Montcare At Wheaton

Based on observation, pertinent document review, and interview, it was determined that the facility failed to have a process in place to communicate with a resident in their preferred language. This was evident for 1 ( # 61) of 2 residents reviewed for communication-sensory during a survey. The findings include: On 6/20/24 at 9:49 AM, the hospital discharge summary of Resident #61, a long-term resident, was reviewed. The review revealed that Resident #61 had a history of dementia and deafness. Also, that she communicated using American sign language (ASL). On 6/18/20 at 7:43 AM, during an interview with GNA staff #6, she reported that she routinely provides care to Resident # 61. She reported that she communicated with the resident through writing on a white board. Staff #6 reported that the resident would also use gestures or pointing to communicate. In addition, she reported she has never used an ASL interpreter to communicate with the resident. On 6/18/24 at 11:49 AM, an observation was made of the Maryland State Service Coordinator for DDA services (an outside provider, staff…

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 complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to notify a resident and the resident's representative of his/her rights upon admission by not executing an admission contract. This was evident for 1 (#90) of 2 residents reviewed for personal property during a complaint and recertification survey. The findings include: Review of complaint MD00187269 on [DATE] revealed an allegation the facility staff failed to return Resident #90's belongings to the family after the resident suddenly died. A review of the facility admission contract/financial agreement on [DATE] at 11:14 AM revealed Section H, Limitations of Liability, paragraph one that stated: The facility is obligated to take reasonable precautions to provide the Resident and the Resident's personal belongings with security, including providing a reasonable amount of secured space for Resident's belongings. The facility, however, cannot be responsible for loss or damage 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.

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 reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 2 (#44, #59) of 6 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. A Medical Orders for Life Sustaining Treatment or MOLST form contains medical orders regarding life-sustaining treatments, the use of medical tests, whether to transfer a patient to a hospital and any other matter considered appropriate by the Department to implement the treatment preferences of patients. A MOLST form is not an advance directive. A MOLST form contains written medical orders related to a patient's medical condition. 1) Resident #44 has 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.

Based on medical record review and staff interviews, it was determined that the facility, 1) failed to notify the provider that the resident was not receiving a medication due to an allergy, 2) failed to notify a resident's family representative after a resident had a change in condition, and 3) failed to notify the provider when a resident's blood pressure was below prescribed parameters, and blood pressure medication was not administered. This was evident for 1 (#5) of 1 residents reviewed for notification of change, 1 (#91) of 11 residents reviewed for neglect and 1 (#95) of 4 residents reviewed for discharge The findings include: 1) Review of Resident #5's medical record on 6/28/24 revealed that the resident had been residing at the facility since March 2024, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and oriented, and able to verbally communicate. On 06/17/24 at 02:32 PM, during an interview with Resident #5, he/she reported having blisters on the back of her/his legs. Record review revealed that, on 5/31/2024 at 10:41, there was a…

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

Based on observation and interview, it was determined that the facility failed to ensure that items in need of repair were reported to the maintenance department. This was found to be evident for 2 out of 23 resident rooms observed in the initial stage of the survey. The findings include: 1) On 6/17/24 at 2:18 PM, surveyor observed in Resident #5's room several areas of the wallpaper with staples in sections where the sheets of wallpaper were separating. Also observed at this time, the material covering the right arm rest padding of the resident's wheel chair was not intact, with a small section missing. On 7/1/24 at 1:44 PM, interview with geriatric nursing assistant (GNA Staff #27) revealed that, if environmental concerns were identified, the staff were able to initiate a computer report for repairs. When asked if a resident's arm rest was peeling or torn, the GNA responded that they would definitely report it. On 7/8/24, Resident #5 was observed in the dining room. Observation of the armrest on the resident's wheelchair again revealed that the material covering the right arm rest…

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, pertinent documentation and staff interviews, it was determined that the facility failed to provide the resident and/or the resident representative, in writing, of a notice of transfer, along with the reason for the transfer. This was evident for 2 (#2, #100) of 4 residents reviewed for hospitalization. The findings include: 1) Resident #22 was admitted to the facility in mid-2022. A quick look in the resident's medical record revealed that s/he was cognitively intact and was his/her own resident representative (RP). On 6/17/24 at 2:53 PM, Resident #22 was interviewed regarding hospitalizations. The resident reported that s/he was hospitalized early this year and did not get any written notification regarding the transfer. A review of Resident #22's medical record on 6/20/24 at 10:40 AM, revealed that s/he was hospitalized on [DATE]. A transfer form was documented by a Registered Nurse (RN Staff #43) that indicated the resident was observed with slurred speech and was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in residents' conditions. This was evident for 2 (#37, #4) of 3 residents reviewed for hospice. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. The nursing home should complete a Significant Change in Status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. 1) A medical record review on 6/17/24 at 1:46 PM showed that Resident #37 was admitted to the facility in June 2020 with diagnoses including stroke with one-sided weakness. Further record review contained an attending…

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 that an order for a hospice consult was acted upon. This was found to be evident for one (#83) of 2 residents reviewed for death. The findings include: On 6/20/24, review of Resident #83's medical record revealed the resident had resided at the facility for several years. On 5/22/24 at 4:31 PM, an order for a Hospice Consult and evaluation was placed in the medical record. The resident passed away on 5/26/24. Hospice care includes a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members. Further review of the medical record failed to reveal documentation to indicate the hospice referral was addressed with the resident or the resident's family after the initial order was put in place. No documentation was found to indicate that a hospice provider was contacted regarding this consult order. On 7/9/24 at 4:31 PM, the Assistant Director…

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, closed medical record, complaint and pertinent documentation review and staff interviews, it was determined that the facility staff 1) failed to store oxygen cylinder tanks securely. This was evident for 1 of 2 nursing units observed 1) Compressed Oxygen Cylinders, also known as oxygen tanks, store pressurized oxygen and need to be secured to prevent them from tipping over and becoming damaged. If the valve on the oxygen tank broke off, causing a leak, the oxygen tank could become a flying projectile. On 6/24/24 at 10:00 AM, during an observation of Unit 2's nursing station, 2 surveyors observed an unsecured oxygen cylinder leaning against a counter in the left, back corner of the nurse's station. The Assistant Director of Nurses (ADON), Staff #8, was on the unit and was immediately shown the unsecured oxygen cylinder. At that time, the ADON confirmed the findings and indicated she would make sure the oxygen tank was secured.

Based on records review and interviews, it was determined that the facility failed to have an effective system in place to monitor and address a resident's significant weight loss. This was evident for 1 (#1, #72) of 4 residents reviewed for nutrition. The findings include: 1) On 6/17/24 at 2:15 PM, Resident #1, a long-term resident at the facility was interviewed. During the interview s/he reported that s/he had recently lost wight. On 6/20/24, review of Residents #1's medical record, under the category weights, revealed the following: 6/8/2024 11:41 103.8 Lbs. 6/7/2024 15:05 97.4 Lbs. 6/4/2024 10:15 99.8 Lbs. 5/24/2024 13:41 104.2 Lbs. 4/7/2024 21:55 124.4 Lbs. 3/1/2024 16:10 124.0 Lbs. On 6/20/24 at 8:48 AM, a dietician's note, dated 5/24/24, written by Dietician staff #15, was reviewed. The review revealed that dietitian Staff #15 recognized and documented a significant weight loss warning for Resident #1.The weight documented on 5/24/24 indicated a 16 percent weight loss in 47 days. Staff # 15 requested a re-weigh to verify the weight change. On 6/20/24, review of Resident #1…

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 1) failed to provide appropriate treatment and services to a resident receiving gastrostomy tube (g-tube) feedings and 2) failed to develop and implement a care plan that addressed the care and maintenance of a resident with a feeding tube. This was evident for 1 (#73) of 1 residents reviewed for tube feeding, and 1 (#107) of 11 residents reviewed for neglect. The findings include: Enteral feeding (tube feeding) is the delivery of nutrients through a feeding tube directly into the stomach or the small intestine. A gastrostomy tube (g-tube) is a feeding tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube. Bolus feeding is the administration of a limited volume of enteral formula over brief periods of time. There are risks associated with residents using feeding tubes for nutrition which include aspiration (accidentally inhaling your stomach contents),…

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 pertinent documents, it was determined that the facility failed to provide Physician/Nurse Practitioner services to the resident at least once every 60 days. This was evident for 1 (#53) of 4 Resident reviewed for dental during a survey. The findings include: On 6/18/24 at 11:40 AM, Resident #53, a long-term care (LTC) resident, was interviewed. During the interview resident #53 reported a concern regarding how frequently s/he sees a physician. On 6/21/24 at 6:57 AM, a review of progress notes from 11/22/23 to 3/8/23, failed to reveal documentation that a Physician or Nurse Practitioner (NP), visited Resident #53. On 6/21/24 at 7:46 AM, the Director of Nursing (DON) was interviewed regarding the required visit frequency of a NP or physician for a long-term resident. The DON reported that, once a resident has been at the facility for 90 days there is normally an order for a physician visit every 60 days for a LTC resident. On 6/21/24 at 8:07 AM, during a second interview with the DON, she failed to provide any handwritten physician visit notes for Resident # 53…

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

Based on observation, medical record review and interview, it was determined that the facility failed to ensure the accurate documentation and accounting of a controlled medication. This was found to be evident for 1 of 2 medication carts reviewed during the survey. The findings include: Review of Resident #138's medical record, on 7/3/24 at approximately 2:00 PM, revealed an order that was in effect since 6/28/24 for Lacosamide Oral Solution 100 mg/10 ml Give 20 ml via g-tube two times a day for seizure for 30 days. Lacosamide, also known as Vimpat, is an anticonvulsant medication. It is classified as a schedule 5 controlled substance. Review of the Controlled Substance Administration & Accountability policy, with a revision date of 12/1/23, included: 3. Ordering and Receiving Controlled Substances: e. The medications delivered are immediately recorded on the appropriate drug disposition record and stored in the controlled drug storage area by the nurse accepting delivery. On 7/3/24, review of the Medication Administration Record (MAR) revealed documentation that Lacosamide was…

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

Based on medical record review and staff interview, it was determined that the facility 1) failed to ensure that psychotropic medication was prescribed as needed (PRN), had an end date, and 2) failed to ensure that a resident who received psychotropic medication was monitored for behaviors and side effects. This was evident for 1 (#35, #64) of 5 residents reviewed for unnecessary medications. The findings include: 1) As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the extended PRN order. On 6/20/24, the records of Resident #35, a long-term resident of the facility, were reviewed. Review of Residents # 35's physicians orders revealed an order for Lorazepam, oral concentration 2mg/ml. Give 0.2ml by mouth, every 6 hours, as needed for anxiety. The order for Lorazepam had a start date of 8/17/23. Continued review 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 observation, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 2 errors identified out of 26 opportunities for error. The findings include: 1) On 6/20/24 at 8:55 AM, surveyor observed nurse (Staff #35) prepare and administer Resident #36's medications. The nurse prepared a total of 10 medications, two of which were lidocaine patches. The nurse was observed applying one lidocaine patch to the resident's right knee and one lidocaine patch to the left knee. No other lidocaine patches were observed being administered at this time. After the administration, the nurse confirmed she signed off a total of 10 medications, stating there were two separate orders for the two lidocaine patches. On 6/20/24 at 10:09 AM review of the medical record revealed there was one order, with a start date of 1/30/24, for Lidoderm Patch 5% apply to both knees, R.[right] thigh/groin topically one time a day for pain management and remove per schedule. There was another order for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, it was determined the facility failed to ensure a resident was free from a significant medication error. This was found to be evident for 1 (#36) of 26 residents observed for medication administration. The findings include: Review of Resident #36's medical record revealed that the resident was admitted in 2023 and whose diagnosis included, but was not limited to, rheumatoid arthritis. Review of the 1/10/24 physician progress note revealed an assessment of left back pain and a plan to order lidocaine 5% to left lower back. A corresponding order, dated 1/11/24 for Lidoderm Patch 5% apply to left lower back topically one time a day for pain management was also found. On 6/20/24 at 8:55 AM, surveyor observed nurse (Staff #35) prepare and administer Resident #36's medications. The nurse prepared a total of 10 medications, two of which were lidocaine patches. The nurse was observed applying one lidocaine patch to the resident's right knee and one lidocaine…

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 ensure medications were stored in accordance with acceptable professional standards. This was found to be evident on two out of two nursing units. The findings include: 1) On 6/20/24 beginning at 6:12 AM, an observation of the night shift medication pass was made. On 6/20/24 at 6:15 AM, an observation was made of med cart #1 on the first-floor nursing unit. Observation revealed a vile of insulin resting on top of the cart. On 6/20/24 at 6: 20 AM, an observation of medication cart #2 revealed 2 clear plastic bins laying on top of the medication cart. One of the plastic bins was labeled team 2 and the other one was labeled team1. Further observation revealed the bins contained Insulin medications, including vials and insulin pens. On 6/20/24 at 6:21 AM, LPN nurse Staff #10 was interviewed. During the interview Staff # 10 reported that the bins contained insulin, and they were separated by teams. After showing the surveyor the 2 bins…

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 interviews and pertinent document reviews, it was determined that the facility failed to provide a resident with dental services while he/she was a long-term resident at the facility. This was evident for 1 (#53) of 4 reviewed for dental during a survey. The findings include: On 6/17/24 at 12:05 PM, Resident # 53, a long-term resident of the facility, was interviewed. During the interview, S/he reported she had not been provided dental services during her stay at the facility. On 6/18/24 at 11:33 AM, a second interview was conducted with Resident # 53. S/he reported that s/he had purchased dental insurance offered to residents, while she was a resident at the facility. In addition, s/he reported s/he had requested dental appointments in the past, but had not seen a dentist since her admission to long-term care. On 6/20/24 at 3:57 PM, a review of the electronic medical records failed to reveal that Resident # 53 had a dental appointment while in the facility. On 6/21/24 at 7:50 AM, a review of orders for Resident #53 revealed an order with a start date of 6/17/24 Consults:…

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

Based on observation, record review, and interviews, it was determined that the facility 1) failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences, and 2) failed to evaluate a resident prior developing a resident's therapeutic diet, resulting in the residents food preference not being considered. This was evident for 2 (#24, #57) of 4 residents reviewed for food during the survey. The findings include: 1) An observation made on 6/17/24 at 12:10 PM of Resident #24's untouched breakfast tray on his/her bedside table. It contained a bowl of oatmeal, three slices of toasted bread, three sausages, and scrambled eggs. The observation also noted a meal ticket on the tray that stated, standing orders-8oz [ounces] coffee, milk low fat. The resident said, I'm supposed to get milk and coffee with all my meals, but as you can see, I don't get it. A medical record review on 6/17/24 at 12:12 PM showed that Resident #24 was admitted to the facility in July 2022, alert, oriented, and able to communicate needs verbally.…

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 1) wear proper personal protective equipment (PPE) before giving direct care to a resident with an indwelling foley catheter and an open wound, 2) store a nebulizer mask in a sanitary manner to prevent the spread of infection. This was evident for 1 (#286) of 2 residents reviewed for respiratory care. The findings include: 1) An observation on 6/17/24 at 11:24 AM noted a signage on Resident #286's door that indicated Resident #286 was on enhanced barrier precautions, which required wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of infection in nursing homes. It involves gown and glove use during high-contact Resident care activities like dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring…

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, pertinent documenatation and staff interviews, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse potential abuse. This was evident for #4 (#137, #104, #107, #108) of 12 residents reviewed for abuse. The findings include Review of Resident #137's medical record on 6/22/24 revealed that the resident had a brief admission to the facility in January 2022. 1) Review of MD00182200, a facility self report of an abuse allegation, revealed that the resident's family had submitted a concern form alleging rough handling by staff while at the facility. Review of the final report by the facility, received by the State Survey Agency on 2/2/22, revealed the alleged events took place on 1/23/22 - 1/24/22 but failed to include a specific shift or name a specific staff member involved. The final report included: Interviews with staff assigned to [him/her] revealed the patient was neither physically or verbally abused . Further review of the facility investigation documentation revealed staffing sheets for evening…

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 notify residents and/or their representatives in writing of the bed hold policy upon transfer to an acute care facility. This was evident for 1 (#107) of 11 residents reviewed for neglect. The findings include: A medical record review completed on 7/3/24 at 12:10 PM showed that Resident #107 was admitted to the facility in July 2023. A continued review found a nurse's note, dated 8/21/23, indicating that Resident #107 had a change in condition. The attending provider was notified and gave an order for Resident #107 to be transferred to the emergency room for evaluation. Further review showed that Resident #107's representative was in the facility at the time of the transfer. However, the review failed to show that a copy of the facility's bed hold policy was given to the Resident's representative. In an interview on 7/3/24 at 2:21 PM, the nursing home administrator said he started mailing out the facility's bed hold policy to residents' representatives in March 2024. This means 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 record review and interviews, it was determined that the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADL) was provided with showers. This was evident for 1 (#102) of 4 residents reviewed for ADL. 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 care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. Medical record review on 7/1/24 at 2:09 PM showed that Resident #102 was admitted to the facility in June 2021 with diagnoses that included a right hip fracture post-surgery. A continued review found an MDS assessment, dated 6/24/21, which documented that Resident #102 had intact cognitive status and required extensive assistance from staff with transfers and bathing. A review of complaint record #MD00169826, on 7/1/24 at 2:09 PM for Resident #102, noted that the Resident had only one shower on 7/6/21 for his/her entire stay in 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 interviews, it was determined that the facility staff failed to effectively manage a resident's pain. This was evident for 1 (#102) of 2 residents reviewed for pain management. The findings include: A review of Resident #102's medical record on 7/1/24 at 2:09 PM showed that the Resident was admitted to the facility in June 2021 with diagnoses including a right hip fracture post-surgery and was able to communicate needs verbally. A continued review found a discharge medication list from the hospital for Resident #102, which included an opioid medication to be taken every six hours as needed for severe pain. A review of complaint record #MD00169826 on 7/1/24 at approximately 2:15 PM showed that Resident #102 arrived at the facility after midnight on the day of admission, had critical pain but had to wait for more than 4 hours to have his/her pain managed by the staff. Further record review, on 7/1/24 at 2:29 PM, found an attending provider's progress note, dated 6/17/21, that stated that Resident #102 complained of severe pain to the right lower…

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

Based on medical record review and staff interview, it was determined that the facility failed to provide a resident snacks as recommended by the dietician and consistent with the resident plan of care. This was evident for 1 (#96) of 6 residents reviewed for general concerns. The findings include: Type 2 diabetes is a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels. Bedtime snacks can help people with type 2 diabetes stabilize their blood sugar levels overnight and prevent high blood sugar in the morning. On 6/28/2024 at 2:00 PM, a review of complaint #MD00180188 revealed the complainant reported that the dietician had stated Resident #96 could have an evening snack, however, the resident, who was a diabetic, was never offered an evening snack and had lost 9 pounds since admission. On 7/9/24 at 4:30 PM, a review of Resident #96's medical record revealed documentation that indicated the resident was admitted to the facility for rehabilitative services in mid-May 2022 following an acute hospital stay, then…

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

Based on surveyor observation, resident and staff interview, and review of clinical records, it was determined that the facility staff failed to revise the plan of care to adequately reflect the needs of the resident. This finding was evident for 2 of 3 residents reviewed for revision of care plans. (#40 and #71) The findings include: 1. On 09-25-19 at 11:28 AM, observation of resident #40 revealed the resident moaning repeatedly. When asked if he/she was in discomfort, resident #40's response was my leg, my leg hurts so bad. The resident began rubbing their right leg. The responsible party who was at the bedside at the time of the observation replied, sometimes the pain is from the bedsore, sometimes it's the leg. I've told the nurses a few times before about it since she got here. Review of the clinical record revealed that resident #40 had a stage 4 sacral pressure ulcer. Review of the care plan for the sacral ulcer listed administer analgesics as needed as an intervention initiated on 07-26-19. However, further review of the clinical record revealed that no analgesic (pain…

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 clinical records and staff interview, it was determined that the facility staff failed to report to the appropriate authorities a resident's elopement (#135). Elopement is defined per the Centers for Medicare and Medicaid Services as occurring when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or for a leave of absence) and/or any necessary supervision to do so. The findings include: On 09-27-19, review of the clinical record for resident #135 revealed that he/she was admitted for short term rehab on 09-13-19. Further review of the clinical record revealed that, on 09-20-19 at 5:55 AM, facility staff were unable to locate resident #135 and an unrelated visiting family member confirmed by viewing a photograph that he/she had let resident #135 out upon entering the facility that morning. Facility staff made a search of the surrounding community and notified the police of the resident's elopement. The resident returned to the facility via a privately owned vehicle at approximately 11:30 AM. The resident was…

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

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice for a resident receiving pain medication. This finding was evident for 1 of 3 residents selected for pain review during the survey (#69) The findings include: On 09-26-19 at 3:15 PM, surveyor review of a resident #69's record revealed 3 physician orders for pain medication, 1) Acetaminophen 325mg, two tablets by mouth every 6 hours as needed for mild pain, not to exceed 3gm in 24 hours, written on 07-01-19, 2) Oxycodone 5mg to be administered in the amount of one tablet every 6 hours as needed for moderate pain written on 07-24-19 and 3) Oxycodone 5mg to be administered in the amount of two tablets every 6 hours as needed for sever(e) pain, also written on 07-24-19. The facility utilized a numeric pain scale between 0 and 10, with 0 being free of pain and 10 being severe pain, in order to assess resident #69's pain levels. On the morning of July 25, 2019, 2 tablets of Oxycodone were given for severe pain rated by the…

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

Based on surveyor observation, review of the clinical record and resident and staff interviews, it was determined that the facility staff failed to provide adequate assistance with activities of daily living (ADL's). This finding was evident for 1 of 1 residents reviewed during survey for the ADL care area (#71). The finding includes: On 09-24-19 at 12:02 PM, surveyor interview of resident #71 revealed a complaint that the facility staff should be using a lift to get me up, but they don't on the rare occasion that they do get me out of bed. The resident also stated that he/she has facial hair that staff won't shave off. On 09-27-19, review of the care plan for resident #71 stated transfer via mechanical lift only, however, facility staff transferred resident with two person assist on 09-25-19 and 09-26-19, and not via mechanical lift as the care plan stated. The transfer via mechanical lift had been recommended by the rehab department. There was no information in the clinical record to indicate this requirement was no longer necessary. On 09-27-19 at 1:35 PM, surveyor observation 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 surveyor observations, review of the clinical record (s) and resident and staff interviews, it was determined that the facility staff failed to adequately manage pain and discomfort for residents with significant pressure injury. This finding was evident for 2 of 3 residents reviewed for pain management during the survey (#40 and #71). The findings include: 1. On 09-25-19 at 11:28 AM, surveyor observed resident #40 moaning repeatedly. When asked if he/she was in discomfort, resident #40's response was my leg, my leg hurts so bad. The resident began rubbing their right leg. Review of the clinical record revealed that resident #40 had a stage 4 sacral pressure ulcer. (A stage 4 pressure ulcer is a wound that extends deep, exposing underlying muscle, tendon, cartilage or bone). Review of the care plan for the sacral ulcer listed administer analgesics as needed as an intervention initiated on 07-26-19, however, further review of the clinical record revealed that no analgesic (pain medication) had been ordered for the resident either routinely, or as needed, for wound care or…

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

Based on surveyor review of the clinical record and staff interview, it was determined that the facility staff failed to ensure that the attending physician addressed a resident's significant weight loss. This finding was evident for 1 of 6 residents reviewed for the nutrition care area during survey (#9). The findings include: On 09-25-19, surveyor review of the clinical record for resident #9 revealed a 10% weight loss since 06-01-19. Review of physicians progress notes, dated 08-23-19 and 09-23-19, revealed no mention by the attending physician of the significant weight loss or any attributable causes or immediate care needs related to the significant weight loss. On 09-25-19 at 9:12 AM, surveyor interview with the facility dietitian revealed interventions initiated by him/her that included supplements and double portions at meal time with family also agreeing to bring in foods that resident #9 enjoys. The dietitian described the resident as being severely underweight and stated the resident had a past history of oropharyngeal cancer (cancer in the tissues of the throat) along…

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 clinical records and staff interviews, it was determined that the facility staff failed to ensure that services provided by the facility met professional standards of quality. This finding was evident in 4 of 37 residents selected for review during the survey (#34, #17, #41 and #269). The findings include: 1. On 08-15-18 at 2:10 PM, surveyor review of resident #34's clinical record revealed a physician order written on 04-13-18 to check a Depakote (medication used for treatment of manic episodes associated with bipolar disorder) level every 4 months. Surveyor review of resident #34's Medication Administration Record (MAR) revealed that Depakote was not being administered to resident #34. Further record review revealed that resident #34 was ordered multiple medications including, but not limited to, Depakote 500 mg twice daily on 01-10-17. However, additional review of resident #34's physician order sheet revealed that Depakote 500 MG was discontinued on 01-17-17 at 10:55 PM. On 04-13-18, resident #34's primary physician a ordered Depakote level lab even…

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 review of the clinical record it was determined that the facility staff failed to administer a narcotic (opiod) pain reliever as ordered by the physician. This finding was evident in 1 in 3 records reviewed for compliance with pain management. (#223) The findings include: On 08-13-18 at 3:49 PM, surveyor observation of resident #223 revealed the resident to be moaning and grimacing. Upon surveyor intervention, the unit manager asked the resident if he/she had pain. (The resident did not speak English) The resident nodded yes and pointed to the right hip area. The unit manager later reported to the surveyor that the charge nurse administered pain medication to resident #223 immediately after the complaint of pain. On 08-16-18 at 12:21 PM, review of the physicians order sheet for resident #223 revealed that the resident had orders which specified the resident be given Percocet, 1 tablet for moderate pain greater than 5, and two tablets for pain greater than 8. In addition, a controlled substance prescription dated 08-10-18 ordered Percocet one tablet…

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 review of the clinical record, it was determined that the facility staff failed to administer a narcotic (opiod) pain reliever as ordered by the physician. This finding was evident in 1 in 3 records reviewed for compliance with pain management. (#223). The findings include: On 08-13-18 at 3:49 PM, surveyor observed resident #223 to be moaning and grimacing. Upon surveyor intervention, the unit manager asked the resident if he/she had pain.(The resident did not speak English) The resident nodded yes and pointed to the right hip area. The unit manager later reported to the surveyor that the charge nurse administered pain medication to resident #223 immediately after the complaint of pain. 08-16-18 at 12:21 PM, review of the physicians order sheet for resident #223 revealed that the resident had orders which specified the resident be given Percocet, 1 tablet for moderate pain greater than 5, and two tablets for pain greater than 8. In addition, a controlled substance prescription, dated 08-10-18, ordered Percocet one tablet every 4 hours as needed for…

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

Based on surveyor review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to notify resident #34's legal guardian when there was a change in treatment and failed to notify the physician and/or family member/responsible party of significant changes in medical condition, #33. This finding was evident for 2 of 4 residents selected for review during the survey (#34 and #33). The findings include: 1. On 08-15-18, review of resident #34's clinical record revealed that the resident's daughter had the durable power of attorney for all resident clinical decisions due to the resident's health condition. Additional record review revealed a physician order written on 08-13-18 for a new medication, Atorvastatin 40 mg, (medication used to treat high cholesterol level) to be given daily at bedtime. An additional order was written to draw blood for labs the next morning to monitor resident #34's cholesterol levels. However, there was no evidence that resident #34's guardian was notified about the new medication and/or lab draw that was…

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

Based on surveyor observation and interview of staff and family, it was determined that the facility staff failed to ensure that contracted nursing assistants/companions had the appropriate abuse training. This finding was evident in 3 of 3 contracted nursing assistants/companions selected for review of this requirement during the survey. The findings include: On 08-13-18 at 11:10 AM, surveyor observation revealed resident #33 in bed asleep with a visitor at the bedside. The visitor was identified as a companion by facility staff. Interview of the companion revealed that he/she is a nursing assistant who was hired by the family of resident #33 through a staffing agency to spend 40 hours per week with the resident. The companion/nursing assistant informed the surveyor that the resident has 2 other companions that assist in providing the 24 hour a day services as contracted by the family. On 08-14-18 at 2:20 PM, the companion/nursing assistant also stated he/she provided resident #33 with activities of daily living assistance to include bathing, dressing, transferring and assistance…

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 failed to review a resident's quarterly plan of care. This finding was evident in 1 of 37 residents selected for review during the survey. (#34). The findings include: On 08-15-18, review of resident #34's clinical record revealed that the resident's daughter has the durable power of attorney for all resident clinical decisions due to the resident's health condition. On 08-15-18, surveyor review of the clinical record revealed the last care plan meeting held to review resident #34's plan of care was held on 03-28-18. On 08-15-18 at 08:30 AM, surveyor interview with resident #34's daughter revealed that she has not been invited or called on the phone to participate in a care plan meeting since March 2018. There was no evidence that a quarterly review of resident #34's care plan was done by the interdisciplinary team as required. Resident #34's representative was not given the opportunity to participate in the review of his/her plan of care.…

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

Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to provide an on-going program based on an individual's interest. This finding was evident for 1 of 2 residents selected for review (#19). The findings include: On 08-13-18 at 2 PM, the surveyor overheard resident #19 cry out for help while interviewing resident #46 in the room. Resident #46 complained that resident #19 constantly yelled out loudly days and nights. On 08-13-19 at 11 AM, 08-13-19 at 2 PM, 08-14-18 at 9 AM and 08-15-18 at 12 noon, resident #19 was found in bed while the television was turned on On 08-15-18, review of the activity assessment, which was completed on 07-23-18 revealed that resident #19 required glasses for reading The resident was interested in music, drawing, painting, making things, cards/games, outdoor activities, religious involvement and talking/conversation. Further review of the July 2018 daily activity/recreation participation documentation revealed the activity staff provided resident #19 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 surveyor review of the clinical records and interview of the facility staff, it was determined that the attending physician failed to visit an individual routinely and the attending physician failed to document in the clinical record or communicate a positive chest x-ray result to a consulting physician. This finding was evident for 2 of 2 residents selected for review (#17 & 223). The findings include: 1. On 08-16-18, review of resident #17's clinical record revealed the attending physician, who was the facility's medical director, visited the resident every 2 months in the past 12 month period, except December 2017. Resident #17 was not seen by the attending physician between November 2017 and February 2018, in a 4 month period. On 08-16-18 at 11:50 AM, interview of the Medical Records Coordinator revealed no evidence that the attending physician visited resident #17 in December 2017. On 08-16-18 at 7 PM, interview of the Director of Nursing revealed no additional information. 2. On 08-04-18, resident #223 received a TB skin test, per facility infection control procedures…

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 resident #17's clinical record and interview of the resident and facility staff, it was determined that the consultant pharmacist failed to identify an irregularity after conducted monthly drug regimen reviews. This finding was evident for 1 of 5 residents selected for review (#17). The findings include: On 08-16-18 at 12 noon, interview of resident #17 revealed the resident was alert and oriented, but required some assistance with activities of daily living. On 08-16-18, review of resident #17's clinical record and Medication Administration Record (MAR) revealed the attending physician ordered acetaminophen 500 mg 2 tablets (1 gram) twice a day for pain. In addition, the PRN (as needed) orders were written to administer 20 ml of acetaminophen 160 mg/5ml (640 mg) every 6 hours as needed (PRN) for pain and 2 tablets of Oxycodone-acetaminophen 5-325 mg every 8 hours as needed (PRN) for severe pain. A specific instruction was given that the resident should not consume more than 3 grams of acetaminophen in a 24 hour period. Based on the above physician'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 surveyor review of the clinical record, staff and physician interviews,and review of infection control policies, it was determined that the facility staff failed to follow the established infection control standards. This finding was evident in 1 in 6 residents reviewed for compliance with infection control procedures.(#223) The findings include: On 08-04-18, resident #223 received a TB skin test per facility infection control procedure for new admissions. The result of the first step of the TB skin test was to be read within 48-72 hours of administration. However, review of the clinical record revealed that it was not read during the identified time frame, (08-06-18 or 08-07-18). Facility staff did not read the result until 08-09-18. (2 days late) On 08-09-18, facility staff identified the results as positive and notified the physician on call who ordered a chest x-ray to rule out tuberculosis. On 08-10-18, the chest x-ray result revealed that resident #223 had a slight right lower lobe infiltrate. (Infiltrates are white spots seen on x-ray that identify an infection). 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.