binder with this surveyor and the Corporate Operations representative and the corporate nurse failed to reveal any other documents with dates for the 2023 or 2024 year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to follow up with outside resources for the care of residents (Resident #15 and #14). This was evident for 2 of 36 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #15's medical record on 12/17/22 revealed the Resident was admitted to the facility for rehabilitation on 11/23/22 following a spinal surgery. Review of the hospital Discharge summary dated [DATE], stated Duration of antibiotics-gave name of facility to follow up with and contact information. Possible stop date is now 12/2/22, but Infectious Disease will need to re-evaluate the labs and patient status prior to stopping. Further review of Resident #15's medical record revealed the Resident went to an Infectious Disease follow up appointment on 12/8/22. Review of the 12/8/22 Consultation Report stated to discontinue the IV antibiotic and start a by the mouth antibiotic Clindamycin 300 mg three times a day. Review of the Resident's 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 medical record review and interview with facility staff, it was determined that the facility failed to constantly document activities of daily living (ADL) care provided to a dependent resident. This was evident during the review of 1 of 36 residents (#32) related to complaints of lack of ADL care. The findings include: Review of reported complaints for Resident #32's on 10:16 AM at 5/14/24 revealed concerns related to being left in bed and soiled with urine and stool for hours. A review of Resident #32's medical record at 10:22 AM revealed a minimum data set (MDS) Kardex documenting that s/he was frequently incontinent of bowel and bladder. The geriatric nursing assistant (GNA) documentation for toileting and bowel and bladder was requested to the facility and received on 5/16/24 at 7:47 AM. Review of this documentation revealed multiple shifts where GNA staff failed to document that care was provided for toileting for this dependent resident, specifically on 3/13/24, which was identified in the complaint as a day of concern. However, a review of the nursing progress…

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 a Resident (#49) with foods of preference. This was evident for 1 of 3 residents selected for review of choices and 1 of 39 selected for review during the annual survey process. The findings include: Surveyor observation of Resident #49's lunch on 7/31/19 at 12:40 PM revealed the resident not eating the lunch. When questioned, Resident #49 stated she/he did not eat ham. Review of the menu tray ticket that accompanied the lunch revealed Resident #49 was only to have: fish, chicken, and turkey only. The tray ticket further revealed Resident #49: dislikes cottage cheese, eggs, milk to drink, beef and pork. Surveyor observation of the resident's lunch tray on 7/31/19 at 12:40 PM revealed the resident was served ham and Resident #49 reinforcing that he/she did not like ham. Interview with the Director of Nursing on 7/31/19 at 2:00 PM confirmed the facility staff failed to provide Resident #49 with foods of preference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility staff failed to determine a resident's wishes regarding life sustaining treatment upon admission to the facility. This was evident for 1 (Resident #416) of 8 residents reviewed for advance directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Review of Resident #416's medical record on 07/30/19 reveled that Resident #416 was admitted from the hospital to the facility on [DATE] without a completed MOLST form. In an interview with MDS nurse #1 on 07/30/19 at 10 AM, MDS nurse #1 confirmed that Resident #416 did not have a completed MOLST form in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure a safe, comfortable, clean homelike environment. This was evident in 3 resident rooms on the ground floor of the facility. The findings include: On 7/30/2019 at 9:37 AM initial tour of the facility revealed broken fins on the air conditioning unit in room [ROOM NUMBER]. Further tour of the facility at 9:40 AM revealed an electrical outlet in disrepair in room [ROOM NUMBER] hanging beside the air conditioning unit. The outlet was loose from the wall, hanging by its wire, with two metal screws protruding from the back. Observation of room [ROOM NUMBER] at 10:31 AM revealed the wall by the headboard of bed 2 was in disrepair. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 8/2/2019.

Based on medical record review and interview, it was determined that the facility staff failed to notify the residents or responsible party in writing of the reason for Residents (#95 and #102) transfer to the hospital. This was evident for 2 of 5 resident reviewed for hospitalization during the annual recertification survey. The findings include: 1. Review of the medical record for Resident #95 revealed the resident was transferred to an acute care facility on 5/15/19. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice in a language and manner that they understand. 2. Review of the medical record for Resident #102 revealed the resident was transferred to an acute care facility on 1/8/19. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice in a language and manner they understand of Resident #39 being transferred to the hospital. On 7/31/19 at 11:50 AM the Director of Nursing was made aware there was no…

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

Based on medical record review and interview, it was determined the facility staff failed to initiate a care plan addressing dental for a Resident (#365) and bowel management for another (#46). This was evident for 2 of 39 residents selected for review during the annual survey. The findings include: 1.The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. The Long-Term Care Minimum Data Set (MDS) is a health status screening and assessment tool used for all residents of long-term care nursing facilities certified to participate in Medicare or Medicaid. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. Once 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 interview, it was determined the facility staff failed to ensure that a resident with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (Resident #91) of 6 residents reviewed for limited mobility during an annual recertification survey. The findings include: In an observation of Resident #91 on 07/30/19 at 11:37 AM, the surveyor observed Resident #91 in bed and a right-hand splint laying on the window ledge. Resident #91 was observed with weakness to his/her right side of the body. An initial review of Resident #91 medical record failed to reveal any documentation or physician orders indicating if the facility staff should be applying the right-hand splint to Resident #91. In an interview with the facility director of the therapy department on 07/31/19 at 12:04 PM, the therapy director indicated Resident #91 only had a right leg splint and not a right-hand splint and that only the therapy staff should be using the right leg splint with…

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

Based on medical record review and interview, it was determined that the facility staff failed to provide an environment free from potential accidents by not checking the placement of Resident #16's alert bracelet. This was evident for 1 (#16) of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #16 revealed on 4/15/2015 the physician ordered: Alert bracelet - check placement every shift. An alert bracelet is a battery-operated bracelet applied to the resident's wrist or ankle. The alert bracelet will keep residents at risk of wandering comfortable and protected. The bracelet will trigger alarms and can lock monitored doors to prevent the resident leaving the facility unattended. Review of Resident #16's electronic Treatment Administration Record (eTAR) revealed that Resident #16's alert bracelet was not checked on the night shift of July 12, 2019. Resident #16's Care Plan, which is developed to address the specific needs of the resident, revealed that Resident #16 is an elopement risk due to their cognitive…

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 document the blood pressure for Resident #49 when the physician ordered parameters. This was evident for 1 of 6 residents selected for un-necessary medication review and 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #49 revealed on 6/16/18 the physician ordered: Hydralazine 50 milligrams by mouth at 2:00 PM and 10:00 PM, hold for systolic blood pressure (top number) less than 110. Hydralazine is used with or without other medications to treat high blood pressure. Review of the Medication Administration Record and documentation of blood pressures in the electronic medical revealed the facility staff failed to document a blood pressure at 1400; however, documented the administration of the medication. Interview with the Director of Nursing on 8/2/19 at 10:30 AM confirmed the facility staff failed to obtain/document the blood pressure for Resident #49 when the physician ordered parameters.

Based on observation and interview, it was determined the facility staff failed to ensure that medications were accurately labeled with residents' name, dose of medication to be administered and date when the medication was open. This was evident for 1 of 3 medication carts observed during the annual survey process. The findings include: Observation of the medication cart for short hall on the 2nd floor on 8/2/19 at 8:30 AM revealed the presence of a bottle of Tegretol. Tegretol is an anticonvulsant used to treat seizures and nerve pain. Further observation of the medication cart at that time revealed the Tegretol did not have a label representative of pharmacy delivery, failed to have resident's name on the bottle; therefore, there was no documented dosage to be administered. There was no date as to when the medication was opened. Further observation revealed the medication had been used at some time, there as a half bottle left and the top of the bottle was sticky. Staff nurse #5 was present and notified at that time. The Director of Nursing was made aware of the finding on 8/2/19…

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.