Restore Health Rehabilitation Center

Based on observations and interviews, it was determined that the facility failed to maintain a functional and sanitary environment. This was found evident in 1 out of 2 dining areas observed during the survey. The findings include: During observations on 6/16/25 at 8:14 AM it was discovered that a non-operating ice and water dispenser was on top of the counter in the Sycamore Café. Further observation revealed the cabinet below the dispenser was missing the handle to the right door. The floor inside the cabinet was broken into pieces and crumbled in the center. The interior of the cabinet had brownish stains running down the walls and on the broken flooring. A broken pipe was found inside the cabinet. During an observation and interview with the Director of Maintenance on 6/17/25 at 2:12 PM he reported that he had been employed with the facility for about four and a half months. He advised he was not aware of the damaged cabinet and described the crumbled flooring as pressed wood. During an interview with the Administrator on 6/17/25 at 2:21 PM she advised the cabinet had been like…

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, staff interviews and an investigation into a complaint, it was determined that the facility failed to report an allegation of suspected resident abuse to the Office of Health Care Quality (OHCQ). This finding was evident for 1 (#166) of 2 residents reviewed for abuse during the annual survey. This finding is related to complaint #MD00185506. The findings include: The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse are to be reported to the Office of Healthcare Quality in a timely manner. A review of complaint intake MD00185506 on 6/30/2025 revealed that on 11/10/2022, Resident #166 alleged that staff members washed him/her in a rough manner while providing assistance with activities of daily living (ADL) care. A review of Resident#166's clinical record on 06/30/2025 at 11:18AM revealed a nursing progress note dated 11/10/2022 at 2:02 PM which stated Resident refused to be…

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

Based on facility staff interview and surveyor record review it was determined that the facility failed to investigate an alleged violation of abuse. This finding was found to be evident in 1 (Resident #187) out of 1 Resident that was reviewed for investigation of an alleged violation of abuse. The findings include: The Office of Healthcare Quality (OHCQ) received a facility reported incident (FRI)/self-report on 6/29/2023 at 8:56 AM from the facility's Assistant Director of Nursing (ADON) for an allegation of Resident abuse (family to Resident) - Intake#MD00193872. Resident #187 was linked to the Intake#MD00193872. The surveyor requested the facility investigation file for the facility reported incident (FRI) for Resident #187 on 6/17/2025 at 7:15 AM from the Licensed Nursing Home Administrator/ED (LNHA/ED). In an interview with the Licensed Nursing Home Administrator/Executive Director (LNHA/ED) on 6/17/2025 later in the day, she stated that she was unable to locate an investigation file for this facility reported incident (FRI) for Resident #187, but that she would continue 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 clinical record review, facility staff interviews and surveyor review of a facility reported incident and a complaint, it was determined that facility failed to provide written notice to the Office of the State Long Term Care (LTC) Ombudsman of a Resident's discharge, and failed to ensure that a discharge summary was completed by a Resident's physician. This finding was found to be evident for 2 (Resident #62 and #171) out of 3 residents reviewed for discharge process during the annual survey. The findings include: 1. On [DATE] at 12:15 PM, a review of Resident #62's clinical record revealed that Resident #62 was admitted to the facility on [DATE] and discharged home on [DATE]. Further review of Resident #62's electronic clinical record revealed no documentation that the local ombudsman was notified of the resident's discharge from the facility. On [DATE] at 03:01 PM, an interview conducted with the Administrator revealed that discharge notices are sent to the ombudsman via email each time a resident is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined the facility failed to initiate wound care upon admission for a Resident with Pressure Ulcers. This was evident for 1 (Resident #191) out of 4 residents reviewed for pressure ulcers during the survey. The findings include: A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). Deep Tissue Injuries (DTIs) are characterized by intact skin that is discolored (purple or maroon) or a blood-filled blister, indicating damage to underlying soft tissue due to pressure or shear. DTIs are…

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 resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' medications were documented at the time of administration, including high risk medications, resulting in a consistent and widespread pattern of medications being documented inaccurately and hours after they were due. This involved multiple staff on all shifts and on both units. This was evident for 5 (Residents #21, #61, #35, #25, and #73) out of 5 residents reviewed in detail for timely medication administration but was also noted in every medication administraion record (MAR) seen during the survey. This practice has the potential to impact all residents. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any and all medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and review of resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that there was sufficient nursing staff to: 1) provide for timely and accurate documentation of residents' administered medications. This was evident for 5 (Residents #21, #61, #35, #25, and #73) out of 5 residents reviewed for timely administration of medications. 2) provide sufficient staff to care for residents. This is evident for 2 out of 2 complaints (Resident # 95 and # 81), 3) to answer the call bell in a timely manner. This was found to be evident for 6 (resident #5, #35, #49, #57, 208 and #309) out of 20 residents observed for call bell response time during the Annual Survey, and 4) have the required number of nursing staff to care for residents resulting in delayed resident care and documentation of care. This was found to be true for 2 out of 2 units. This practice has the potential to affect all residents. The findings include: Surveyors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview with facility staff and observation it was determined that the facility failed to maintain consistent and accurate documentation in the residents' medical records related to care, notification and behaviors respectively. This was evident in 4 of 70 medical records (#99, 95, 26, and #29) reviewed during the annual survey. The findings include: 1) Surveyor reviewed Resident #99's medical record on 9/21/2022 at 9:23 AM secondary to complaints that s/he was not given the appropriate meals during his/her stay at the facility. Record review at that time revealed diagnoses including dysphagia (difficulty swallowing), following a cerebral infarction (stroke, when blood flow is disrupted to the brain). The Physician orders initiated on admission noted for Resident #99 Eating with assist of one, patient is a feeder. Additionally, noted a week later an order was entered to Assist patient with eating during mealtime. A review of the Geriatric Nursing Assistant (GNA) point 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 observations and interviews it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection as evidenced by: 1) lack screening for visitors upon entrance to the facility and 2) staff did not wear face mask appropriately. This was found to be evident for 1 out of 1 staff members observed during a facility tour and 4 out of 4 surveyors upon entrance to the facility. The findings include: COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets and particles can be breathed in by other people or land on their eyes, noses, or mouth. In some circumstances, they may contaminate surfaces they touch. Wearing a well-fitting mask that covers your nose and mouth will help protect yourself and others. 1) On 8/31/2022 6 AM surveyors entered the facility and were not accurately screened by facility staff for sign and symptoms of COVID-19. Surveyors observed facility staff members stationed at the entrance on the [NAME] Oak Unit, to…

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

Based on record reviews and facility staff interviews it was determined that the facility failed to designate at least one Infection Preventionist who is responsible for the facility's Infection Prevention and Control Program. This was evident during the Infection Control portion of the recertification survey. An interview held with the Interim ADON/IP (Assistant Director of Nursing/ Infection Preventionist), RN#3, on 8/30/2022 at 10:00 AM stated that she started working at the facility two weeks prior to the beginning of the survey and is assisting with the IP role during her time at this facility. On 9/12/2022 at 8:45 AM an interview was held with the Human Resources (HR) Director, Staff #50, revealed that the previous IP's, RN #61, last day worked was 5/19/2022. An interview held with Clinical Consultant, RN #14, and the Administrator on 9/12/2022 10:30 AM revealed that when RN #61 resigned on 5/19/2022, part- time RN #63 assisted with the responsibilities of the IP role. Once RN #63 left, the IP role remained vacant and various RN staff members would assist in completing IP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to: 1) ensure that each resident or responsible party (RP) received education regarding benefits and risk and document that the residents or the responsible party were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization and 2) that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was evident for 1 of 5 residents (Resident #52) reviewed for immunization. The findings include: On 9/21/2022 9 AM the facility influenza immunization policy and procedure was reviewed and revealed the following: all patients/residents will be offered the influenza vaccine when it becomes available upon admission during the vaccine season, October 1 through March 31 and each year after .Documentation in the record should include: a) Education provided concerning the risks…

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, interviews, and record review it was determined that the facility staff failed to ensure the dignity of a resident as evidenced by the resident's uncovered urine catheter bag lying on the floor uncovered, under the resident's bed. This was found to be evident for 1 (Resident #20) out of 13 residents observed during a tour of the nursing unit. The findings include: During a tour of the nursing unit on 8/30/2022 at 10:37 AM, the surveyor observed Resident #20's urine catheter bag lying flat on the floor, uncovered, under Resident #20's bed in plain view to be seen by anyone walking the hallways or entering the resident's room. During an interview held with Resident #20, the resident asked the surveyor if the floor was wet and advised the surveyor to be careful of the slippery floor because the night shift GNA (Geriatric Nursing Assistant) had spilled urine from the bag when emptying at the end of the shift. Resident #20 could not recall the identity of the GNA. During an observation and interview on 8/30/2022 at 10:45 AM Licensed Practical Nurse (LPN) #6 and LPN…

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 resident medical record, interview with resident representatives and facility staff, and review of facility policy, it was determined that the facility failed to: 1) ensure that Resident #96's shower preferences were obtained at the beginning of his/her stay; and 2) failed to have access to the facility's communication system. This was found to be evident for 1 (Resident #96) of 4 residents reviewed for activities of daily living (ADL) and 2 out of 20 residents (Resident #26, and #44) reviewed during the annual survey. The evidence includes: 1) The surveyor interviewed Resident #96's responsible party (RP) on 9/19/22 at 11:13 AM. During the interview, the RP indicated that Resident #96 was never given a shower during their 30+ day stay. The surveyor reviewed Resident #96's medical record on 9/19/22 at 11:18 AM. The review revealed that Resident #96 was admitted to the facility from mid-April to late-May 2022, with diagnoses that included anemia, unsteadiness, and dementia without behavioral disturbance. The resident's admission Minimum Data Set (MDS) assessment…

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 resident medical record and interview with facility staff and residents' representatives, it was determined that the facility failed to ensure that physicians and residents' representatives were notified when the resident sustained a change in condition. This was evident for 2 (Resident #75 and #7) of 10 residents reviewed for change in condition. The findings include: 1)The surveyor interviewed Resident #75's responsible party (RP) on 9/14/22 at 11:00 AM. During the interview, the RP stated that the resident was not capable of making decisions and that the resident's family should have been informed of all changes in the resident's condition. The RP stated that the resident's family had never been notified of swelling in the resident's hand or of pressure ulcers that developed during the resident's stay. The surveyor reviewed Resident #75's medical record on 9/14/22 at 12:20 PM. The review revealed that the resident was admitted to the facility from late December, 2019, to the end of January, 2020, with diagnoses that include urinary tract infection,…

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, interview and review of pertinent facility policies and documentation, it was determined that the facility failed to prevent incidents of abuse and neglect. This was evident during the review of 2 of 19 abuse investigations, including complaints and facility reported incidents. The findings include: 1) Surveyor reviewed an allegation of neglect reported to the state agency from a family that their loved one, Resident #100, was left soiled for hours. In addition, the facility also completed an investigation into the neglect allegation. The facility investigation reviewed by the surveyor on 9/09/2022 at 8:24 AM included witness statements stating observing Resident #100 soiled and wet around 12:30 PM, notified geriatric nursing assistant (GNA) staff #100 and Resident #100 was still wet on follow up around 6:00 PM. GNA Staff #32 was interviewed by the facility Administrator regarding the allegation of leaving Resident #100 soiled for an extended period on 4/21/2022. When GNA #32 was asked to sign 'corrective action form' the Administrator documented 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 facility documentation review and staff interview it was determined the facility failed to timely report investigations to the Survey Agency, which is the Office of Health Care Quality (OHCQ) within 24 hours of an alleged incident and the final report within 5 working days. This was found to be evident for 2 (Resident #26, and #54) out of 19 residents reviewed for abuse during the annual survey. The findings include: 1) A record review of the Nurse Practitioner's (NP) #60 progress note for Resident #26 was conducted on 09/09/2022 at 9:17 AM. The NP's note dated 01/14/2022 stated Xrays were done, revealed ligament injury. Further review of the Resident #26's medical records did not reveal documentation of the ligament injury. On 09/09/2022 at 9:33 AM a review of the Situation, Background, Assessment and Recommendation (SBAR) communication form dated 01/14/2022 stated left wrist pain, splint on left wrist and ice for 10 mins TID (three times a day) for one week due to Xray result. On 09/09/2022 at 9:47 AM a review of the physician order stated apply ice to left wrist for 10…

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, administrative record review and review of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate incidents of alleged physical abuse and allegations of neglect. This was evident for 3 out 19 residents (Resident #26, #24 and #70) reviewed for abuse. The findings: 1a) Review of Facility Report Incident for Resident #26 on 08/31/2022 at 10:55 AM revealed that the Administrator was notified by the Charge Nurse /License Practical Nurse (LPN) #6 that an X-Ray was ordered for Resident #26 because the Charge Nurse observed swelling on her right ankle. The review of the facility's investigation did not include interviews for the other residents and staff on the nursing unit to determine if someone witnessed the injury. During an interview conducted on 08/31/2022 at 11:19 AM, the Surveyor advised the Administrator that the investigation did not include resident and staff interviews and therefore was incomplete. The Administrator advised s/he would see if there were any more documentation including…

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 recent facility discharge practices and interview with facility staff, it was determined that the facility failed to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed hold policy. This was evident for 3 of 3 (#24, 67 and 74) resident records reviewed regarding unexpected hospitalizations. The findings include: 1) Review of the medical record for Resident #24 on 8/31/2022 at 10:07 AM regarding a complaint revealed a hospitalization following a fall on 5/3/2022. Further review of the medical record failed to reveal documentation from the facility that they provided timely notification to the family regarding the bed hold notice. Interview on 9/8/2022 with staff # 57, the Admissions Director, at 11:59 AM, revealed that there was no notification to the family when a resident is sent out to the hospital regarding the bed hold policy (A bed hold is when a nursing home holds a bed for you when you go into the hospital). She further stated…

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, medical record review, review of facility reported incidents and interviews it was determined the facility failed to ensure that care plans were revised as required. This was found to be evident for 2 (Resident #49 and #69) out of 20 residents reviewed for Care Plans during the Annual Survey. The findings include: 1) During an interview conducted on 08/31/2022 at 11:58 AM, the Surveyor observed bruises on Resident #49 right forearm. The resident stated the bruises were caused by an anticoagulant that had been prescribed. Anticoagulants are medicines that help prevent blood clots. They're given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes and heart attacks. Lovenox (enoxaparin sodium) Injection is an anticoagulant (blood thinner) used to prevent blood clots. On 08/31/2022 at 12:19 PM a review of the physician ordered revealed an order for Lovenox (enoxaparin) syringe; 40 mg/0.4 mL; amount to administer: 40mg sub [subcutaneous] q [once] nightly for prophylaxis (an attempt to prevent disease).…

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

Based on medical record review and interview with residents and staff, it was determined that the facility failed to provide resident with identified assistance for activities of daily living (ADL) as identified in the resident's care plans. This was evident for 2 of 3 (#73, 74) residents reviewed for ADL's. The findings include: 1. Review of the medical record for Resident #73 on 9/13/2022 at 1:37 PM revealed admission to the facility with multiple diagnoses including muscle weakness, lack of coordination and need for assistance with personal care. Secondary to a complaint, Resident #73's ADL's and physician orders were reviewed. The physician orders revealed a general order set from admission that Resident #73 required the assistance of one person for eating and toileting. Review of the ADL documentation from Geriatric Nursing staff for support provided to Resident #73 from 2/11/2020-3/11/2020 revealed that of 90 opportunities to aid with eating, staff only documented help 18 times and documented that s/he was independent in eating 28 times. This concern was reviewed with 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.

Based on observation, medical record review and interview with facility staff, it was determined that the facility failed to: 1) ensure ordered splints were in place, 2) failed to administer a medication as ordered by the physcian. This was evident for 2 (Resident #24 and #42) of 19 residents reviewed for neglect during the annual survey. The findings include: 1) Surveyor completed initial tours of the facility and multiple observations of Resident #24 on 8/30/2022. During these observations Resident #24 was observed up in his/her wheelchair without any noticeable splints or braces in place. Medical record review for Resident #24 on 8/31/2022 at 10:09 AM revealed multiple diagnosis including hemiplegia (Muscle weakness or partial paralysis on one side of the body) and hemiparesis (weakness on one side of the body) post cerebral vascular accident (stroke) affecting left dominant side, dysphagia, unspecified dementia without behaviors and chronic pain. Further Resident #24's physician orders were reviewed and noted the following; a. Ensure brace (a device fitted to something, 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 resident medical record, it was determined that the facility failed to intervene when a newly identified stage 2 pressure ulcer was found on Resident #75's skin. This was evident for 1 (Resident #75) of 4 residents reviewed for pressure ulcers. The findings include: The surveyor interviewed Resident #75's responsible party (RP) on 9/14/22 at 11:00 AM. During the interview, the RP stated that the resident was discharged from the facility at the end of January, 2020, to a hospital due to a change in the resident's condition. The RP further stated that, at the hospital, the resident was diagnosed with stage 2 pressure ulcers on both buttocks. The RP claimed that the facility never contacted family regarding any skin condition that the resident developed at the facility. The RP noted that the resident was not capable of making decisions and that the resident's family should have been informed of all changes in the resident's condition. The surveyor reviewed Resident #75's medical record on 9/14/22 at 12:20 PM. The review revealed that the resident was admitted 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 review of resident medical record and interview with facility staff, it was determined that the facility failed to address a significant weight loss for a resident. This was evident for 3 (Residents #76, #42 and #55) of 5 residents reviewed for nutrition. The findings include: 1) The surveyor interviewed the responsible party (RP) for Resident #76 on 9/20/22 at 1:16 PM. During the interview, the RP stated that the resident had lost 50 lbs while at the facility and that it was never addressed by the facility. The surveyor reviewed Resident #76's medical record on 9/20/22 at 1:18 PM. The review revealed that the resident was admitted to the facility from February to May, 2020, with diagnoses that included orthopedic care, anemia, kidney failure, type 2 diabetes mellitus, and high blood pressure. During the review, the surveyor examined all of the weights obtained by the facility for the resident. They were as follows: - 2/14/20: 232 lbs - 4/9/20: 230 lbs - 5/5/20: 184 lbs - 5/7/20: 187 lbs - 5/11/20: 209…

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

Based on record review and staff interview it was determined that the facility failed to establish and made understood the roles and responsibilities for the Nurses functioning in the role of Director of Nursing (DON) in their absence. The findings include: During an interview with the Administrator on 09/08/22 at 11:17 AM. S/he revealed that the Director of Nursing (DON) had been on an extended leave since July 2022. In their absence, s/he along with Registered Nurses (RN) #3 and #2 shared the DON responsibilities. The Administrator added it was a combined effort, and the RNs were aware of their specific roles and duties. An interview was conducted with RN #3 and RN #2 on 09/08/22 at 11:55 AM. RN #3 and RN #2 identified themselves as Assistant Director of Nursing (ADON) and assigned to work on the Sycamore and [NAME] Oak Units. RN # 3 stated they were contracted for a limited time to work at the facility. RN #2 stated that they began training as an ADON 4 weeks prior. The RNs were asked what specific duties traditionally assigned to the DON that they were responsible to perform 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 observation of medication administration, interview with facility staff, and review of medication administration records and facility policy, it was determined that the facility failed to have a medication administration rate of less than 5 percent during the medication administration facility task. Out of 26 observed medications administered, 2 medications were split by a soiled communal pill cutter, resulting in an error rate of 7.96%. This involved 2 of 4 residents (Resident #208 and Resident #7), 1 of 1 Certified Medication Aide (CMA) and 1 of 2 Licensed Practical Nurses (LPN #7) that were observed. The findings include: 1) On 9/1/22 at 8:14 AM, the surveyor observed CMA #43 administrating medications to Resident #208. CMA #43 obtained a pill cutter from the top of the medication cart. The pill cutter had a white powder substance noted in the chamber where pills are placed to be split. CMA #43 used the pill cutter to cut one of Resident #208's metoprolol tablets (a medication used for blood pressure). During an interview with CMA #43 on 9/1/22 at approximately 8:30 AM,…

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

Based on staff interviews, review of other pertinent documentation and survey findings, it was determined the facility staff failed to ensure that effective quality assessment and assurance performance improvement policies and procedures were implemented to ensure deficiencies were not repeated and residents remained in a safe, enriching, and comfortable environment. This was found to be evident during the facility's annual Medicare/Medicaid survey. The findings include: The facility's previous annual survey conducted on 12/2018 found the facility cited for deficiencies including representative notification, resident/representative notification of the bed hold notice and care plan revisions. Additionally, a focused infection control survey (FIC) was conducted on 2/2022 citing concerns with infection control practices and medical records within the facility. During this year's annual survey conducted from 8/30/2022 through 9/21/2022 again found the same deficiencies affecting a pattern (both units, not all shifts) of residents including related to staffing and the repeated…

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 staff interviews, review of other pertinent documentation and survey findings, it was determined the facility staff failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address identified quality deficiencies. This was found to be evident during the facility's annual Medicare/Medicaid survey. The findings include: The facility's previous annual survey conducted on 12/2018 found the facility cited for deficiencies including representative notification, resident/representative notification of the bed hold notice and care plan revisions. Additionally, a focused infection control survey (FIC) was conducted on 2/2022 citing concerns with infection control practices and medical records within the facility. During this year's annual survey conducted from 8/30/2022 through 9/21/2022 again found the same deficiencies affecting a pattern of residents. The Surveyor reviewed the facilities Quality Assurance Program (QAPI) plan with the facility Administrator on 9/20/22 at 1:26 PM. Although there is a QAPI plan 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 medical records and staff interviews, the facility staff failed to do a monthly medication review on Resident #3 and Resident #6's medications. This was evident for 2 out of 5 residents investigated for unnecessary medications during the survey process. The findings include: On 12/17/18 around 02:47 PM, Resident #3's medication orders were reviewed for unnecessary medications. It was noted that there were no pharmacy reviews documented for October, November, and December 2018. The Sycamore Unit nurse stated that the Pharmacist was in the facility in December. There was no documentation related to the visit. On 12/17/18 around 04:19 PM, the writer reviewed Resident #6's medical record for unnecessary medications. It was, also, noted that there were no monthly medication reviews documented since the month of September 2018.

Based on medical record review, staff and responsible party interviews, it was determined the nursing staff failed to notify the designated responsible party of changes in Resident # 47's condition during a hospital transfer. This was evident in 1 out of 29 residents reviewed during the survey process. The findings include: The facility admission record face sheet is a document that provides the facility staff with contact information about who to contact in the event of any change in physical or mental conditions involving each resident, in the event of a medical emergency. Surveyor's review of Complaint #MD00134006 revealed concerns that Resident #47's Responsible Party (family member) alleged that he/she was not notified by the facility of the physical changes in the resident's condition in a timely manner. Resident #47 was admitted to the facility with an advanced directive which listed that the medical power of attorney /responsible party (POA/RP) was to make medical and financial decisions for Resident #47. Review of the medical record revealed that Resident #47 was…

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

Based on the medical record, the facility staff failed to provide written notice to Resident #40, #63, 61 and 47 or the resident's Responsible Party, of a transfer out of the facility. This was evident for 4 out of 4 residents investigated for hospitalizations during the survey process. The findings include: 1). On 12/13/18 at approximately 12:15 PM, Resident #40's medical record was reviewed for a recent hospitalization. On 11/12/18 the resident was transferred to a community hospital's emergency room (ER) to rule out sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs); due fever, increased heart rate, increased breathing rate, and confusion Per the doctor, the resident was extremely difficult to arouse. The resident unable to verbalize due to slurring of speech and patient immediately closes eyes after opening them. The resident was sent to the ER for escalation of care. During further review of the medical record, it was noted that there was no documentation of a written notice given to 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.

Base on chart review and interview with the Admissions Director, The facility failed to send out a bed hold policy to the Responsible Party of Resident # 63. This was evident for 1 out of 3 resident medical records reviewed as transferred to the hospital. The findings include: Resident # 63 went out to the hospital on 6/14/18 through 6/16/18, and 7/2/18 through 7/10/18 and did not get a bed hold policy or notification in writing of the discharge according to the Director of Admissions Staff # 2.

Based on medical record review and staff interviews it was determined that the facility failed to revise and update the care plan for Resident #47 after a change in condition. This was evident 1 out of 23 resident's involving Resident #47 during the survey process. The findings include: The care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Medical record review revealed that Resident #47 was admitted to the facility with diagnoses which included but was not limited to surgical aftercare with muscle weakness and other chronic health conditions which require ongoing treatment. Continued record review revealed that on 11/19/18 Resident #47 had experienced a fall as a change in condition. The resident was transferred to an acute care hospital for further evaluation. Medial record review revealed a fall care plan with an admission/initiation date of 11/02/018 which included goals and interventions for fall preventions. Further review of the medical record revealed that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on investigations of the medication storage areas, it was determined the facility staff failed to dispose of out dated medical supplies and label another. This was evident for 1 out of 2 medication storage rooms inspected during the survey, and 1 out of 3 medication carts inspected. The findings include: On 12/17/18 around 3:20 PM, while inspecting the medication storage room on the [NAME] Oak Uunit, the following items were noted: 1. [NAME] 0.9% Sodium Chloride Inj USP 1000 ML- Labeled Discard 11/29/18 2. [NAME] 0.45% Sodium Chloride Inj UPS 1000 ML- Labeled Discard 11/24/18 3. [NAME] 5% Dextrose & 0.9% Sodium Chloride -Labeled Discard 9/10/18 4. [NAME] 5% Dextrose & 0.9% Sodium Chloride -Labeled Discard 5/17/18 5. [NAME] 5% Dextrose & 0.45 % Sodium Chloride -Labeled Discard 5/17/18 In the medication cart: 1. Latanoprost Ophthalmic 0.005% Solution was opened, not dated. The above stated items were given to staff #4