Autumn Lake Healthcare At Glade Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of records, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident for 2 (Residents #85, #8) of 6 Residents reviewed for ADLs. 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. 1) During an initial tour of the facility on 5/26/26 at 11:12 AM, Resident #85's hair was observed to be matted and greasy. Resident #85 was questioned at that time about whether he/she had received showers and responded that the surveyor should look at his/her hair and determine whether he/she had received showers. Resident #85 added that he/she had received only bed baths (washing the Resident in bed). A record review on 5/27/26 at 12:02 PM included an MDS assessment dated [DATE] for 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.

Based on medical record review and interviews, it was determined that the facility failed to 1.) identify and follow up on a resident's significant abnormal laboratory value and 2.) ensure orders for psychiatric medications were kept active in the absence of a plan to reduce the dosage. This was evident in 1 complaint (#2735716 related to Resident #126) of 5 complaints reviewed during the annual survey, and 1 (Resident #3) of 5 residents reviewed for unnecessary medication. The findings include: 1) A complete blood count (CBC) is a laboratory test that checks, in part, for hemoglobin. Hemoglobin is an iron-rich protein inside a person's red blood cells. Its main job is to carry and transfer oxygen to the cells in the body. Hemoglobin is measured in grams per deciliter (g/dL) of blood. Normal levels of hemoglobin are between 12.0 -17.5 g/dL. A hemoglobin level between 7.1 - 9.5 g/dL is considered moderate anemia and would cause symptoms such as noticeable weakness, pale skin, and rapid heartbeat. An anticoagulant is a medication that stops the blood from clotting too easily by…

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, record review, and interviews, it was determined that the facility failed to ensure that residents with a limited range of motion received treatment and services to prevent further decline in the range of motion. This was evident for one (Resident #106) out of one resident reviewed for position and mobility. The findings include:An observation on 5/26/26 at 11:29 AM showed that Resident #106's fingers were bent at the knuckles and pressed into the left palm. The resident was unable to straighten them and had no device available. A subsequent observation on 5/27/26 at 1:57 PM showed Resident #106 sitting in the common area on the sugar loaf unit, still not wearing a device for the left-hand contracture. A record review noted a current care plan for Resident #106, initiated on 3/16/19 and revised on 10/26/22, which stated that the resident exhibits alterations in functional mobility related to contracture deformity. The care plan's goal stated that the resident will tolerate palm guard on left hand. A continued review of an occupational therapy (OT) evaluation…

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, interview and observation it was determined that the facility failed to ensure informed consent was obtained prior to the initiation of side rails. This was found to be evident for one (Resident #39) out of one resident reviewed for side rail usage. The findings include:Review of Resident #39's medical record revealed the resident has an intellectual disability. The resident was admitted to the facility on [DATE], and a nursing note indicates the resident arrived at 7:50 PM. Review of the 5/15/26 Minimum Data Set assessment revealed a Brief Interview for Mental Status was not completed due to the resident being rarely or never understood. Two physicians determined that the resident lacks adequate decision-making capacity due to intellectual disabilities and developmental delay.On 5/26/26 at 10:44 AM surveyor attempted to interview Resident #39, but the resident was unable to answer questions. On 5/27/26 at 9:53 AM surveyor observed the resident had quarter side rails in the up…

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 failed to ensure pain medications were administered within the ordered parameters. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications. The findings include: On 5/28/26 review of Resident #3's medical record revealed an order, in effect on 3/4/26 for oxycodone (an opioid pain medication) 5 mg to be given every 6 hours as needed for pain rated greater than 6 out of 10 on a numeric pain scale. Review of the Medication Administration Record (MAR) revealed documentation that the oxycodone was administered on 3/4/26 for pain at a level of 4. Further review of the MAR revealed that from 3/10-3/17/26 there was an order for oxycodone 5 mg to be given every 6 hours as needed for pain rated greater than 6 out of 10 on a numeric pain scale. Review of the Medication Administration Record (MAR) revealed documentation that the oxycodone was administered on 3/13 for a pain level of 2; on 3/14 for a pain level of 3; on 3/15 for a pain level of 5; and on 3/16 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 observation, record review, and staff interview, the facility failed to ensure medication refrigerator temperatures were consistently monitored and documented to verify that medications requiring refrigeration were stored within appropriate temperature ranges. This deficient practice was observed in 1 (Sugarloaf Unit) of 2 medication storage refrigerators reviewed.The findings include:On 5/28/26 at 10:00 AM, following a medication administration observation, the surveyor conducted a review of the medication storage room on the Sugarloaf unit with Licensed Practical Nurse (LPN) #4. During the observation, LPN #4 opened the medication room and unlocked the medication refrigerator.On 5/28/26 at 10:05 AM, the surveyor requested to review the refrigerator temperature log. The unit manager stated that the temperature log was not maintained near the medication refrigerator in the medication storage room and left the area to retrieve it. After a few moments, LPN #4 returned with the temperature log and held it in front of the surveyor for review.Review of the May 2026 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 interview and review of facility documentation it was determined that the facility failed to have a qualified food service director. This was found to be evident for the one out of one food service director at the facility. The findings include On 5/26/26 at 8:15 AM while conducting the initial tour of the kitchen, Staff #6 was asked if she was the Food Service Director. Staff #6 referenced her name tag which stated Account Manager but indicated she was the person in charge. Staff #6 reported she was currently in training to become a Certified Dietary Manager but confirmed she did not at present have that certification.Review of the list of key personnel that was provided by the facility identified the Food Service Director as Staff #6.On 5/27/26 at approximately 1:00 PM surveyor interviewed Registered Dietitian (RD) #9 in the office of the main kitchen. RD#9 reported she is at the facility 3 days a week and another RD is in the building on Fridays. When asked if she acts as a kitchen supervisor, RD #9 reported only when specifically asked to assist. If a qualified…

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, observation and review of menus it was determined that the facility failed to ensure menus were followed as posted. This was found to be evident for one (Resident #76) out of one resident included in the sample for review of food. The findings include: During an interview on 5/26/26 at 8:55 AM regarding food, Resident #76 reported: you get choices but sometime they serve me something else. On 5/27/26 at 5:28 PM surveyor observed staff deliver Resident #76's dinner tray to the resident. The tray included: two egg salad sandwiches; broccoli, and potato salad. No dessert was observed on this tray. Review of the Resident Meal Change ticket revealed the resident had requested the B meal. One of the B meal items was egg salad sandwich with chips. No chips were observed on the resident's tray. The resident expressed concern that no peach parfait was included on the tray. Surveyor observed that there was no dessert on the tray. Review of the menu posted in the hallway revealed the alternative meal items for this dinner were: egg salad sandwich, broccoli salad 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 medical record review and interview it was determined that the facility failed to ensure the psychiatric providers notes were accurately documented. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications. The findings include: On 5/28/26 review of Resident #3's medical record revealed an order, in effect since 3/2/26 for Sertraline (an antidepressant) to be given one time a day for depression. Review of the Medication Administration Records (MAR) revealed the medication was being administered daily as ordered since 3/2/26. Further review of the medical record revealed the resident was seen by the psychiatric nurse practitioner (NP #5) on 3/6/26. Review of the corresponding note revealed the resident was being seen to evaluate for agitation, anxiety and depression. The diagnosis included adjustment disorder with mixed anxiety and depressed mood. Review of the list of active medications failed to include the use of the Sertraline or any other antidepressant medication. Review of the Assessment and Plan section of the note…

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 administrative record review and staff interviews, it was determined that the facility staff failed to ensure that a resident was free of verbal abuse while in the care of a Geriatric Nursing Assistant (GNA). This was evident for 1 (#7) of 4 residents reviewed for abuse. The findings include:Verbal abuse is defined as the willful use of oral, written, or gestured language that includes disparaging, derogatory, or threatening terms to residents or their families, or within their hearing distance, regardless of the resident's age, ability to comprehend, or disability. On 1/15/26 at 9:54 AM, a review of the facility's investigation for facility reported incident #354455 revealed the facility had substantiated verbal abuse based on resident and staff interviews. The facility's investigation revealed on 6/19/25, approximately 6:30 PM, there was a verbal argument between Staff #4, Geriatric Nursing Assistant (GNA) and Resident #7 and foul language was exchanged between them. As a result of the facility's investigation, Staff #4, was terminated for his/her actions and reported 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 administrative record review and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administration and the state agency. This was evident for 1 (#7) of 4 residents reviewed for abuse. The findings include: On 1/15/26 at 9:54 AM, a review of the facility's investigation documentation for facility reported incident, #354455, which alleged a verbal altercation with profane words exchanged between Staff #4, GNA and Resident #7 occurred on 6/19/25 at approximately 6:30 PM and was witnessed by Staff #2, GNA. Following the altercation, Staff #4, GNA did not report his/her altercation with Resident #7 to the administration, and Staff #2, GNA failed to notify the facility's administration of the witnessed the verbal altercation. Following the incident, In a resident interview statement, on 6/19/25, Staff #1, Licensed Practical Nurse (LPN),Unit Manager (UM) documented Resident #7 requested to speak to a manager. When Staff #1, LPN, UM, accompanied by Staff #14, LPN, Shift Supervisor, went to speak 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 record review and resident and staff interviews it was determined the facility staff failed to conduct a thorough investigation of an allegation of abuse. This was evident for 1 (#5) of 5 residents reviewed for Abuse. The findings include:Facility reported incident #2675137 and Resident #5's medical record were reviewed concurrently on 1/20/26 at 9:15 AM. The facility's report revealed that Resident #5's family member called the facility on 11/21/25 at 9:25 AM and reported the resident told them a nurse threw urine in his/her face. The facility reported the incident to the state agency and conducted an investigation. The facility's investigation documentation included an Abuse Allegation Incident Report dated 11/21/25 11:00 (it did not indicate AM or PM) by Staff #1 the Sugarloaf Unit Manager. The report included Nursing Description: Resident alleging GNA intentionally threw urine in [his/her] face after [s/he] threw a full urinal bottle towards him/her. A written statement dated 11/21/25 7:27 PM was signed by Staff #5 an agency GNA (Geriatric Nursing Assistant) assigned 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, review of pertinent documents, and staff interviews, it was determined that the facility failed to provide the appropriate care for activities of daily living to residents for a resident who was dependent on staff for showers and bathing. This was evident for 1 (#) of 5 residents reviewed for quality of care. The findings include:ADLs are activities that people perform every day such as, getting dressed, taking showers or baths, cooking, and eating. On 1/16/26 at 11:11 AM, a review of complaint #2663151 which was received at the state office on 10/31/25, alleged while Resident #8's hygiene was poor prior to being discharged home from the facility and days the resident never got cleaned up A review of associated complaint #2663151, received at the state office on 11/7/25, alleged while at the facility, Resident #8, who was bedbound, incontinent and dependent on staff for care, was often left soiled for extended periods of time without assistance. Review of Resident #8's electronic medical record (EMR) revealed Resident #8 was admitted to 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 observations, record review, and interviews, it was determined that the facility staff failed to implement the use of a gait belt resulting in avoidable falls. This was evident for 1 (#14) of 6 residents reviewed for a complaint. The findings include: Hemiparesis is weakness on one side of the body and hemiplegia is paralysis that affects only one side of the body. A gait belt (transfer belt) is a safety device used to stabilize, guide, or support a patient during mobility. On 1/22/26 at 9:43 AM, a review of complaint #2716523 was conducted. The complaint alleged that while at the facility recovering from a stroke, Resident #14 had three falls (10/24/25, 11/6/25, 11/27/25) in the presence of a staff member who failed to put a gait belt on the resident. On 1/22/25 at 10:30 AM, a review of Resident #14's electronic medical record (EMR) was conducted. The medical record documented Resident #14 was admitted to the facility in mid-October 2025 following an acute hospitalization with diagnosis which included hemiplegia and hemiparesis following cerebral infarction (stroke),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, it was determined that the facility failed to conduct thorough investigations of an allegation of abuse. This was evident for 4 (Resident #9, #71, #77, #33) of 10 residents reviewed for abuse. The findings include: 1) On 4/22/25 at 2:06 PM, in an interview with the Director of Nursing (DON), she stated that a thorough investigation of alleged abuse should include real-time documentation in Nurse Progress Note in Point Click Care (PCC- an electronic health record) and notification of the Nursing Home Administrator (NHA) and DON. The nurse should have performed and documented a risk management assessment. The DON stated, I expect these to be documented in PCC and to be part of the investigation file. On 4/28/25 at 12:30 PM, a record review of the facility-initiated incident report revealed: On 1/21/25 at 11:55 AM Resident #9 and her friend, the complainant, made Licensed Practical Nurse (LPN #9) aware of alleged verbal abuse that occurred on 1/19/25 between Geriatric…

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 interview, it was determined that the facility failed to provide privacy to a resident during a dressing change. This was evident for 1 (Resident #108) of 4 residents observed for pressure ulcer care. The findings include: On 04/24/25 at 01:16 PM during an observation of Resident #108's dressing change, the resident's frontal private area was exposed. The privacy curtain was only half drawn around the bed. Present were the Licensed Practical Nurse (LPN #6), unit manager (Staff #41), and an unidentified Geriatric Nursing Assistant (GNA). During the observation, another unidentified GNA entered the resident's room to collect meal trays. The surveyor informed the second GNA that Resident #108 was having personal care provided and tried to redirect the GNA. The GNA proceeded into the room, walked past the exposed resident, and stated I know, I'm collecting the [roommate for Resident #108] tray. On 4/24/25 at 4:10 PM in an interview with the unit manager (LPN #3), she was informed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, pertinent document review and interviews, it was determined that the facility failed to have an effective process in place to ensure that the residents receive their choices from the alternative menu. This was evident for 1(Resident #69) in a random dining observation. The findings include: On 4/24/25 at 6:52 PM an observation in the dining room of the [NAME] Grove nursing unit was made. An observation of Resident #69's dinner tray revealed two separate meal tickets laying on the dinner tray. One of the meal tickets was titled Resident meal change. It revealed that a peanut butter & Jelly sandwich was circled and extra gravy was handwritten on the ticket. The second meal ticket indicated that the resident was to receive hot tea. Observation of Residents #69's dinner plate revealed steak and rice with no gravy and failed to reveal a peanut butter sandwich or hot tea. On 4/24/25 at 7:00 PM, interviews were conducted with the residents sitting at the table with Resident #69. Resident #88…

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 ensure that Beneficiary Protection Notifications were issued to residents 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 (Resident #5, #39) 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. The NOMNC informs the beneficiary of his/her right to an expedited review of the services termination. The resident and/or their representative must…

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 and observation it was determined that the facility failed to maintain a clean home-like environment. This was evident for 1 shower room out of 2 shower rooms observed during a survey. The findings include: On 4/25/25 at 8:06 AM, Resident #69, a long-term resident of the facility, reported to the surveyor that the [NAME] Grove shower room floors had a black and brown substance on/in the cracks in the shower room floor. On 4/25/25 at 8:15 AM an observation of the Sugar Loaf shower room was made with the nurse unit manager (Staff #5). The observation revealed cracks along the grout edge of the floor in the two of the three shower stalls rooms. In addition, small black and brown spots were visible in the cracks of the shower stall floor. Staff #5 reported she would notify housekeeping and maintenance. On 4/25/25 at 9:51 AM The Maintenance Director (Staff #18) was interviewed. Staff #18 reported that he was aware of the concerns with the shower stall floors. He reported that he recommended the…

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

Based on record review and interviews, it was determined that the facility failed to identify a Grievance Official in the facility's grievance policy, and failed to ensure that grievances were followed up with a written response. This was evident for 5 of 5 grievance investigations reviewed during the recertification survey. The findings include: A review of the facility's grievance policy, dated 12/22/22 revealed Name and Title instead of the grievance officer's name, and List contact information instead of the actual contact information. Further review of the policy revealed the following definition: The Grievance Official for the facility navigates the grievance process as a part of resident rights by receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. On 04/28/25 at 02:44 PM, a review of the grievance investigations for February 2025 was conducted with documents…

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

Based on a record review and interview it was determined that the facility failed to report a resident's allegation of missing money. This was evident for 1 (Resident #263) and was discovered during the investigation of the facility reported incident #MD00212599. During the survey 15 facility reported incidents were investigated. The findings include: A review of the facility reported incident (FRI # MD00212599) revealed that Resident #373 alleged that on 12/02/24 money was missing from the locked drawer in his/her room. A review of the facility's investigation file failed to reveal evidence that any other residents were asked if they also had money missing. On 4/30/25 at 9:44 AM an interview was conducted with the Nursing Home Administrator (NHA) to review the facility's investigation of FRI #MD00212599. When the NHA was asked if any other residents had reported missing money, the NHA said, yes, Resident #373's roommate (Resident #263) also reported missing money on the same date as Resident #373's. The NHA said she did not report Resident #263's allegation of missing money to the…

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

Based on record review, interviews, and observation, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 2 (Resident #39, #48) of 4 residents reviewed for limited range of motion (ROM), 1 (Resident #40) of 7 residents reviewed for unnecessary medications, and 1 (Resident #110) of 3 closed record reviews. The findings include: The MDS (Minimum Data Set) is a complete assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) A record review for Resident #39 on 4/21/25 at 1:48 PM included occupational and physical therapy evaluations dated 11/29/24 that had recorded that Resident #39 had impaired ROM to his/her left lower extremity and full ROM to both upper extremities. However, continued review of Resident #39's MDS assessments dated 12/1/24 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 pertinent document review and interviews, it was determined that the facility failed to perform a Pre-admission Screening and Resident Review (PASSAR) screen within 40 days of the resident admission. This was evident for 1 (Resident #69) out of 4 residents reviewed for PASSAR screening during a survey. The findings include: On 4/21/25 at 11:57 AM Resident #69, was a long-term resident of the facility. Review of medical records revealed Resident # 69 has a pre-admission screening and resident interview (PASSAR) screening completed on 12/12/23. Further review revealed that the attending physician certified, before admission to the nursing facility, that the resident is likely to require less than 30 days at the nursing facility. On 4/22/25 a review of Residents medical record failed to reveal an additional PASSAR completed within 40 days of Resident # 69 residing in the facility. 04/22/25 04:53 PM The Administrator was interviewed. She confirmed that Resident #69 was required to have new PASSAR screen after residing in the facility more than 40 days. The Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to develop and implement a baseline care plan. This was evident for 1 (Resident #369) of 4 residents reviewed for pressure ulcers and injuries. The findings include: Resident #369 was admitted to the facility for short-term managed care rehabilitation following hospitalization due to weakness related to a recent COVID-19 infection and chemotherapy treatment for cancer. The resident also presented with unstageable sacral wounds and history of depression, anxiety, and pain. A baseline care plan is a detailed, initial plan developed for each resident within 48 hours of their admission. It outlines the essential care instructions needed to provide effective and person-centered care. This plan serves as a foundation for the residents' overall care, ensuring continuity and staff communication. On 4/29/25 at 8:50 AM, in response to complaint MD00204145, the surveyor reviewed Resident #369's medical record which revealed that 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 record reviews and interviews, it was determined that the facility failed to develop and implement a comprehensive care plan. This was evident for 1 (Resident #369) out of 4 residents reviewed for pressure ulcers and injuries. The findings include: Resident #369 was admitted to the facility for short-term managed care rehabilitation following hospitalization due to weakness related to a recent COVID-19 infection and chemotherapy treatment for cancer. The resident also presented with unstageable sacral wounds and history of depression, anxiety, and pain. A comprehensive care plan is a detailed, individualized document that outlines a resident's goals, needs, and the services they will receive to achieve those goals. It's a collaborative effort involving the residents (if able), their family, and the care team, and it's designed to improve their overall well-being. Facilities are required to complete a comprehensive MDS assessment within 14 days of the resident's admission, and the care plan must 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 record review and interviews, it was determined that the facility failed to ensure that care plans were reviewed and revised after a change in a resident's condition. This was evident for 1 (Resident #48) of 2 residents reviewed for care planning. The findings include: A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. They must be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). 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. The information collected is used in the Resident's care planning decisions. The facility must have care plans developed and revised by an interdisciplinary team (IDT), including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's…

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

Based on record reviews, interviews and observations, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) were provided with showers and incontinence care. This was evident for 3 (Resident #57, #366, #365) of 3 residents reviewed for ADL. The findings include: 1) In an observation on 4/21/25 at 12:20 PM, Resident #57 was observed sitting in a Geri-chair, in the unit dining area, and was noted with white flaky particles in facial hair and on his/her clothes. In a subsequent observation on 4/24/25 at 5:01 PM, Resident #57 was noted lying in bed and continued to have white, flaky particles in his/her facial hair. A record review later that day contained an MDS assessment (Minimum Data Set- a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs) dated 2/4/25 for Resident #57. The MDS had recorded that Resident #57 depended on staff for most of his/her self-care needs. A continued review of Resident #57's order summary report as of April 2025…

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 ensure that medications and treatments were administered per physician orders. This was evident in 1 (Resident #363) of 53 residents reviewed during the survey. The findings include: Resident #363 has a medical history of kidney failure, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), depression, and chronic pain. On 4/30/25 at 8:10 AM, the surveyor reviewed Resident #363's Medication Administration Records (MAR) and Treatment Administration Records (TAR), which revealed multiple instances of missed medications and treatments that had been ordered by the resident's physician. The missed medications and treatments are as follows for March 2025: -3/31 - Mirtazapine 15 mg -3/19 & 3/31 - Rocklatan Ophthalmic Solution 0.02-0.05% -3/19 & 3/31 - Buspirone 7.5 mg -3/19 & 3/31 - Trospium Chloride 20 mg -3/21 - Behavior monitoring for medication side effects (related to Buspar, Hydroxyzine, Remeron, and Zoloft) -3/21 - Observation for side effects related to psychotropic…

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 pertinent document review and interviews, it was determined that the facility failed to provide treatment for a pressure injury. This was evident for 3 (Residents # 364, #369 and #108) out of 4 Resident reviewed for Pressure injury during a survey. The findings include: 1) On 4/29/25 at 12:50 PM a review of intake #MD00215184 revealed a concern regarding Resident #364's medical treatment during their stay at the facility. On 4/29/25, a review of medical records revealed that Resident #364 was transported to the hospital 2 days after admission to the facility. Review of the hospital Discharge summary dated [DATE] revealed that resident #364 had a pressure injury described as moisture related skin injury. The continued review of the medical record revealed that Resident #364 returned to the facility on 1/3/25 . On 4/29/25 at 1:15 PM a review of Resident #364's medical record revealed that s/he received visits by the wound care team on 1/16/25, 1/23/25 and 1/30/25. Review of the wound care team'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 Interview and record review, it was determined that the facility failed to have an effective process in place to ensure that recommendations from therapy are communicated to the nursing staff, failed to provide treatment to maintain a resident's range of motion (ROM), and failed to provide necessary adaptive equipment during meals. This was evident for 2 (Residents #50, #48) out of 4 reviewed for position and mobility and 1 (Resident #108) of 4 residents reviewed for pressure ulcers during a survey. The findings include: 1) On 4/21/25 at 4:33 PM Resident # 50, a long-term resident of the facility, was interviewed. During the interview s/he reported that s/he used to have a leg/ankle splint that s/he kept in their room, but now the splint is kept in the therapy room. Resident #50 stated s/he had worn the ankle when s/he walked. On 4/24/25 at 10:45 AM a review of a physical therapy discharge summary revealed that Resident #50 received Physical therapy in February 2025 through April 4th, 2025. Further…

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

Based on observation, interview, and record review, it was determined that the facility failed to provide proper urinary catheter care. This was evident for 1 (Resident #108) reviewed during the initial screening of the 32 residents of the Catoctin unit during the recertification survey. The findings include: A record review revealed an order dated 04/02/25 for Foley catheter 16 FR with 10cc balloon to bedside straight drainage for diagnosis of hx [history] of urine retention on Resident #108's Treatment Administration Record (TAR). A urinary catheter is a flexible tube inserted into the bladder to drain urine. When a catheter is in use, the drainage bag must be kept below the level of the bladder at all times to ensure urine flows by gravity, which helps prevent urine backflow into the bladder and reduces the risk of urinary tract infections (UTIs). This positioning is a standard infection control practice and is typically outlined in facility policy and The Centers for Disease Control (CDC) guidelines for catheter care. On 4/21/25 at 1:57 PM Resident #108 was observed in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, it was determined that the facility failed to have an order in place for oxygen administration and failed to follow an attending physician's order to administer oxygen to a resident. This was evident for 2 Resident (Resident #74, #315) of 3 residents reviewed for Respiratory Care during the survey. The findings include: On 4/21/25 at 1:57 PM, Resident #74, a long-term resident of the facility, was observed in his/her room with oxygen being administered through a nasal cannula at a rate of 2 liters per min (2L/min). On 4/21/25 a review of Resident #74's orders failed to reveal an order for oxygen. On 4/22/25 at 7:44 AM, surveyor alerted Licensed Practical Nurse (LPN #6) regarding concerns with oxygen order in the facility. On 4/22/25 at 3:12 PM, a review of the medication administration report (MAR) revealed that Resident #74 received oxygen on 3/1/25 through 3/26/25. The oxygen order was discontinued when Resident #74 was transferred to the hospital 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 employee files and staff interviews, it was determined that the facility failed to conduct annual nursing staff performance reviews ensuring competencies in their skills. This was evident for 5 out of 5 employee files (#3, #15, #26, #36 and #39) reviewed for skill competencies during the recertification survey. The findings include: On 4/22/25 at 7:38 AM, in an interview with the Director of Human Resource (Staff # 37), she communicated that staff must, as a condition of employment, complete annual online in-service training and maintain competencies. On 4/30/25 at 10:21 AM, in an interview with the Director of Nursing (DON), she could not provide documentation of staff competencies, and stated, The process for tracking staff training and competencies is broken. On 4/30/25 at 12:47 PM, Staff #37 acknowledged that the facility did not maintain employee records. On 4/30/25 at 1:09 PM, a review of employee files (#3, #15, #26, #36 and #39) revealed that all staff were missing documentation for annual skill competencies.

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews and ensure twelve (12) hours of annual in-service education was provided. This was evident for 2 (GNA #15 and GNA #36) of 2 personnel files reviewed during the recertification survey. The findings include: On 4/22/25 at 11:52 AM, a review of GNA #15's and GNA #36's personnel files lacked evidence of yearly evaluations and 12 hours of in-service education. On 4/30/25 at 10:21 AM, in an interview with the Director of Nursing (DON), she acknowledged that annual performance reviews are supposed to be completed by the DON or unit manager and stated they're supposed to be in the employee file. On 4/30/25 at 12:47 PM, the Director of Human Resources (Staff #37) confirmed that the on-line training takes 9.4 hours to complete, and that the facility was deficient in maintaining employee records. No other documentation was provided to show additional GNA training hours for the remaining 2.6 hours.

Based on record reviews and interviews, it was determined that the facility failed to ensure that a controlled substance logbook was signed by 2 licensed staff at change of shifts. This was evident for 1 of 4 controlled substance logbooks inspected during the survey. The findings include: Controlled substance logbooks are typically kept in medication carts and are used to determine that drug records are in order and that an account of all controlled drugs are maintained with sufficient detail. All controlled substances kept in the medication cart should match their record in the drug control book. On 4/22/25 at 11:55 AM, a review of the controlled substance logbook for April of 2025, on cart #2 in the Catoctin unit of the facility was conducted. The review revealed that the documentation had several columns to indicate information that include the date, time, nurse counting out, and nurse counting in. The review identified several concerns that include: a) Dates were not all in chronological order b) Dates with only 1 signature from a licensed staff c) Dates with no signature from…

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

Based on medical record review and interviews, it was determined that the facility failed to ensure that the attending physician reviewed irregularities identified by the pharmacist, acted upon them in a timely manner, and documented them in the Resident's medical record. This was evident for 1 (Resident #40) of 7 residents reviewed for unnecessary medications. The findings include: A medical record review on 4/23/25 at 1:12 PM showed a consultant pharmacist's note that indicated that Resident #40's monthly medication regimen review (MRR) was completed on 10/16/24 with irregularities identified. The note stated, see report comments/recommendation(s). However, the continued review failed to show the report filed in Resident #40's medical record and documentation that the Resident's attending provider reviewed and addressed the recommendation. In an interview on 4/24/25 at 7:57 AM, a Unit Manager Licensed Practical Nurse (LPN #2), reported that once the irregularity on the MRR was addressed, it was kept on the Resident's hard chart. However, staff stated she could not find the report…

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 non-pharmacological interventions were provided or attempted prior to administering a psychotropic medication. This was evident for 1 (Resident #371) of 7 residents reviewed for unnecessary medications. The findings include: Resident #371 was admitted to the facility in early 2024. A review of the complaint related to MD00202745 alleged that the resident was over sedated due to the combination of medications that were being administered to the resident. On 4/23/25 at 2:17 PM, a review of Resident #371's medical record was conducted. The review revealed that the resident was prescribed Ativan (Lorazepam) on an as needed basis from 1/10/24 to 1/24/24. The electronic Medication Administration Record (eMAR) indicated that the Ativan was administered on 1/11/24, 1/14/24, and 1/18/24. Lorazepam (Brand name- Ativan) is used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. Lorazepam is a benzodiazepine that works in 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 observations and record reviews, it was determined that the facility failed to ensure medications were stored and labeled properly as evidenced by failing to discard expired medications and failing to date medications when they were opened. This was evident in 1 of 2 medication storage rooms and 3 of 4 medication carts inspected during the survey. The findings include: An inspection of 2 medication storage rooms and 4 medication carts was conducted during the recertification survey. Concerns identified during the inspection were: 1) On 4/22/25 at 9:48 AM, a Licensed Practical Nurse (LPN #6) was interviewed about her process in restocking her medication cart. LPN #6 reported that most medications come from the pharmacy and the rest were kept in the medical records room. On 4/22/25 at 10:04 AM, the Director of Nursing (DON) confirmed that most medications are supplied by the pharmacy that are specific to the residents. The few medications that are supplied by the facility were stored in the medical records room. The DON accompanied the surveyor to the medical records room for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and pertinent document review, it was determined that the facility failed to have a process in place to ensure that Residents receive their meal in a timely manner and at a palatable temperature. This was evident for 1 of 1 food test tray reviewed during a survey. The findings include: On 4/21/2025 at 1:54 PM, Resident #74, a long-term resident of the facility, was interviewed. During the interview s/he reported that food is often late and does not have a palatable taste or temperature. On 4/24/25 at 7:20 AM, the Surveyor observed breakfast Catoctin cart 1 delivered to the unit by dietary Staff #33. On 4/24/25 at 7:21 AM, review of Document titled Glade Valley Center: Meal Deliver log revealed that the breakfast tray line starts at 7:00 AM and contains a nurse initial that the tray was received on the unit at 7:20 AM On 4/24/25 7:40 AM continued observation of Catoctin cart 1, failed to reveal that any trays were removed from the cart. Continous observation revealed the last…

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 staff interview, it was determined that the facility failed to ensure care documentation was accurate. This was evident for 1 (Resident #108) of 4 residents reviewed for pressure ulcer care. The findings include: A record review revealed a physician's order dated 4/15/25 stating, Apply foam adaptors at meal times. Nursing to apply with meals for optimum intake and independence. A review of the Medication Administration Record for April 2025 revealed that the nursing staff had been documenting that Resident #108 used adaptive device for each shift from 4/16/25 through 4/24/25. On 4/24/25 at 6:16 PM, Resident #108 was observed as he/she ate dinner in bed without the use of any adaptive utensils. The resident, the resident's spouse, and the therapy director (Staff #23) were present. Staff #23, the spouse, and the resident all confirmed that the adaptive device had not been available for the past week. Staff #23 also said that the device was supposed to be stored at the resident's bedside. On 04/25/25 at 1:01 PM during an interview with unit…

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

Based on observation, interview and record review, it was determined that the facility failed to ensure infection prevention and control practices were followed when 1) an unlabeled, uncovered bedpan was left on the handrail in a resident's bathroom, and 2) hand hygiene was not performed during a dressing change of a pressure ulcer. This was evident for 1) 1 (Resident #109) of 6 residents in the initial screening pool, and 2) 1 (Resident #108) of 4 residents reviewed for pressure ulcer care. The findings include: 1) On 4/21/25 at 11:44 AM, an observation was conducted of Resident #109's bathroom. An unlabeled and uncovered bedpan was against the wall on top of a hand rail, and an unlabeled and uncovered bath basin was upside down with bath linens on the floor. On 4/21/25 at 2:55 PM, during an interview with Geriatric Nursing Assistant (GNA #1) she said that she did not know to whom the bedpan and bath basin belonged since they were not labeled. The GNA acknowledged that the bedpan and bath basin should not have been there and that the usual process was to clean them and then place…

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

Based on interview and observation it was determined that the facility failed to maintain a Residents shower rooms in good repair. This was evident for 1 out of 2 resident shower rooms observed during a survey. The findings include: On 4/29/25 at 3:15 PM, Resident #69, a long-term resident of the facility, was interviewed. During the interview s/he reported that he/she had received a skin tear in the shower room when his/her arm rubbed against a jagged edge on a shelf in the shower room. On 4/29/25 at 3:17 PM, an observation of the Sugar Loaf shower room revealed a shelf at the back of the room. The shelf had a lament cover. Approximately 1 foot of the laminated edge was peeling off. Further observation revealed clear tape was placed over the edges of the lament, creating a smooth edge. On 4/29/25 at 3:31 PM, the Sugar Loaf nurse unit manager (Staff #5) was interviewed. Staff #5 confirmed that on 4/10/25, Resident #69 received a skin tear, when his/her arm rubbed against a sharp edge on the shelf in the resident shower room. Staff #5 reported that she logged the concern 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 reviews of employee files and staff interviews, it was determined that the facility failed to develop a system that provides and tracks the required training for dementia management, abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 5 of 5 random employee files (Staff #3, #15, #26, #36 and #39) and 1 employee reviewed for an allegation of abuse during the survey. The findings include: 1) On 4/22/25 at 7:38 AM, in an interview with the Director of Human Resource (HR) (Staff #37), she communicated that staff must, as a condition of employment, complete the required annual in-service training. On 4/30/25 at 8:33 AM, in an interview with the Director of Nursing (DON), she explained that annual training is through Carefeed. All employees receive an email and/or text to complete the required training. Human Resources tracks staff participation. If an employee doesn't stay current, they are removed from the schedule- that's my practice, I can't speak for other departments. On 4/30/25 at 08:46 AM, in a subsequent interview 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 a record review of a facility reported incident, employees' file and staff interviews, it was determined that the facility failed to ensure Geriatric Nurse Assistants (GNA's) received training that included dementia management, abuse, neglect, exploitation, and misappropriation of resident property. This was evident for 4 of 4 GNA's employee files (#15, #21, #29 and #36) reviewed during the recertification survey. The findings include: On 4/22/25 at 7:38 AM, in an interview with the Director of Human Resource (HR) (Staff #37), she communicated that staff must, as a condition of employment, complete the required annual in-service training. On 4/22/25 at 11:52 AM, a review of employee records for facility GNA's #15 and #36 and agency GNA's #29 and #36's revealed the lack of required training. On 4/30/25 at 08:46 AM, in an interview with Staff #37, she explained that HR is responsible for tracking facility staff's compliance through Carefeed and that nursing leadership tracks agency compliance. On 4/30/25 at 10:07 AM, in an interview with the DON, she acknowledged that agency…

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

Based on record review and interview, it was determined that the facility failed to ensure that their residents were free of misappropriation of property as evidenced by a staff member taking a resident's personal property from the facility without their permission. This was evidenced by 1 (#13) of 12 residents reviewed for abuse. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. On 11/14/23 at 8:30 PM, a review of the facility's investigation file revealed a statement from the Maintenance Director (MD) #7 which documented that he was approached by Resident #13 on 2/7/23, who reported to him that their wedding rings were missing. According to his statement, Unit Manager (UM) #2 was aware and bringing forms for the resident to complete regarding the missing property. Furthermore, he noted that, on 2/8/23, the resident told him that Maintenance…

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 employ a qualified Activity Director. This was evident for 1 of 1 Activity Director. The findings include: On 11/14/23 at 11:30 AM, an interview with the Activity Director revealed that he did not meet the qualifications for the position. He reported that he was currently enrolled in an approved training program. On 11/14/23 at 12:24 PM, an interview with the Nursing Home Administrator (NHA) revealed that the Activity Director had been hired a year ago and confirmed he was currently enrolled in an approved training program. Furthermore, she reported that they had an activity consultant to oversee his work while he was completing the training. A review of the Activity Director's employee file on 11/15/23 at 2:30 PM, revealed he had been hired in 9/22. There was a copy of a certificate that he had completed Module 1 of the approved training program on 8/4/23, 11 months after the hire date. On 11/15/23 at 2:40 PM, a review of the activity consultant notes, dated 3/20/23, revealed that the facility 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 interview, it was determined that the facility failed to provide a resident quality care based on standards of professional practice for a pressure ulcer/injury. This was evident for 1 (#14) of 3 resident reviewed for pressure ulcer/injury. The findings include: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the…

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

Based on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that nurse aides were receiving performance evaluations annually and that in-services training was provided to the nurse aide based on the outcome of the performance evaluation. This was evident for 2 of 2 staff reviewed for annual performance evaluations. The findings include: On 10/7/21 at 8:34 AM, a review of Geriatric Nursing Assistant (GNA) #62's employee file revealed that GNA #62 had been employed for 4 years and there was no evidence found of performance evaluations. On 10/7/21 at 8:44 AM, a review of GNA #63's employee file revealed that GNA #63 had been employed for 16 years and no evidence was found that performance evaluations were completed. An interview with the Infection Control Preventionist/Nurse Practice Educator (ICP/NPE) #1 on 10/7/21 at 12:03 PM, revealed that he/she had been working on a schedule for competencies and was determining which competencies to include in the training based on problems the facility staff had identified. However,…

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 provide training to staff related to mental and psychosocial disorders that affected residents with trauma and a history of post-traumatic stress disorders as evidenced by those residents being identified in Facility Assessment Tool, however, there was no documentation that such training was provided to staff. This was evident for 4 (#60, #61, #62, and #63) of 4 facility staff reviewed. The findings included: On 10/7/21 at 8:34 AM, a review of the employee file for Geriatric Nursing Assistant (GNA) #60 failed to reveal that GNA #60 had received training about how to care for residents with mental and psychosocial disorders that included residents with trauma and post-traumatic stress disorder. On 10/7/21 at 8:34 AM, a review of employee file for GNA #61 failed to reveal that GNA #61 had the required training for how to care for residents with mental and psychosocial disorders that had included residents with trauma and post-traumatic stress disorder. On 10/7/21 at 8:34 AM, review of employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interview, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect multiple residents. The findings include: On 10/8/2021 at 12:51 PM, interview with Residents #14 and #74 revealed concerns about the cleanliness of room [ROOM NUMBER]'s bathroom. Observation of the bathroom at this time revealed dirt and debris stuck in the doorway of the bathroom where the tile and solid floor meet. On 10/8/2021 at 12:53 PM, the Sugarloaf Unit's shower room was observed with rings in the toilet. The shower stall furthest from the door was filled with multiple Hoyer lift swings, commode chairs, a linen cart and cardboard boxes rendering it unusable. The overhead lights in the remaining two stalls were not working. Both showers had black residue in the grout between tiles. A whirlpool tub was observed with a loose seal which was collecting dust and debris. Inspection of a bariatric…

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 clinical record and policy reviews, and staff interview, it was determined that the facility failed to implement a thorough investigation according to the abuse policy for 9 (#200, #204, #209, #210, #11, #69, #83, #35, #88) of 32 residents reviewed for abuse during an annual survey. The findings include: Review of the facility's updated 7/2019 Abuse Investigation and Reporting Policy documented, Role of the Investigator: The individual conducting the investigation will, as a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; interview the person(s) reporting the incident; Interview the witnesses to the incident; Interview the resident (as medically appropriate); interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged…

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 reviews, and staff interview, it was determined that the facility failed to 1) ensure all allegations of abuse were timely reported to the appropriate state regulatory authority within the required time period and 2)ensure the procedures included in the document that was being utilized as their policy were implemented as evidenced by the failure to report allegations of abuse in a timely manner. This was evident for 11 (#95, #98, #99, #195, #197, #200, #202, #216, #35, #88, #69) of 32 residents reviewed for abuse during the annual survey. The findings include: Review of the facility's updated 7/2019 Abuse Investigation and Reporting Policy documented, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in bodily injury; or Twenty-Four (24) hours if…

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 reviews, and staff interview, it was determined that the facility failed to timely report allegations of abuse and the results of the investigations within the regulatory timeframes. This was evident for 10 (#95, #98, #99, #195, #197, #200, #202, #216, #35, #88) of 32 residents reviewed for abuse during the annual survey. The findings include: Review of the facility's updated 7/2019 Abuse Investigation and Reporting Policy documented, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in bodily injury; or Twenty-Four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The Administrator or his/her designee, will provide the appropriate agencies or individuals listed above with a written report 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 clinical record and policy reviews, and staff interview, it was determined that the facility failed to thoroughly investigation allegations of abuse for 11 (#200, #204, #209, #210, #11, #69, #83, #35, #88, #69, #83)) of 32 residents reviewed for abuse during an annual survey. The findings include: Review of the facility's updated 7/2019 Abuse Investigation and Reporting Policy documented, Role of the Investigator: The individual conducting the investigation will, as a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; interview the person(s) reporting the incident; Interview the witnesses to the incident; Interview the resident (as medically appropriate); interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;…

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 staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1(#196) of 14 residents reviewed for falls, 2 (195, #206) of 32 residents reviewed for abuse and 1 (#95) of 3 residents reviewed for hospitalization during the annual 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 that 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) Review of Resident #196's medical record on 10/6/21 at 9:17 AM revealed that the resident had a fall with no injuries on 6/30/20. Review of Resident #196's quarterly MDS, with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care that were resident specific with measurable objectives and goals. This was evident for 4 (#196, #36, #62, #40) of 92 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of Resident #196's medical record on 10/6/21 at 9:17 AM revealed the resident was admitted to the facility on [DATE] with a history of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and hypoxemia (a low level of oxygen in the blood). Further review of Resident #196's medical record revealed a physician's order, written on 6/26/20, which stated, Oxygen at 2 L/min via Nasal Cannula continuously, every shift for Shortness of Breath related to ACUTE RESPIRATORY…

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 staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal up to date interventions for residents who requested for certain staff not to care for them. This was evident for 6 (#95, #96, #210, #97, #24, #84) of 92 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Review of facility reported incident MD00139227 on 10/13/21 at 9:30 AM revealed Resident #95 and Resident #96 did not feel comfortable when a particular GNA (geriatric nursing assistant) rendered care during ADL (activities of daily living). Resident #95 and Resident #96 were interviewed twice by facility administration and the second time expressed that they felt uncomfortable with a male GNA and wished to not have a male nursing assistant. A handwritten note from the Social Worker…

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 other pertinent documentation, and interview, it was determined that the facility failed to ensure that nursing staff did not erroneously document the administration of medications that were not available for administration. This was found to be evident for 1 (Resident #295) out of the 4 residents whose medical records were reviewed as part of the medication administration task. The findings include: On 10/6/21 at 11:44 AM, a review of Resident #295's medical record revealed the resident was admitted to the facility in September 2021 with diagnoses that included, but were not limited to, Parkinson's disease, kidney disease, and dementia. The resident had current orders for the following: -Fludrocortisone Acetate Tablet 0.1 mg give 1 tablet one time a day for sodium retention, originally ordered 9/18/21 -Rivastigmine Patch 24 hour apply 13.3 mg transdermally one time a day for the treatment of dementia, originally ordered 9/18/21. On 10/7/21, Review of the Proof of Delivery Shipment Detail report revealed 7 Rivastigmine patches had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review , it was determined the facility failed to ensure the physician addressed the resident's need for and use of oxygen in his assessment, failed to include orders for the use and monitoring of oxygen therapy, and failed to develop a care plan that included goals and interventions for respiratory care for a resident with a known history of respiratory issues. This was evident for 2 (#296, #84) of 4 residents reviewed for respiratory care during the annual survey. The findings include: 1) Medical record review on 10/06/21 at 08:25 AM revealed resident # 296 was admitted to the facility on [DATE] with the diagnoses that included, but were not limited to, Pneumonia due to Methicillin-Resistant Staphylococcus Aureus (MRSA), Acute and Chronic Respiratory Failure with Hypoxia and Asthma with Acute Worsening. Hypoxia refers to a lack or low amount of oxygen in the tissues and cells of the body to maintain its normal function. A medical record…

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 review of documentation, it was determined that the facility failed to 1) ensure that expired medications and supplies were removed from medication storage areas and to ensure regular monitoring of the medication refrigerator temperature, 2) to keep medication carts locked and secured when unattended to prevent access from residents and unauthorized individuals and 3) to document administration of a controlled substance after signing out the medication on the controlled substance log . This was evident for 1 of 3 nursing units observed during an annual survey. This was found to be evident for two out of the two medication storage rooms, 1 of 3 nursing units and 1 (#62) of 5 residents reviewed for pain, respectively. The findings include: 1) On 10/7/21 at approximately 2:10 PM, surveyor observed the medication storage unit on the Catotin unit with the unit nurse manager (Staff #28). Several supply items were observed in this room and the unit nurse manager confirmed the supplies in this area would be used if needed. Surveyor identified a central…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, it was determined that facility staff failed to 1) implement infection control policies as evidenced by facility staff failing to date and initial oxygen tubing to ensure it was changed as needed and failed to change the normal saline by the expiration date written on the container and 2) failing to wear appropriate Personal Protective Equipment (PPE) prior to entering an identified isolation room [ROOM NUMBER] of a resident on contact precautions. This was evident for 2 of 92 residents (#84, #296) and one Geriatric Nursing Assistant (GNA#5) observed during the survey. The findings include: Oxygen therapy is the administration of oxygen at concentrations more significant than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of inadequate levels of oxygen. The nasal cannula is a device used to deliver supplemental oxygen or increased airflow to residents in need of respiratory help. This device consists…

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 that residents had a means of directly contacting staff. This was evident for 2 showers in the Sugarloaf Units shower room. The findings include: On 10/8/2021 at 12:53 PM, environmental observations of the Sugarloaf Unit shower room revealed that the emergency pull chords in the open shower stalls were wrapped around the assist bars, thus, preventing the call light system from being activated. The Director of Nursing was made aware of these findings on 1/8/2021 at 2:00 PM.

Based on observations and interviews, it was determined that the facility failed to ensure that residents received their meals in a timely manner. This was found to be evident for 2 (resident # 349 & #367) out of 6 resident observed during the survey. The findings include: During a tour conducted on 10/04/2021 at approximately 7:45 am on the Catoctin Nursing Unit, the Surveyor observed staff deliver breakfast trays to the residents. During an interview conducted on 10/04/2021 at 8:20 am, on the Catoctin Nursing Unit, Resident #349 stated s/he had not received a breakfast tray. During an interview conducted on 10/04/2021 8:32 am, the Surveyor asked the Geriatric Nursing Assistant (GNA) #4 if Resident #349 had a breakfast tray, the GNA responded yes. The Surveyor observed the GNA retrieve Resident #349's breakfast tray from the food cart and deliver the tray to the resident's room. On 10/04/2021 at 8:35 am, the Surveyor advised the Nursing Supervisor #8 of the delayed breakfast tray delivered to Resident #349. On 10/04/2021 at 9:10 am, the Surveyor advised the Administrator 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 review of medical records, facility documentation and interviews, it was determined that the facility failed to ensure residents were free from misappropriation of property as evidenced by the removal of narcotic medication from residents' supply without administering the medication to the resident. This was found to be evident for two (Resident #145 and #146) out of the 32 residents reviewed for abuse during the survey. The findings include: Review of a facility reported incident (MD00167082) revealed that, on 5/8/21, oxycodone for residents #145 and #146 had been removed from the supply by nurse #59 but had not been administered to the residents. The police were notified and the nurse was reported to the state board of nursing. 1) On 10/5/21, a review of Resident #145's medical record revealed that the resident was admitted to the facility in May of 2021 with diagnoses including, but not limited to: joint replacement and pain. Review of the orders revealed an order with a start date of 5/4/21 for oxycodone 10 mg, to be given every 4 hours as needed, for pain on a scale 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 medical record review and staff interview, it was determined that the facility failed to have an effective system in place to ensure that baseline care plans addressed all of the residents needs as evidenced by failure 1) to address pain management for a resident with pain related to a recent procedure; and 2) failed to address a residents respiratory interventions and goals for a resident with chronic lung disease. This was evident for 2(resident # 296 and # 298) of 2 residents reviewed for base line care plans during the annual survey. The findings include: A baseline care plan is a guide that addresses the unique needs of each resident. It must be completed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. 1) Review of medical records for Resident # 298 on 10/04/21 at 8:21 AM 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 medical record review and interviews, it was determined that the facility failed to provide evidence of the implementation of an ongoing program of activities that met the needs of Residents # 16, and #45 that was based on their abilities, interests and treatment . This was evident for 2 of 6 residents reviewed for activity needs during this annual 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 per CMS guidelines. 1. On 10/04/21 at 11:40 AM, during an interview, Resident #16 stated that Activities sStaff had not visited the resident to provide activity materials and had not invited the resident to participate in group activities. A review of Resident #16's medical record on 10/14/21 at 11:30 AM showed a care plan that addressed activities. The last care plan, revision date 2/15/2021, revealed a goal for Resident #16 to have opportunities to make decisions and choices related to/or self-directed involvement in meaningful activities. 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, record reviews and interviews, it was determined the facility failed to ensure the safety of the resident by not implementing fall precautions. This was found to be evident for 1 (resident # 92) out 3 residents reviewed for falls. The findings include: During a tour conducted on the Catoctin Nursing Unit on 10/04/21 at 7:55 am, Resident #92 was observed in a Geri chair in the day room across from the nurse's station. During the observation, LPN #3 stated the resident recently fell and was hospitalized due to a fractured hip. During an interview on 10/04/2021 at 7:57 am, Resident #92 stated s/he tried to get out of the chair and fell and broke her hip. On 10/05/2021 at 09:25 AM, record review of Resident #92's progress note, dated 09/28/2021, revealed a change of condition Brief Synopsis of Change: resident climbed out of Geri Chair while in the day room area and fell to floor on her left side, with her left arm underneath her and slightly behind her. Resident wearing grip socks at the time. Summary of Change in Condition: resident not transferred.…

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 with facility staff, it was determined that a facility physician failed to include treatment orders and documentation about the continued appropriateness of the resident's current treatment regimen. This was evident for 1 (Resident # 296) of 4 residents reviewed for respiratory care during the annual survey. The findings include: Medical record review on 10/06/21 at 08:25 AM revealed resident # 296 was admitted to the facility on [DATE] with the diagnoses that included, but were not limited to, Pneumonia due to Methicillin-Resistant Staphylococcus Aureus (MRSA), Acute and Chronic Respiratory Failure with Hypoxia and Asthma with Acute Worsening. Hypoxia refers to a lack or low amount of oxygen in the tissues and cells of the body to maintain its normal function. During an observation on 10/06/21 at 08:55 AM, the surveyor noted resident # 296 was receiving oxygen through a nasal cannula, while lying in bed in his/her room. Oxygen therapy is the administration of oxygen…

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 review of records and policies, it was determined that the facility failed to 1) ensure that counts of controlled substances were completed by two nurses at the change of shifts 2) that the narcotic counts were accurate for all controlled medications, 3) ensure that narcotics removed from the supply were administered to the residents as evidenced by failure to document the need for, request of, or administration to the resident, and 4) have an effective system in place to ensure regularly scheduled medications were re-ordered in a timely manner to ensure residents did not miss doses. This was found to be evident on two of the the three units in the facility and 2 out of 2 residents (Resident #350 and #367) selected for further review of narcotic control sheets during the medication storage review, and 1 out of the 4 residents (Resident #295) observed during medication pass administration. The findings include 1) Review of the facility's Controlled Substances Policy, which was provided by the Director of Nursing (DON) on 10/7/21, revealed that 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 record review and interview, it was determined that the facility staff failed to ensure that residents were not prescribed unnecessary medication as evidenced by a physician's order for pain medication for Resident #62 that had not been administered for 4 months. This was evident for 1 (#62) of 5 Residents reviewed for pain management. The findings include: A medical record review for Resident #62 on 10/7/21 at 8:23 AM, revealed a progress note, dated 6/20/21, from the attending physician that resident had been admitted following a surgical procedure and required pain management. A review of the Medication Administration (MAR) for 5/21, revealed that on 5/21/21, an order for Oxycodone 5 mg give 1 tablet by mouth every 6 hours as needed for pain (7-10). Further review of MARs for 6/21, 7/21, 8/21, 9/21, and 10/21 revealed that the last time staff had administered this medication to Resident #62 had been 6/9/21. Also, monthly pharmacy reviews had been conducted and had not addressed this unnecessary medication. An interview with the Director of Nursing (DON) on revealed that…

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

Based on medical record review and staff interview, it was determined that facility staff failed to ensure that a resident's medication regimen was free of unnecessary psychotropic medications as evidenced by the failure to monitor behaviors that attributed to the need for the psychotropic medication. This was evident for 1 (#40) of 12 resident reviewed for unnecessary medications. The findings include: A medical record review for Resident #40 on 10/13/21 at 9:09 AM, revealed a History and Physical conducted by Resident #40's attending physician on 7/21/21 which had documented that Resident #40 had anxiety and Bipolar disorder. Also documented were the following medications to treat the psychiatric disorders: Aripiprazole (antipsychotic) for depression, Duloxetine (antidepressant) for depression, Lamotrigine (anti-seizure) for Bipolar disorder, and Seroquel (antipsychotic) for depression. Review of the psychiatric consult notes revealed that on 7/28/21, the nurse practitioner documented that Resident #40 experienced behavioral disturbances. Further review of the medical record…

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 medical record review, it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by the identification of 3 errors out of 31 opportunities for error observed during a medication pass observation. The errors were identified related to one (Resident #295) out of the four residents whose medication administrations were observed during the survey. The findings include: On 10/6/21 starting at 10:03 AM, surveyor observed nurse #16 prepare and administer Resident #295's morning medications. The nurse confirmed that three ordered medications were not available: Fludrocortisone, rivastigmine patch and Prosource. Nurse #16 also reported that she works at this facility about once per month and does not normally have problems with medications. On 10/6/21 at 11:44 AM, review of Resident #295's medical record revealed that the resident was admitted to the facility in September 2021 with diagnoses that included, but were not limited to Parkinson's disease, kidney disease, and dementia. The resident had current orders for 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 that the facility staff failed to maintain medical records in the most complete and accurate form. This was evident for 2 (#97, #84) of 92 residents selected for review during the annual 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. 1) On 10/13/2021 at 10:39 AM a review of Resident #97's medical record revealed a nurses note from 9/7/2021 stating that the resident had decided that morning they would be leaving the facility Against Medical Advice (AMA). The note goes on to specify that Resident #97 and the writer signed a document stating the resident was leaving AMA. This document could not be found in the electronic or paper record. Interview with the Director of Nursing and Administrator on 10/15/2021 at 8:05 AM confirmed 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 record review and staff interview, it had been determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) had the required 12 hours of in-service training based on needs identified through performance evaluation and the required training subjects. This was evident for 2 (#62, and #63) of 2 staff reviewed for training requirements. The findings include: On 10/7/21 at 8:34 AM, a review of Geriatric Nursing Assistant (GNA) #62's employee file revealed that GNA #62 had been employed for 4 years, however, there was no evidence that the required 12 hours of in-service training had been completed. On 10/7/21 at 8:44 AM, a review of GNA #63's employee file revealed that GNA #63 had been employed for 16 years, however, there was no evidence that the required 12 hours of in-service training had been completed. An interview with the Infection Control Preventionist/Nurse Practice Educator (ICP/NPE) #1 on 10/7/21 at 12:03 PM, revealed that he/she had been working on a schedule to inservice staff, however, it had not been fully instituted at the time 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.