Complete Care At Wheaton

Based on staff interviews and medical record review, it was determined that the facility failed to provide written notification for Residents that were transferred to the hospital. This was found to be evident for 3 Residents ( #4, #18, #48) out of 3 Residents reviewed for hospitalization. The findings include: During medical record review for Resident #48 on 04/04/25 at 11:15 AM. It was revealed that the resident was transferred to the hospital on 4/2/24, 8/27/24 and 8/28/24, the facility did not provide written notification to the resident or the resident ' s representative regarding the reason for the transfer to the hospital. During continued records review on 04/04/25 at 12:57 PM Resident ' s #4 record review revealed resident was transferred to the hospital on 5/18/24, 6/18/24 and 2/16/25 with no evidence that the facility provided written notification and reason for transfer to resident or resident's representative during transfer to the hospital. During an interview with the Regional Clinical Nurse Manager (RCNM) on 04/04/25 at 1:00 PM regarding written notification to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility staff and Resident interviews and surveyor record review, it was determined that the facility failed to provide written notification of the bed hold policy for a Resident that was transferred to the hospital. This finding was found to be evident for 1 Resident (#95) out of 1 Resident reviewed for hospitalization. The findings include: A Bed Hold is the act of holding or reserving a Resident's bed while the Resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility Residents regardless of payment source. The Bed Hold policy should be disclosed in the admission packet during an initial admission to the facility and it should be disclosed to Resident/Resident Representative at the time of transfer. On 04/01/2025 at 07:40 AM during the tour of the nursing unit, the surveyor interviewed Resident #95. Resident #95 stated that he/she had a recent hospitalization due to stomach collapse. The surveyor reviewed Resident #95's medical record 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 record review and interview, it was determined that the facility failed to conduct an accurate Preadmission Screening and Resident Review (PASRR). This was found evident for 1 (Resident #27) out of 1 resident reviewed for PASRR screening. The findings include: According to the Centers for Medicare and Medicaid (CMS), the Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. Furthermore, Congress developed the PASRR program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities. Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened, thoroughly evaluated, found to be appropriate for NF placement, and will receive all specialized services necessary to meet the individual's unique MI/MR needs. If a resident tests positive for a Level I, they…

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 interviews, it was determined that the facility failed to revise a care plan. This was evident for 3 (#4, #48, and #445) out of 3 residents reviewed for care plans. The findings include: A review of a Nurse ' s note for Resident #4 was conducted on 04/02/25 at 12:43 PM. The note dated 03/04/2025 at 16:07 stated Writer went to assess the patient after receiving a verbal call from a caregiver that the patient was on the floor. Observed patient sitting near the bed and wheelchair with no visible injury. The patient denied pain upon assessment. No swelling or skin discoloration noted. The patient had a light scratch on [resident ' s gender] left side, not related to the fall but sustained while using the bathroom. The patient self-transferred from the floor to the bed. A care plan is a comprehensive, individualized plan of care developed for each resident. It outlines the residents ' medical, psychological, emotional, and social needs, as well as the goals, interventions, and…

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

Based on record review and facility staff interview, the facility failed to 1) assess a Resident with an actual fall and 2) document a witnessed fall. This was evident for 1 (resident #445) of 1 resident reviewed for quality of care. The findings include: A fall is defined as an unintended descent to the floor or other lower surface, with or without injury to the resident or patient. This includes slips, trips, or loss of balance, whether witnessed or not, and whether or not the individual is able to get up without assistance. A fall assessment is a systematic process used by healthcare professionals to identify a patient's risk of falling and to determine contributing factors. It typically involves evaluating medical history, medications, cognitive status, mobility, gait, balance, and environmental risks. The goal is to guide the development of individualized interventions to prevent falls and improve patient safety. A nursing care plan is a structured, written document that outlines the nursing care to be provided to a patient, tailored to their specific healthcare needs 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 surveyor observation, facility staff interviews and surveyor record review it was determined that the facility failed to follow appropriate respiratory care and services. This finding was found to be evident in 1 (Resident #93) out of 1 Resident reviewed for respiratory care and services. The findings include: On tour of the East Wing Nursing Unit on 03/31/2025 at 11:49 AM the surveyor observed Resident #93 with oxygen in use. There was an oxygen humidifier bottle and oxygen tubing attached to the oxygen concentrator and an oxygen cannula in Resident #93's nostrils. The surveyor did not observe an oxygen usage sign on the Resident door or on the doorframe of Resident #93's room. The surveyor conducted a record review of Resident #93's medical record on 04/02/2025 at 10:30 AM. The record review revealed that Resident #93 had physician orders for oxygen and to change the oxygen humidifier bottle tubing every Thursday on the night shift. Further review of the medical record revealed that Resident #93 had a care plan for oxygen therapy related to respiratory illness. In…

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

Based on review of employee records and staff interview, it was determined that the facility failed to complete annual performance reviews for Geriatric Nursing Assistants (GNAs). This was evident for 2 (#10, #17) out of 5 GNA staff members reviewed during the annual survey. The findings include: Performance evaluations are to be completed once every 12 months to identify in-service education needed to address competencies of the geriatric nursing assistants. On 04/08/25 at 1:44 PM, a review of GNA #10 and GNA #17's employee records revealed that no performance reviews for 2023 and 2024 were included. On 04/09/25 at 11:59 AM, an interview conducted with the Nursing Home Administrator (NHA) confirmed that annual GNA performance evaluations for 2023 and 2024 had not been done for GNA #10 and GNA #17. At the time of exit conference, the facility did not provide any additional evidence to show that performance evaluations for 2023 and 2024 were completed for GNA #10 and GNA #17.

Based on observation of medication administration, medical record reviews, and staff interviews, it was determined that the facility licensed staff failed to maintain a medication error rate of less than 5 percent for 2 out of 2 residents ( #94 and #81). This finding was evident for 3 out of 26 opportunities observed for errors which resulted in a medication error rate of 11.54%. The findings Include: 1) On 04/02/25 at 8:20 AM, during a medication administration observation for Resident #94, the surveyors observed Licensed Practical Nurse (LPN) #1 administer scheduled medications to the resident. The medications included 1 tablet Amlodipine 10 mg (milligram). LPN #1 stated, I am holding the Amlodipine due to the resident ' s heart rate of 59 and I will contact the physician. 2) During medication administration on 04/02/25 at 8:52 AM for Resident #81, the surveyors observed Licensed Practical Nurse (LPN) #1 administer scheduled medications to the resident. The surveyors observed LPN #1 administer 1 drop of Brimonidine Tartrate Ophthalmic Solution 0.2% to the resident ' s right eye.…

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, staff interviews and record review, it was determined that the facility failed to properly store medications. This was found to be evident in 2 of 2 medication storage rooms and 3 of 3 medication carts observed during the recertification survey. The findings include: During a medication cart observation conducted on 04/07/25 at 9:17 AM of the [NAME] Wing (Cart #2) with Licensed Practical Nurse (LPN) #14, the following were observed, two Tylenol tablets and 1 Vitamin tablet were found stored in a medication cup inside the cart. LPN #14 stated that the resident initially requested the medications but later refused them and asked for Oxycodone instead. Further observations of the medication cart revealed an open, used and undated Basaglar 100-unit insulin pen, twelve 12 loose pills, 10 individually packaged Spiriva Handi Haler 18 mcg (microgram) capsules that were not labeled with a resident ' s name, and 1 individually packaged Ondansetron 4 mg (milligram) tablet also not labeled with a resident ' s name. On 04/07/25 at 9:25AM, the surveyor interviewed LPN#14…

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 medical record review, it was determined that the facility failed to ensure that residents who required dental services on a routine basis, received the necessary services in a timely manner. This was evident for 1(Resident#59) of 1 resident reviewed for dental services. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses including Dementia, and Cognitive Communication Deficit. On 03/31/25 at 09:36 AM Resident#59 informed the surveyor that he/she experienced pain when chewing food. On 04/03/25 at 10:36AM a review of Resident# 59's clinical record revealed that the resident had not seen a dentist since admission to the facility on [DATE]. On 04/07/25 at 08:20 AM the surveyor observed Resident #59 for 25 minutes eating breakfast. The resident took small bites and at the end of the 25 minutes had consumed one slice of toast, one half bowl of Oatmeal and one serving of Cheerios. Resident #59 stated that he/she experienced pain in the right jaw while…

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

Based on surveyor observation, facility staff interview and facility record review, it was determined that the facility failed to maintain proper sanitation for storage of food on the nursing units and in the kitchen. This was found to be evident on 1 out of 3 nursing units and on the initial tour of the kitchen during review of food storage and sanitation. The findings include: During the initial tour of the kitchen on 03/31/2025 at 08:15 AM with the Food Services Director (FSD) in attendance, the surveyor observed the following sanitation concerns: personal coffee mug on meal tray cart; employee personal items (coat, back pack and keys) in the chemical storage room; opened container of stir fry sauce, opened container of distilled vinegar and opened container of salt not dated on bottom shelf of the food prep table; no thermometer on the inside of the walk in-freezer and walk-in refrigerator (only a thermometer on the outside of walk-in freezer and refrigerator). In an interview during the initial tour of the kitchen on 03/31/2025, the Food Services Director (FSD) acknowledged the…

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

Based on surveyor observation and facility staff interview it was determined that the facility failed to dispose garbage and refuse properly. This finding was found to be evident during the tour of the outside dumpster area. The findings include: On 03/31/2025 at 08:55 AM the surveyor toured the outside dumpster area with the Food Services Director (FSD) in attendance. This tour revealed the observation of the dumpsters not covered with the attached lids. Additionally, next to the dumpsters were an old mattress, dresser and a soda can. In an interview on 03/31/2025 following the tour with the Food Services Director (FSD) the surveyor asked what the expectation was for the dumpsters being covered with lids. The FSD stated that the dumpsters should be covered with lids. The FSD acknowledged the surveyor and covered the dumpsters with the respective lids that were attached to the dumpsters. The surveyor reviewed the findings with the Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Nurse Consultant on 04/09/2025 at 03:20 PM. No additional information was provided 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that the medical records for a resident who was required to wear a cervical collar, were maintained in the most accurate form. This was evident for 1(Resident #35) of 1 resident reviewed for cervical collar application. The findings include: A Treatment Administration Record (TAR) is an essential document in health care settings that provides detailed information about the treatments prescribed to a resident, including dosage, administration times and special instructions. It serves as a crucial tool for nurses to ensure safe and accurate treatment administration. On 04/02/25 at 7:30AM a review of Resident #35's clinical record revealed that the resident sustained a fall on 02/14/25 which resulted in a head injury. The resident was transferred to the emergency room and returned to the facility on [DATE] with a physician's order for Aspen cervical collar to remain in place at all times. May remove to check skin…

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

Based on record review and interview, it was determined that the facility failed to have the minimum required members in attendance at the Quality Assessment and Assurance (QAA) committee. This was found evident during the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) review, which has the potential to affect all residents. The findings include: According to the Centers for Medicare and Medicaid, Quality Assessment and Assurance (QAA) specifies the QAA committee composition and frequency of meetings in nursing facilities and requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies. On 04/10/25 at approximately 10:50 AM, the facility's QAA attendance sheets were reviewed. It was found that there were inconsistencies with attendance sheet sign-ins. For the QAPI meetings of 02/25/25 and 03/25/2025, all signatures for the federal-required employees are present except for the Infection Preventionist (IP). Attendance sheets for the dates of 10/29/2024, 02/25/2025, 01/28/2025,…

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 observation, interview and record review, it was determined that the facility failed to follow Enhanced Barrier Precautions (EBP). This was evident for 1 (Resident #53) out of 1 Resident reviewed for infection control. The findings include: According to the Centers for Medicare and Medicaid Services (CMS), Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Furthermore, EBP are indicated for residents with any of the following: Infection or colonization with a CDC (Centers for Disease Control and Prevention)-targeted MDRO (multi-drug resistant organism) when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. An indwelling urinary catheter is a thin, hollow tube that is inserted into the urethra to reach the bladder in order to drain urine into a bag. On 03/31/25 at 10:30 AM, an observation…

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, it was determined that the facility failed to keep a sanitary environment. This was evident during the tour of the laundry room conducted as part of the facility's annual recertification survey. The findings include: On 04/01/25 at 11:31 AM the surveyor did a tour of the laundry room with the Environmental Services Supervisor (ESS) and Staff# 16. The surveyor observed the floor tiles in the room with the washing machines were visibly dirty. There were brown spills on the floor covering an area of approximately 1.5 ft x1.5ft in front of a platform where the chemicals for the washing machines were located. A brown dirt-like substance was observed throughout the length of the laundry room leading to the platform. In the clean area of the laundry room was a Heating Ventilation and Air Conditioning (HVAC) unit with 3 rusty grille vent covers that had thick layers of dust. Staff #ESS acknowledged the findings and stated we need to do some cleaning On 04/02/25 at 07:00 AM the surveyor informed the Nursing Home Administrator (NHA) of the findings 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 surveyor review of the clinical record and interviews with residents and facility staff, it was determined that the facility failed to ensure interdisciplinary care conferences, including the participation of residents. This finding was evident for 2 of 23 residents selected during the survey (Resident #64 and #73). In addition, the facility failed to ensure the revision of a comprehensive plan of care for Resident #67. This finding was evident for 1 of 23 residents selected during the survey. The findings include: 1a. On 03-08-2021 at 3:30 PM surveyor interview with Resident #64 revealed that the resident had not been invited or attended an interdisciplinary care plan conference for some time now. Further interview revealed the resident was unable to recall a date of the last conference that he/she had attended. On 03-11-2021 surveyor review of the clinical record for Resident #64 revealed documentation the resident's total Brief Interview for Mental Status (BIMS) score of a 14 out of 15. BIMS is a test given by medical professionals that helps determine a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of administrative files, surveyor observations and staff interviews, it was determined that the facility staff failed to ensure staff to identify and wear the appropriate personal protective equipment in accordance with infection control procedures. This finding was evident for 2 of 4 units in the facility (the East and Terrace units). The findings include: 1. According to Centers for Disease Control and Prevention (CDC) guidelines published on November 20, 2020 for preparing for Covid-19 in nursing homes, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty 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.

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents. This finding was identified for 2 of 23 residents selected for review during the survey (Residents #30 and #76). The findings include: The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. 1. On 03-10-2021 surveyor review of section E (Behavior) of the MDS assessment for Resident #30, with an Assessment Reference Date 01-14-2021, revealed staff indicated that the resident had no wandering behavior for the look back assessment period of 01-08-2021 through 01-14-2021. However, 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 surveyor review of the clinical record, surveyor observations and staff interviews, it was determined that the facility staff failed to develop and implement comprehensive care plans for residents. This finding was evident for 3 of 23 residents reviewed for care plan area during the survey (#289, #71, and #76). The findings include: 1. On 03-08-2021 at 1:51 PM surveyor observation of Resident #289 revealed a central line in place on the resident's right upper arm. A central line dressing was on the insertion site that was dated for 02-26-2021. A central line is a type of catheter for vascular access that is placed in a large vein that allows multiple intravenous (IV) fluids to be administered and blood to be drawn. On 03-08-2021 clinical record review of Resident #289 revealed facility staff had a comprehensive care plan initiated for the resident's central line. Per the care plan, the central line dressing was to be changed every seven (7) days per physician order. The next central line dressing was due to be changed on 03-5-2021. However as of 03-08-2021, the care plan…

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 review of the clinical record and interview with Resident #62's representative and facility staff, it was determined that the facility failed to ensure standards of professional practice for Resident #62. This was evident for 1 of 23 residents selected for review during the survey. The findings include: On 03-08-2021 A review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with a percutaneous endoscopic gastrostomy tube (PEG) to receive artificial nutrition. A PEG tube is used to provide a route for artificial nutrition, hydration, and medication administration in residents who are likely to have prolonged inadequate or absent oral intake. Further review of Resident #62's clinical record revealed that page 2 of the resident's Maryland Medical Orders for Life-Sustaining Treatment (MOLST) was completed on 04-16-2020 by the resident's attending physician. Page 2, section 7C was selected by the physician, which states that, may give fluids for artificial…

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 review of the clinical record, surveyor observations, resident and staff interviews, it was determined that the facility staff failed to follow physician orders for residents. This finding was evident for 2 of 23 residents reviewed during survey (#289 and #71). The findings include: 1. On 03-08-2021 clinical record review of Resident #289 revealed that the resident was admitted to the facility on [DATE] with a central line located in the resident's right upper arm. A central line is a type of catheter for vascular access that is placed in a large vein that allows multiple intravenous (IV) fluids to be administered and blood to be drawn. Further record review revealed the attending physician ordered for staff to change the central line dressing every seven (7) days. The next central line dressing was scheduled to be changed on 03-5-2021; However, surveyor observation on 03-08-2021 at 1:51 PM revealed that the central line dressing on Resident #289's right upper arm was dated for 02-26-2021. 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 surveyor review of the clinical record, and interview with Resident #76 and staff, it was determined that the facility staff failed to provide treatment/devices to maintain the hearing of 1 of 1 resident reviewed for the hearing and vision area during the survey (Resident #76). The findings include: On 03-08-2021 at 11:00 AM, surveyor interview of Resident #76 revealed the resident was having difficulty in hearing the surveyor. The resident on multiple times asked the surveyor to repeat questions and to speak louder. The resident informed the surveyor that he/she had hearing deficits in both ears. Further interview revealed that a hearing exam had been completed while in the facility, and was told that hearing aids were needed. However, the resident had never received the hearing aids. On 03-09-2020 surveyor review of the clinical record review of Resident #76 revealed that a hearing exam was completed on 03-23-2020. Further review of the results revealed the recommendation for hearing aids on both ears and for a medical consult to obtain clearance for the hearing aids.…

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

Based on surveyor review of the clinical record and interviews with the facility staff, it was determined that the facility failed to address a significant weight loss for 1 of 4 residents reviewed for nutrition during the survey (Resident #52). The findings include: On 03-09-2021, surveyor review of Resident #52's clinical record revealed the resident experienced a significant weight loss during the time frame from April to May 2020. On 04-10-2020, the resident weighed 138.1 lbs. On 05-5-2020, Resident #2's weight was 121.8 pounds. This is an 11.8% decrease in weight. There was no documented evidence that the facility had addressed any nutritional or therapeutic interventions for the resident's change in weight. On 03-11-2021 at 4:30 PM, surveyor interview with the facility's dietician revealed that she had started working at the facility in July 2020, which is when she started to monitor Resident #52's weight. She stated that she introduced interventions for the resident at that time. On 03-11-2021 at 5:00 PM, interview of the Director of Nursing revealed no additional information.

Based on clinical record review and interviews with facility staff, it was determined that the facility's pharmacist failed to identify and/or report a gradual dose reduction (GDR) of a psychotropic medication irregularity for 1 of 5 residents reviewed for Unnecessary Medications Review during the survey (Resident #79). The findings include: On 03-11-2021 surveyor review of Resident #79's clinical record revealed a progress note from a psychiatric staff member on 10-22-20 who recommended a change in the GDR of the resident's psychotropic medication Seroquel from 0.5 mg in the morning and 1 mg at bedtime (a total of 1.5 mg), to 0.5 mg two times (A total of 1 mg). Further review of Resident #79's clinical record revealed an order dated 10-22-2020 for 0.5 mg of the psychotropic medication to be administered two times a day. However, a review of the October and November 2020 Medication Administration Records (MARs) revealed the 1 mg bedtime dose continued to be administered by facility staff in addition to the 0.5mg administered twice a day until 11-13-2020. Additional review of…

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

Based on clinical record review and interviews with facility staff, it was determined that the facility failed to ensure 1 of 5 residents reviewed for the Unnecessary Medications remained free of an unnecessary psychotropic medication (Resident #71). The findings include: On 03-11-2021 surveyor review of Resident #79's clinical record revealed a progress note from a psychiatric staff member on 10-22-2020 that recommended a Gradual Dose Reduction (Gradual Dose Reduction) of a psychotropic medication from 0.5 mg in the morning and 1 mg at bedtime (a total of 1.5 mg in a day), to 0.5 mg two times a day (a total of 1 mg a day) as a GDR attempt. Further review of Resident #79's clinical record revealed an order dated 10-22-2020 for the psychotropic medication Seroquel 0.5 mg to be administered two times a day. However, a review of the October and November 2020 Medication Administration Records (MARs) revealed that the full 1 mg dose at bedtime and the 0.5 mg twice daily (for a total of 2 mg per day). On 03-11-2021 at 3:00 PM surveyor interview with the Assistant Director of Nursing…

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

Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility staff failed to ensure accurate documentation in the clinical record for 1 of 23 residents reviewed during the survey (Resident #71). The findings include: On 03-09-2021 surveyor review of the clinical record of Resident #71 revealed Registered Nurse (RN) #3 had documented on the March 2021 Treatment Administration Record (TAR) that she had changed Resident #71's midline dressing on 03-08-2021. A midline is a peripherally inserted line, a type of vascular access. The midline catheter is advanced and placed so that the catheter tip is level or near the level of the axilla and distal to the shoulder. However, on 03-09-2021 at 9:26 AM, surveyor observation revealed Resident #71's midline dressing was dated for 3-01-2021. On 03-10-2021 at 7:42 AM, an interview with RN #3 revealed that she had documented Resident #71's midline dressing change on 03-08-2021 on the TAR in error. On 03-09-2021 at 5:10 PM, an interview with the East/Terrace unit manager…

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.