Williamsport Health And Rehabilitation Center

Based on interviews and a review of pertinent documents, the facility failed to follow the required procedure for addressing residents' grievances. This was evident for 1 (Resident #6) out of 3 residents reviewed for personal property during a survey.The findings include:On 7/15/2025 at 10:09 AM, Resident #6, who was admitted to the facility for rehabilitation, reported that one of her/his long pants was missing. S/he stated that this had been reported to a facility staff member.On 7/17/2025 at 11:20 AM, the Director of Social Services and Discharge Planning (Staff #3) was interviewed. She confirmed that she did not have a grievance form regarding the resident's missing pants.On 7/17/2025 at 11:24 AM, the Director of Social Work & Discharge Planning (Staff #3) was interviewed. She reported that a resident or family member can report grievance either electronically or verbally to a staff member. A staff member who receives a grievance is expected to document it online. The grievance is then sent to the appropriate department, and the actions taken to resolve the grievance 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 interviews with facility staff and review of the dietary supervisor credentials, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation.The findings include:On 7/15/25 at 8:10AM an observation of the facility kitchen was made. During the interview the kitchen manager (Staff #13) reported that her highest level of credentials were in serv safe. She reported that she was in the process of taking the Certified Dietary Manager (CDM) class. She reported that she received consultation from the Regional Dietary Manager. On 7/18/25 at 10:17 AM an interview was conducted with the Regional Dietary Manager (Staff #31). He reported that he was just filing in with the regular dietary manager. Dietary Manager (Staff #31) reported he was not sure he reviewed his certificated dietician certification (CDM), but he would look for it and provided it to the survey team. No CDM certification was provided prior to the end of the survey.On 7/21/2025 9:32 AM during an interview 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 observations and interviews, the facility failed to maintain a clean and comfortable homelike environment. This was evident for eight of eight days of environmental observations.The findings include: On 7/15/2025 at 8:20 a.m., the surveyor noted a strong odor of urine in the C-wing and observed stains on the carpeting throughout the C-wing.On 7/15/2025 at 10:20 a.m., the surveyor interviewed Resident #33 and their family member. Both expressed concerns about the facility's cleanliness. The family member pointed to the carpet near the resident's bed and stated that it was filthy. The surveyor observed heavy staining on the carpet in that area.On 7/15/2025 at 3:37 p.m., Resident #33's family member called the surveyor to express continued concerns, stating that the facility had drastically gone downhill, especially regarding cleanliness. They commented, We knew something was going on because there was more cleaning and staff here today than ever, referring to the presence of surveyors in the building.On 7/16/2025 at 9:56 a.m., the surveyor noted that the strong urine smell…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure the proper storage of medications. This was evident for 1) three of five medication storage areas reviewed, 2) one unsecured storage room (C-Wing), 3) inappropriate temperature control and ice buildup in two refrigerators (C-Wing and A-Wing), and 4) the presence of food items in a medication refrigerator (West View Heights).The findings include: Based on observation, interview, and record review, it was determined that the facility failed to ensure the proper storage of medications. This was evident for 1) one medication room that was unable to be secured (C-Wing) of three medication rooms reviewed, 2) two medication refrigerators kept at inappropriate temperatures in two of three medication storage rooms (C-Wing and A-Wing), 3) one medication refrigerator that contained food on one (West View Heights) of three medication rooms observed, 4) one unlocked medication cart of two medication carts reviewed on canal side terrace B unit, and 5) one unlocked treatment cart of one…

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 interviews, it was determined that the facility failed to honor the resident's/resident representative's right to access personal and medical records. This was evident for 1 (Resident #133) of 2 residents reviewed for neglect. The findings include:A review of the intake information related to MD00217274 indicated that Resident #133's representative had requested medical records after the resident's death and was wrongfully denied the request.In an interview with the resident representative on 7/17/25 at 12:31 PM, s/he reported filling out a medical records request form at the front desk of the facility. Then after some time, had received a phone call from a facility staff informing him/her that the request was denied and no further explanation was provided.The Director of Nursing (DON) was interviewed on 7/23/25 at 2:16 PM. During the interview, she reported the process to request medical records and indicated that a record request form is filled out and submitted to the medical records coordinator (Staff #44) to be processed.On 7/23/25 at 2:45 PM, 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 record review and interviews, it was determined that the facility failed to protect residents from verbal and psychosocial abuse. This was evident for two (Resident's #13 and #52) out of six residents reviewed for abuse.The findings include:1. Resident #13 has a medical history of heart failure, type 2 diabetes, chronic kidney disease, anxiety, and depression.On 7/15/2025 at 2:06 PM, the surveyor reviewed Facility-Reported Incident (FRI) #335325 in which Resident #13 alleged they were subjected to verbal and emotional abuse. The facility investigated the allegation and substantiated findings of verbal and psychosocial abuse by a nursing assistant (GNA #20).According to the facility report, Resident #13 stated that GNA #20 consistently acted rudely, refused to assist, stated she did not have time to help, and told the resident to stop going home because all [you] do is fall. The facility investigation included a statement from GNA #20, who admitted to making inappropriate comments, including that other…

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 record review, it was determined that the facility failed to report an injury of unknown origin. This was evident for one (Resident #33) out of six reviewed for abuse.The findings include: Resident #33 has a medical history of hypertensive heart disease, bladder and fecal incontinence, pressure ulcers, chronic pain, and require assistance with personal care.On 7/15/2025 at 3:37 PM, the surveyor received a phone call from Resident #33's family member, who expressed concerns regarding a prior incident they believed had not been investigated. The family member reported that, a few weeks earlier, they received a phone call from the facility around 7:00 PM. When they attempted to return the call, they were unable to reach anyone. They then contacted Resident #33 directly, who was reportedly very upset and stated that their [private] area was bleeding. The family member indicated that they had reported this concern to the facility. According to the family member, the facility checked Resident #33's fingernails to see if they had caused the injury by scratching but…

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 record reviews, it was determined that the facility failed to investigate an injury of unknown origin. This was evident for one (Resident #33) out of six reviewed for abuse.The findings include:Resident #33 has a medical history of hypertensive heart disease, bladder and fecal incontinence, pressure ulcers, chronic pain, and require assistance with personal care.On 7/15/2025 at 3:37 PM, the surveyor received a phone call from Resident #33's family member, who expressed concerns regarding a prior incident they believed had not been investigated. The family member reported that, a few weeks earlier, they received a phone call from the facility around 7:00 PM. When they attempted to return the call, they were unable to reach anyone. They then contacted Resident #33 directly, who was reportedly very upset and stated that their [private] area was bleeding. The family member indicated that they had reported this concern to the facility. According to the family member, the facility checked Resident #33's fingernails to see if they had caused the injury by scratching…

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 interviews, it was determined that the facility failed to accurately reflect residents skin assessment on the MDS assessment. This was evident for one (Resident #11) out of two reviewed for pressure ulcer care.The findings include: A Minimum Data Set (MDS) is a standardized assessment tool used to evaluate the health status of residents in long-term care facilities. The information gathered assists facilities in developing patient-centered care plans based on the resident's unique needs. The MDS assessment is a mandated requirement for all residents.Resident #11 is legally blind, has a medical history of a stroke (cerebral infarction), is incontinent of bowel and bladder, and requires assistance with personal care.On 7/22/25 at 10:23 AM, the surveyor performed a record review of Resident #11's MDS assessment dated [DATE]. Section M, Skin Conditions, revealed the following: Section M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, was coded as zero or none for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it was determined that the facility failed to ensure that residents received proper treatment and assistive devices to maintain their hearing abilities. This was evident for 1 resident (Resident #13) out of 2 residents reviewed for sensory/communication during a survey.The findings include:On 7/16/2025 at 9:11 AM, Resident #13, a long-term resident of the facility, reported that s/he has hearing aids but stated that staff don't have time to put them in. The surveyor observed that the resident was not wearing hearing aids.On 07/23/2025 at 10:16 AM, a review of the Care Plan failed to show any reference to Resident #13 having hearing aids.On 07/23/2025 at 10:21 AM, a review of the admission assessment dated [DATE] under the Sensory Communication section revealed that the resident was hard of hearing. Further review showed documentation stating that the resident did not have hearing aids.On 07/23/2025 at 10:24 AM, during an interview with Nurse (Staff #15), he…

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 record review, it was determined that the facility failed to provide pressure ulcer wound care as ordered by a physician. This was evident in two (Resident's #11 and #33) of two reviewed for pressure ulcer care.The findings include:1). Resident #11 is legally blind and has a history of stroke (cerebral infarction), urinary incontinence, aphasia (a language disorder that affects the ability to communicate), skin disorders, and requires assistance with all personal care.On 7/22/25 at 10:31 AM, the surveyor reviewed Resident #11's care plan, which documented the following: The resident has an unstageable pressure ulcer to the sacrum and is at risk for wound deterioration and the development of additional wounds due to inability to turn and reposition independently and moisture-associated skin damage. The resident is at risk for pressure ulcers related to decreased mobility. Interventions include assessing the resident for risk of skin breakdown, keeping skin clean and dry, performing skin assessments as indicated. The resident is noted to have impaired tissue…

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

Based on record reviews, interviews and observations, it was determined that the facility failed to ensure a urine collection bag was secured below the bladder. This was evident for 1 (Resident #73) of 3 residents reviewed for urinary catheters. The findings include:A Foley catheter is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons. Another name for a Foley catheter is an indwelling urinary catheter.Resident #73 was admitted in early 2023 with diagnoses that include chronic kidney disease. On 7/15/25 at 9:54 AM, Resident #73 was observed during the initial pool of the survey. The resident was in bed in the lowest position and a tube was observed sticking out on the side of the bed from the resident's blanket. An amber colored fluid was observed on the tubing.The Licensed Practical Nurse (LPN #5) assigned to care for Resident #73 was interviewed on 7/15/25 at 9:57 AM, in the resident's room. During the interview, LPN #5 lifted the resident's blanket and 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 record review and interview, it was determined that the facility failed to provide proper monitoring of a resident receiving nutrition through a gastrostomy tube. This was evident for 1 (Resident #6) of 1 resident reviewed for tube feeding during the survey.Findings include:On 7/16/25, a review of Resident #6's medical records revealed that s/he was admitted to the facility for rehabilitation and received nutrition via a gastrostomy tube.A gastrostomy tube (G-tube) is a flexible plastic tube inserted through a small opening in the abdomen directly into the stomach. It enables delivery of nutrition, fluids, and medications when a person cannot eat or swallow normally.On 7/16/25, a review of Resident #6's weight records revealed the following:On 6/6/25, the resident weighed 180 lbs.On 7/1/25, the resident weighed 177 lbs.On 7/21/25, a review of medical orders failed to reveal an order for weights. However, further review revealed the following order: Check for residual prior to feeding every shift. If it is greater than 120 mL, hold feeding for 1 hour and recheck. If residual…

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

Based on record review, interviews and observation, it was determined that the facility failed to ensure oxygen therapy was provided according to the physician's order. This was evident for 1 (Resident #5) of 1 resident reviewed for respiratory care.The findings include: During the initial pool of the survey, Resident #5 was observed on 7/15/25 at 9:11 AM. During the observation, the resident was in bed receiving oxygen via nasal canula, set at a rate of 3 liters per minute.On 7/15/25 at 11:33 AM, Resident #5's medical order was reviewed and revealed an oxygen therapy order of 2 liters per minute via nasal canula.The Licensed Practical Nurse (LPN #5) assigned to care for Resident #5 was interviewed on 7/15/25 at 12:40 PM. During the interview, LPN #5 confirmed that the resident was currently receiving oxygen at 3 liters per minute. LPN #5 was asked if she knew what the order was for the resident's oxygen therapy. LPN #5 stated, I'm not sure what his/her orders are and indicated that she would check the computer.After reviewing the orders at 12:44 PM, LPN #5 confirmed that the rate…

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 interviews, it was determined that the facility failed to ensure pain management was provided to the resident based on professional standards of practice. This was evident for 1 (Resident #139) of 1 resident reviewed for pain management. The findings include:Resident #139 was newly admitted into the facility. In an interview with the resident on 7/16/25 at 9:24 AM, s/he reported that s/he was taking pain medication but was not helping that much.Tramadol is used to relieve moderate to moderately severe pain, including pain after surgery. It is also used to treat pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. A review of Resident #139 medical record on 7/24/25 at 9:08 AM revealed an order for Tramadol to be taken every 8 hours as needed for pain. The electronic medication administration record (eMAR) for July 2025 revealed that the resident received the Tramadol 5x (7/16/25-5:20am; 7/17/25-1:10pm, 9:12pm; 7/21/25-3:13pm; and 7/22/25-4:26pm).There was no order or documentation…

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 failed to ensure Geriatric Nursing Assistants (GNAs) received an annual performance review and 12 hours/year of in-service training for 2 (GNA #20 and GNA #21) out of 2 employee records reviewed during the survey.The findings include:Geriatric Nursing Assistants (GNA) require a performance appraisal to be completed at least every 12 months to identify the potential for and receive at least 12 hours/year of in-service education. On 7/23/25 between 1:00 and 4:00 PM six employee training records were reviewed. On 7/24/25 at 9:18 AM in an interview with the Director of Nursing (DON) it was revealed that the facility uses Relias, an online training and education application. It was also revealed that the Staff Development Coordinator (SDC) tracks employees’ compliance of the training required. On 7/24/25 at 9:31 AM in an interview with the SDC (RN #19) it was revealed that her position was started in April 2025. She acknowledged that it was her responsibility to track staff compliance via Relias. On 7/24/25…

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 interview, it was determined that the facility failed to ensure the accurate documentation of controlled substances in the narcotics daily count logs. This was evident for two of two narcotic record books reviewed (A-wing and C-wing) during the medication administration observation task.The findings include:On 7/17/2025 at 8:44 AM, the surveyor observed and reviewed the narcotics log for the C-wing of the facility. The following discrepancies were identified: On 4/5/25 at 7:00 PM, 4/6/25 at 7:00 AM, and 4/10/25 at 11:00 PM, the narcotics log was not signed, and the count was not confirmed as correct. On 4/11/25 at 11:00 PM, the narcotic count was signed by only one staff member, instead of the required two signatures to validate the count.On 7/17/2025 at 9:16 AM, the surveyor conducted a further review of the narcotics log and noted that the following fields were incomplete:Narcotic Kit Sealed, Narcotic Kit Seal Number Verified, and Status of Count Exact. These fields were left blank on: 7/13/25 at 7:00 AM, 3:00 PM, and 11:00 PM 7/15/25 at…

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 interviews, it was determined that the facility failed to ensure the provider responded to a recommendation made by a consulting pharmacist. This was evident for 1 (Resident #21) of 5 residents reviewed for unnecessary medications.The findings include: A review of Resident #21's medical record was conducted on 7/17/25 at 8:18 AM. The review revealed a medication regimen review (MRR) report was conducted by the consultant pharmacist on 6/30/25.The consultant pharmacist indicated that Resident #21's order for Risperidone lacked an allowable diagnosis to support its use and listed several diagnosis/conditions for the provider to consider adding to the order. The report was signed by the Psychiatric-Mental health Nurse Practitioner (Staff #37) on 7/7/25 but failed to indicate a response to the recommendation.A review of Resident #21's medical order for Risperidone was conducted on 7/17/25 at 10:13 AM. The review revealed that the order for risperidone was last revised on 7/29/24 and still lacked the appropriate diagnosis to support its use. The Director 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 pertinent document review and interview it was determined that the facility failed to provide the residents with medications as ordered by the physician. This was evident for 1 Resident (resident #135) out of 4 residents reviewed for neglect during a survey. The findings include: On 7/22/25 8:00 the Review of a complaint submitted from a county agency revealed a concern that Resident #135 did not receive her/his medications on time.On 7/22/25 at 10:10 AM the surveyor requested the medication administration audit for Resident # 135 for the following dates: 2/26/25 through 3/03/25 07/22/2025 11:31 AM the Nurse Unit Manager (Staff # 8) was interviewed. She provided interpretation of the medication administration audit. She reported that the first column indicated what time the medication was ordered the second column indicated what time the medication was administered.On 7/22/2025 11:22 AM a review of the audit included but was not limited to the following medications not being administered according to professional standards.Medication: hydroxyzine HCL Oral Tablet, give 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, interviews and observations, it was determined that the facility failed to provide routine dental services to a Medicaid funded resident. This was evident for 1 (Resident #21) of 3 residents reviewed for dental care.The findings include: Resident #21 was admitted into the facility in mid-2020. Medical records indicated that the resident had intact cognition.On 7/15/25 at 1:08 PM, Resident #21 was interviewed. During the interview, the resident was observed to have broken teeth and reported that s/he had not seen a dentist since being in the facility.On 7/16/25 at 3:13 PM, a review of the most recent comprehensive assessment of Resident #21, with a reference date of 5/1/25 indicated that the resident had an obvious or likely cavity or broken natural teeth.The Director of Nursing (DON) was interviewed about dental services on 7/21/25 at 11:58 AM. during the interview, the DON reported that the facility uses Healthdrive as the group providing dental services to all residents since the facility's change of ownership in October of 2024. The DON explained 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, interview, and record review, the facility failed to implement an effective process to ensure that residents received their preferred beverages. This was evident for 4 (Resident #108, # 17, 90, #91) out of 6 residents observed for Dinning during a survey.The findingsOn 7/17/25 at 12:26 PM an observation was made of lunch trays delivered on the terrace unit. On 7/17/25 at 12:30 PM an observation of Resident #108's meal ticket indicated that milk was listed as part of the meal. However, observation of the food tray revealed that milk was not present. GNA (Staff # 11) confirmed that the milk was missing from the tray. On 7/17/25 at 12:30 PM an observation of Resident #17s meal ticket indicated that milk was listed as part of the meal. However, observation of the food tray revealed that milk was not present. Admissions Director (Staff #12) confirmed that the milk was missing from the tray. On 7/17/25 at 12:37 PM an observation of Resident #90's meal ticket indicated that milk was listed as part of the meal. However, observation of the food tray revealed that milk…

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

Based on observation, interview and record review it was determined that the facility failed to ensure resident care equipment was in good working order. This was evident for 1 (R#94) of 34 residents screened on the A Wing unit during the recertification survey.The findings include:On 7/15/2025 at 9:48 AM an observation of Resident #94's room was conducted. The resident was in bed, and an air mattress pump machine was seen hanging on the footboard. The electrical wires were lying on the floor, the ends were frayed, and none of the machine's indicator lights were on. The unit nurse (Staff #1) came into the room during the observation but was unaware of the non-functioning, broken air mattress pump until the surveyor informed her. She said she would call maintenance to fix it.On 7/17/2025 at 10:45 AM the A wing unit manager (Staff #22) was interviewed regarding Resident #94's air mattress. She said she was unaware that the resident air mattress pump was broken and further explained that all resident care equipment should be checked each shift. When asked for documentation that the…

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

Based on observations and interviews, it was determined that the facility failed to ensure residents had access to call bells and failed to ensure that call bells were maintained in working condition. This was evident for four of thirty-five residents reviewed (Residents #37, #92, and #112, #5) who did not have call bells within reach, and for two of twenty-seven residents (Residents #25 and #42) whose call bells were present but not functioning.The findings include: 1.) On 7/15/2025 at 8:20 AM, the surveyor began the initial screening of residents for the facility annual survey. On 7/15/2025 at 8:25 AM, the surveyor observed Resident #92 sitting at their bedside eating breakfast. The surveyor noted that the call bell had been placed in the resident's drawer, out of the resident's reach. Additionally, the surveyor observed their roommate, Resident #112, sleeping in bed with their call bell on the floor and out of reach. The surveyor saw the Unit Manager (Nurse #22) walking down the hallway and asked her about the facility's expectations regarding call bell placement. She confirmed…

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 record review it was determined that the facility failed to have a process to ensure that all grievances were investigated and received a response in a timely manner. This was evident for 2 (#87 and #95) of 2 residents reviewed for the grievances. The findings include: 1) During an interview with the Director of Nursing (DON) on 4/2/25 at 8:08 AM, she reported that Resident #87 had requested to speak with a surveyor. The DON reported that this resident had an ongoing complaint about the number of staff assigned to the unit. She stated that when the resident used his/her call light, they expected it to be answered right away. She stated that when she had pulled the audit reports the resident's wait time was about 16 minutes. The DON stated they offered the resident a room change, but s/he had declined. An interview with Resident #87 on 4/2/25 at 8:46 AM, revealed that s/he had concerns with the number of staff assigned to their unit because s/he waited extended times for call light response. When asked if the resident had reported this concern to 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 record review and staff interview; it was determined that the facility failed to protect a resident (resident #59) from misappropriation of personal funds from a facility staff member. This was evident for 1 of 94 residents reviewed during an complaint survey. The findings include: The surveyor reviewed a complaint (MD00186172) sent to the State of Maryland's Office of Health Care Quality in 12/22 alleging that facility staff made unauthorized charges on resident #59's credit card. Medical record review for resident #59 on 3/31/25 at 11:00am revealed the resident was transferred from the facility on 11/3/22 for a change in condition. The resident was expected to return to the facility, so the resident's belongings remained in the facility. On 3/31/25 at 11:20am, The surveyor interviewed the Administrator regarding the allegation of facility staff making unauthorized charges to resident #59's credit card in 11/22. The Administrator provided the surveyor with the facility investigation into the…

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

Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #61) This was evident for 1 of 94 residents reviewed during a complaint survey. The findings include: On 4/14/23, the facility reported an incident (Intake # MD00191371). Resident # 61 received a blister/burn from an incorrectly placed warm compress. Medical record review for resident #61 on 4/1/25 at 8:40am revealed a progress note dated 4/15/23 at 1:45pm which reported that the resident sustained a blister/burn to his/her right lower lateral foot after facility nursing staff applied a resident- requested warm compress. Surveyor review of the facility's investigation of the reported incident on 4/1/25 at 9:30am revealed the nursing staff reported an observed right lateral foot blister measuring 2.5cm x 1.2 cm on 4/15/23. Nursing staff applied a skin barrier ointment to the blister. Resident #61 did not complain of any pain. Nursing staff statement on 4/18/23 reported that the warm compress was applied to resident #61's right foot after request. The…

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

Based on interview and record review it was determined that the facility failed to ensure that there were enough staff on duty to answer call lights in a timely manner for the residents. This was evident for 2 of 3 complaints for call bell response times. The findings include: 1) An interview with Resident #87 on 4/2/25 at 8:46 AM, revealed the resident had concerns about the call light response times. The resident recalled that s/he had waited a few hours for staff to answer his/her call light on a day in the last couple of weeks. The resident could not recall the exact date and thought it occurred between breakfast and lunch. The resident reported s/he needed assistance with incontinence care. The extended wait time for call lights was confirmed on 4/2/25 at 10:00 AM when a review of the call bell audits for 3/20/25 - 4/1/25 was conducted. Resident #87 waited 30 minutes to 3 hours for his/her call light to be answered. 2) An interview with Resident #95 on 4/3/25 at 9:01 AM, revealed that s/he had extended wait times when s/he put his/her call light to use the bathroom. 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 the review of a complaint, medical record review and interview with residents and staff, it was determined that the facility staff failed to administer medications to residents without any significant medication errors by inappropriately administering insulin to 2 residents that were not diabetic. This was evident during the review of a complaint that affected 2 of 2 residents during a medication pass. The findings include: Complaint #MD00190191 was initiated on 3/27/25 at 11:31 AM regarding Resident #36. The allegation was that s/he was given insulin on 3/17/23 inappropriately as s/he is not diabetic. According to medical record review at this time, Resident #36 was admitted to the facility over 5 years ago for care related to a kidney/pancreas transplant, Resident #36 is also diagnosed as legally blind and monitored for hypoglycemia. Second, to the transplant, Resident #36 is not considered diabetic and does not take any insulin products. Review of the complaint #MD00190191 on 3/27/25 at 11:40AM revealed an allegation that on 3/17/23 Resident #36 was 'stuck in the arm…

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 develop and implement abuse policies and procedures. This was evident during the survey and has the potential to affect all residents. The findings include: On 6/16/22 at 12:24 PM, the Associate Administrator provided a copy of the Resident Abuse Reporting Policy and Procedure and reported that this was the version that was active. It was noted as Corporate Policy - Abuse 5-2017 in the bottom right corner of the policy. A review of the policy and procedure revealed that, on page 2, under Reporting Procedure: Maryland law requires employees to report all alleged violations involving resident neglect, or abuse, including injuries of unknown origin, and misappropriation of property. The first bullet stated to report immediately or within 2 hours of forming the suspicion and the second bullet included documentation to report suspected abuse to the Administrator, or to the immediate supervisor who must then report to the Administrator. On page 3 of the document, it was noted that the Administrator…

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

Based on a review of medical records, policies, and other pertinent documentation, observations, and interviews, it was determined that the facility failed 1) to ensure that staff completed the controlled drug count at the change of shift as evidenced by missing/inaccurate documentation by nursing staff that the count had been completed prior to the end of the shift, and 2) to ensure that nursing staff routinely signed that the count was correct at the change of shifts. This was evident for 6 (Rehab units 1 & 2, long-term care units A, B, and C) out of 6 medication carts reviewed for the controlled drug count verification sheet.The findings include: A controlled drug means a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction. The control applies to the way the substance is made, used, handled, stored, and distributed. Controlled substances include opioids, stimulants, depressants, hallucinogens, and anabolic steroids. (National Institutes of Health) Controlled Drug Count Verification is the shift count sheet for narcotics…

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

Based on observation, interview and review of relevant documentation, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food safety as evidenced by the facility's failure to 1) have a cleaning schedule for the ice machine; 2) seal and label open containers of food; and 3) ensure that elevated temperatures in the nursing unit food refrigerators were reported to maintenance. This has the potential to affect all residents. The findings include: On 6/6/22 at 10:00 AM, the following observations were made during a tour of the kitchen with the Executive Chef Staff #43: -Observation of the ice machine revealed scattered small black dots covering 3/4 of the ceiling of the ice machine. The executive chef was unable to locate a cleaning schedule for the ice machine and was unable to report when it was last cleaned. - In refrigerator #4, an opened bag containing hotdogs was observed unsealed. Three containers wrapped in foil were not labeled or dated. The executive chef identified these as cheese and removed them from the…

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

Based on observation, resident and staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that the facility had the resources and that those resources were used effectively in order to meet the health and safety needs of each resident and failed to identify and correct inappropriate care processes/standards, as evidenced by 1) failing to revise and update the facility's Resident Abuse Reporting Policy and Procedure, 2) failing to ensure that facility staff protected residents from abuse and neglect, 3) failing to ensure the facility reported investigations to the State Agency within the required time frame, 4) failing to ensure that all allegations of abuse were thoroughly investigated so that the necessary actions could be taken to prevent further abuse. The Administration's failure to ensure that processes were in place that could identify and correct deficient practices in care that had the potential to adversely affect the health and safety of all the residents 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 record review and interview, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 19 out of 22 staff (Geriatric Nurse Aide #9, #18, #24, #27, #31, #39, #46, #47, #48, #49, #50, #51, #55, Licensed Practical Nurse #1, #19, #32, Registered Nurse #34, #35, and Social Worker #21) not up to date staff reviewed for COVID-19 testing during the survey This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The finding includes: COVID-19 Vaccine up-to-date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. (Center of Disease Control: CDC) The CDC has developed COVID-19 Community Levels to help communities decide what prevention steps to take based on the latest local COVID-19 data. Levels are determined each week for each county in the U.S. A county's risk level can be low,…

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 with facility staff, a review of the facility's policies and procedures, and a review of the facility's testing documentation, it was determined that the facility failed to implement their policies and procedures for testing staff who were granted an exception for COVID-19 vaccinations. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The finding includes: On 6/22/22 at 09:40 AM, the facility's policy and procedure titled Vaccine Exemptions & Accommodations was reviewed. It stated, All unvaccinated employees are required to submit to twice-weekly testing (or more frequently if indicated by Federal, State, or Local law or guidelines or WRV) regardless of the community transmission rate. All results must be entered into the testing database, SimpleReport., and all unvaccinated staff are required to wear an N95 while in the facility unless eating or drinking during break times. The surveyor randomly selected 10 unvaccinated staff on 6/22/22 at 10:20 AM and reviewed their COVID-19 testing record from 5/1/22 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 medical record review and interview, it was determined that the facility staff failed to ensure that 2 physicians' certificates of incapacity were obtained, and Advance Directives were completed as per the Health Care Decisions Act prior to allowing resident representatives to make informed health care decisions on the resident's behalf. This was evident for 7 (#97, #71, #83, #70, #35, #78 and #26) of 26 residents reviewed for advance directives during the survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. According to the Health Care Decisions Act: 5-602 (d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to appoint an agent to make health care decisions for the…

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

Based on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that restorative nursing services were incorporated into residents' care plans and provided by staff as recommended upon discharge from therapy. This was found to be evident for 3 (#28, #7, #33) of 6 residents reviewed for decline in activities of daily living and positioning. The findings include: 1) On 6/7/22, Resident #28 was observed to have contractures in both hands. The resident confirmed that his/her hands had been like that since before admission to the facility. A contracture is a tightening of muscles that causes joints to become stiff, preventing normal movement of the joint. Contractures can be caused by inactivity. On 6/14/22, review of the medical record revealed orders for occupational therapy (OT) starting in January 2022. The OT orders were discontinued on 2/4/22. On 6/15/22, review of the 3/17/22 Minimum Data Set assessment revealed the resident had function range of motion impairment on both sides of the body in both upper and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, it was determined that the facility failed to maintain complete and accurately documented medical records for each resident as evidenced by: A) Failing to have an effective system in place to ensure that both paper and electronic versions of the MOLST forms were voided when a new MOLST was established for 6 (#97, #7, #71, #26, #35, and #70) of 13 residents reviewed for advance directives. B) Falsely documenting completion of treatment interventions that were not actually provided for 1 (#35) of 13 residents reviewed for abuse. C) Failing to document resident behaviors as per the physician order for 1 (#201) of 13 residents reviewed for abuse. The findings include: A) Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. Once a MOLST order form is completed and…

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

Based on observations, review of facility records, and resident and staff interview, it was determined that the facility failed to implement an effective Quality Assessment and Assurance (QAA) based on repeat deficiencies related to 1) resident abuse, 2) abuse policies and procedures, 3) timely reporting of allegations of abuse to the state agency, 4) conducting a thorough investigation of allegations of abuse, 5) physician notification for a resident's change in condition, 6) notice of bed hold policy, 7) respiratory care services, 8) residents unnecessary medications, 9) improper storage of medications, 10) inaccurate/incomplete medical records, and 11) posting of nursing staff for all units. This was evident for 1 recertification survey reviewed and 1 complaint survey reviewed. The failure to assess and correct identified deficient practices has the potential to affect all residents in the facility. The findings include: 1) On 6/23/22 at 4:15 PM, a review of a complaint survey that was conducted 9/23/20, 9/24/20 - 10/2/20, and 10/5/20 - 10/8/20, revealed that 4 complaints and 7…

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

Based on medical record review and staff interview, it was determined the facility failed to document that education was provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff. This was evident for 2 (#21 and #71) of 5 residents and 4 (#28, #35, #46, and #47) of 4 facility staff members reviewed for COVID-19 vaccinations during the survey. The findings include: On 6/16/22 at 4:20 PM, a medical record review was conducted for Resident #21. A consent form was found in the resident's paper chart marked as refused COVID-19 vaccine, dated 6/02/21. However, no documentation was found for evidence of education provided under the resident's paper chart or electronic medical record. A medical record review of Resident #71 was conducted on 6/17/22 at 8:00 AM. The resident signed a COVID -19 Vaccination Declination form on 10/13/21. However, there was no supportive documentation regarding the resident's education regarding the risks or benefits of receiving the vaccine. During an interview with the Director of Nursing (DON)…

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 interview, it was determined that the facility failed to allow residents to exercise their rights as evidenced by staff throwing away old newspapers that belonged to a resident who had asked staff not to throw them away. This was evident for 1 (#63) of 61 residents reviewed. The findings include: On 6/6/22 at 3:16 PM during an interview with Resident #63 regarding the care and services that he/she received, Resident #63 reported that he/she had some old newspapers that had been thrown away by Geriatric Nursing Assistant (GNA) #9 after Resident #63 had told her not to throw them away. Resident #63 reported that the cleaning person had come in and emptied the trash and now his/her papers were gone and he/she had wanted to keep them. Resident #63 stated that he/she had not reported this incident to facility staff. On 6/6/22 at 3:30 PM this incident was reported to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) immediately following the interview. A follow up interview was conducted with the ADON on 6/14/22 at 8:39 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 medical record review, staff interview, and resident interview, it was determined that the facility failed to fully inform the resident in a manner that they could understand of the reason for their special contact isolation isolation secondary to a possible C-Diff infection. This was evident for 1 (#513) of 15 residents reviewed. The finding includes: On 6/7/22 at 12:40 PM, an interview was conducted with Resident #513. During the interview, the resident stated, I don't know why I need to be isolated, nobody explained why or how long I need to. I had no issue when I was in the hospital. On 6/13/22 at 9:39 AM, a review of the medical records revealed the resident was admitted to this facility on 5/28/22 for rehabilitation. The resident's BIMS (Brief Interview for Mental Status) score was 15/15 on admission, indicating the resident was cognitively intact. Further record review revealed that Resident #513's physician ordered special contact isolation to be maintained for possible C.diff on 6/4/22. C. diff (also known as Clostridioides difficile or C. difficile) is a germ…

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 family and staff interview, it was determined that the facility staff failed to notify the physician when a resident's blood pressure was high. This was evident for 1 (#251) of 4 residents reviewed for complaints. The findings include: On 6/9/22 9:00 AM, at a review of complaint #MD00175512 was conducted. In the complaint, the complainant reported concerns related to the care that Resident #251 received while they resided in the facility. At that time, a review of Resident #251's medical record revealed that the resident was admitted to the facility in October 2021 with multiple diagnosis including, but not limited to Hypertension, and had a history of Coronary (heart) artery disease, and had Coronary artery bypass grafting (surgery where a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart. On 6/9/22 at 9:40 AM, during a phone interview, the complainant reported that following Resident #251's discharge from the facility, the complainant requested a copy of the…

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

Based on interview and observation, it was determined that facility staff failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. This was evidenced by the facility's failure to ensure that the resident's bathroom walls were clean and sanitary for 1 (#18) of 7 residents reviewed for general concerns. The findings include: An interview was conducted with Resident #18 and his/her friend on 6/16/22 at 2:18 PM after the resident indicated that he/she would like the friend to participate in the interview. During the interview, the resident's friend indicated that housekeeping was in and out of the resident's room in 5 minutes and that many times, the floors had not been cleaned. The friend reported that there was a spot on the wall in the bathroom between the toilet and the sink, that it had been there for a while, and no one had cleaned it. Resident #18 added that he/she utilizes a bedpan and staff empty it in the toilet in the bathroom, Resident #18 stated they must have splashed it on the wall. An observation was made of the bathroom 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that grievances were thoroughly investigated and failed to ensure documentation of investigation follow up. This was found to be evident for 1 (#28) of 13 residents reviewed for abuse during the survey and 1 (#38) of 3 resident's reviewed for Personal Property. The findings include: 1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process. On 6/15/22, review of the Concern Reports pertaining to Resident #28 revealed two reports for May 2022. The first one was dated 5/27/22 and was in reference to a letter the resident's family member had submitted regarding an employee that had been talking disrespectfully. The…

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

Based on record review and interview, it was determined that the facility failed to ensure that their residents were free of abuse as evidenced by staff to resident abuse that was substantiated. This was evident for 1 (#61) of 11 residents reviewed for abuse. The findings Include: A medical record review for Resident #61 on 6/14/22 at 7:40 AM revealed an annual MDS, with an Assessment Reference Date of 4/22/22, which documented in section C that resident had scored a 13 out of 15 on a Brief Interview for Mental Status (BIMS - a standardized test to determine a resident's level of cognitive functioning) which indicated an intact cognition. Section E documented that Resident #61 had physically agressive behaviors directed towards others such as hitting and kicking. Also, it was noted that these behaviors occurred 1-3 days during the 7 days reviewed, and that it interfered with care. In section G it was documented that Resident #61 was totally dependent on staff to provide care. On 6/13/22 at 3:38 PM, a review of the Facility's Investigation file for the self-report MD00174072 revealed…

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

Based on record review and staff interviews, the facility failed to maintain an environment free of physical restraints. This was evident for 1 (#509) of 11 residents reviewed for abuse. The findings include: A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. A gait belt or transfer belt is an assistive device put on a person who has mobility issues, by a care giver, prior to moving the person and can be used to help a person transfer from one surface to another, stand, or walk around. On 6/23/22 02:31 PM, a facility reported incident #MD001793 was reviewed. The facility's self-report indicated that the report was for abuse, and included documentation that, on 6/17/22 at approximately 7:00 PM, a nurse entered Resident #509's room and witnessed that Resident #509 had a gait belt around his body as well as his/her chair, confining the resident to the chair. Review of the facility's investigations into 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 review of medical records, facility investigation documentation and other pertinent documents, and interviews, it was determined that the facility failed to develop and implement abuse policies and procedures to ensure that facility staff appropriately identified and reported allegations of abuse to the Administrator immediately and to ensure that once the facility had been aware of an allegation of abuse that they reported it to the state agency within the required timeframes. This was evident for 4 (#28, #71, #61, and #35) of 13 residents reviewed for abuse during the survey. The findings include: 1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process. On 6/14/22, review the facility reported incident MD00177857 revealed the resident reported to a nurse on 5/28/22 that on 5/26/22 GNA #13 stated you have a big butt. On 6/14/22 at 8:35 AM, 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 medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that abuse allegations were thoroughly investigated to determine if abuse occurred and take appropriate action. This was found to be evident for 4 (#28, #35, #63, and #83) out of 13 residents reviewed for abuse during the survey. The findings include: 1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated that the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process. On 6/14/22, review of the facility reported incident MD00177857 revealed that the resident reported to a nurse on 5/28/22 that, on 5/26/22, GNA #13 stated you have a big butt. Interview with the Assistant Director of Nursing (ADON) on 6/14/22 at 8:35 AM revealed that she had spoken to the resident and…

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

Based on medical record review and interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status as evidenced by failure to accurately identify a resident's range of motion status. This was found to be evident for 2 (#74, #33) of 4 residents reviewed for position and mobility. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident.On 6/9/22, review of Resident #74's medical record revealed the resident had resided at the facility for several years. Since 5/3/22, the resident's diagnosis include contractures of left and right hip and both knees. A contracture is a tightening of muscles…

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 1) failed to have an effective system in place to ensure that restorative nursing services were incorporated into resident care plans, 2) failed to develop and implement a comprehensive person-centered care plan for a resident with limited range of motion and contractures and a resident with hypomagnesemia, 3) and failed to follow the care plan. This was evident for 3 (#74, #28, #7) of 4 residents reviewed for a decline in activities of daily living, 1(#88) of 4 residents reviewed for hospitalization, 1 (#33) of 4 residents reviewed for position/mobility, and 1 (#251) of 4 residents reviewed for complaints. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 6/9/22, review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnosis included contractures of left and right hip and both knees. Review of…

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

Based on review of the medical record, it was determined the facility staff failed to ensure that the resident's plan of care was reviewed and revised by the interdisciplinary team after a quarterly review assessment. This was evident for 1 (#5) of 3 residents reviewed for skin assessments. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Resident #5's medical record was reviewed on 10/26/22 at 11:00 AM. The record revealed that 2 Plans of Care were developed related to Resident #5's skin integrity. The first: Potential for impaired skin integrity was initiated 8/8/16 and included an updated focus: 6/22/22, scratch to left lower jawbone. It indicated that it was revised on 10/3/22 but did…

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, review medical records and facility policy, and interview with staff, it was determined that the facility failed to ensure that each resident received necessary respiratory care and services. This was evidenced by the facility staff's failure to properly date and label oxygen tubing when changed for 2 (#78 and #26) of 6 residents reviewed for Respiratory Care, and failed to ensure that care was provided in accordance with facility policy and the resident's plan of care for 1(#26) of 6 residents reviewed for Respiratory Care. The findings include: 1) On 6/7/22 at 11:09 AM, the surveyor observed Resident #78 sitting in a wheelchair at a table in the dining room, socializing with other residents. An oxygen concentrator (a machine that concentrates oxygen from the air) was behind the resident. The resident was wearing a nasal cannula (oxygen tube with nose prongs) that was connected to the concentrator. The tubing was not date labeled to indicate when it was last changed. When asked, the resident was unable to recall when it was last changed. Review of Resident…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that physician's progress notes accurately reflected the medications that the resident was currently receiving. This was found to be evident for 2 (#74 and #1) of 7 residents reviewed for unnecessary medications. The findings include: 1a) On 6/9/22,a review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnoses included, but were not limited to, non-alzhiemer's dementia; anxiety, depression and a psychotic disorder not related to schizophrenia. The resident had been receiving the antipsychotic medication Seroquel for more than one year. On 6/13/22, review of the orders and the Medication Administration Record (MAR) for June 2022 revealed that the resident was receiving Seroquel 25 mg every morning and Seroquel 75 mg every evening at bedtime. On 6/13/22 at 11:03 AM, review of the psychiatric nurse practitioner's (#44) note, dated 6/6/22, revealed a section for Current Medications. This section included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with facility staff, it was determined that the facility staff failed to post the required staffing information in a prominent place easily accessible to residents and visitors. This was evident for 1 (Canal Side Skylight) of 6 resident care areas observed during the survey. The findings include: The surveyor observed the C wing 3rd floor - Canal Side Skylight Unit on 6/6/22 at 10:49 AM. Access to the unit required travel via elevator or stairs that required entry of a code into a keypad to unlock. The unit consisted of 8 bedrooms, housing 11 residents. The surveyor was unable to find the unit staffing assignment posted in a prominent place accessible to residents and visitors. Further observation of several bedrooms on C wing 3rd floor including room [ROOM NUMBER], #304 and #310, confirmed that staffing information was not posted within the resident rooms. On 6/6/22 at 11:03 AM, Staff #45 was asked how the C wing 3rd floor Unit was staffed. She indicated that 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 medical record review and interview, it was determined that the facility failed to ensure that the residents were free from unnecessary medications as evidenced by 1) failing to follow a physician's order to monitor a resident's blood sugar four times a day for a resident receiving insulin; and failure to follow the physician's order to hold the insulin injection when the blood sugar level was below 120 and 2) failing to discontinue a duplicate medication as ordered by the attending physician. This was found to be evident for 2 (#59 and #34) of 7 residents reviewed for unnecessary medications during the survey. The findings include: 1) On 6/21/22, review of Resident #59's medical record revealed a diagnosis of diabetes and orders for insulin injections. Further review of the medical record revealed an order, with a start date of 5/11/22, for Fingerstick Blood Sugar levels four times a day and to contact the provider if the level was less than 70 or greater than 400. Review of the Medication Administration Record (MAR) revealed that the Fingerstick Blood Sugar levels were…

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

Based on medical record review and interview, it was determined that the facility failed to ensure the residents were free from unnecessary psychotropic medications as evidenced by 1) the administration of as needed antianxiety medication in the absence of documentation of the need for or request of the medication. This was found to be evident for 1 (#1) of 7 residents reviewed for unnecessary medications. The findings include: On 6/22/22, review of Resident #1's medical record revealed diagnoses that included but not limited to depression and generalized anxiety disorder. The resident had an order, with a start date of 5/16/22, for Xanax every 8 hours as needed for anxiety for 14 days. Xanax, also known as alprazolam, is an antianxiety medication. Review of the May 2022 Medication Administration Record (MAR) revealed that Xanax was administered on 5/19, 5/24 and 5/30. Further review of the medical record failed to reveal documentation of behaviors or requests that would indicate the need to administer the as needed antianxiety medication. Further review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policies review, it was determined that facility staff 1) failed to ensure documentation of a multi-use medication's expiration date when opened, 2) failed to discard medication bottles and medical supplies when expired, and 3) failed to develop policy and procedures for multi-use medication containers and follow the directions. This was evident in 2 of 5 rehab nursing units observed during random observations made during the survey. The findings include: 1) On [DATE] at 1:37 PM, the surveyor inspected a medication storage room on the [NAME] view 2nd-floor with Registered Nurse (RN) #34 attending. The surveyor observed that the Allergy relief medication bottle was opened with the handwritten date marked as 1/23. There was no expiration date marked on the bottle. The surveyor informed RN #34 of the finding. She stated that any opened multi-dose medication bottle would be located on the medication cart and opened bottle should not be placed in the medication…

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

Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure lab results of COVID tests were kept in the resident's medical record. This was found to be evident for 3 (#74, #1 and #59) of 3 residents whose COVID testing results were reviewed during the survey. The findings include: 1) On 6/9/22, review of Resident #74's medical record revealed the resident resided at the facility for several years. Review of the Medication Administration Record for June revealed documenation to indicate that staff had obtained a Nasopharyngeal Swab for COVID testing on 6/1, 6/9 and 6/16/22. The most recent COVID test results found in the electronic health record were from October 2021. On 6/21/22, a review of Resident #74's paper chart failed to reveal documentation of COVID test results. 2) On 6/22/22, review of Resident #1's medical record revealed documenation to indicate staff had obtained a Nasopharyngeal Swab for COVID testing on 6/1, 6/9 and 6/16/22. Further review of the medical record failed to reveal documentation…

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 with the resident and staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to 1) ensure staff were performing hand hygiene between changing gloves, and 2) provide a safe and sanitary environment as evidenced by staff failure to store a resident's toothbrush in a sanitary manner. This was evident for 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and this was evident for 1 (#18) of 61 resident's reviewed during the survey. The findings include: 1) On 6/10/22 at 9:56 AM, an observation was made for RN #33's wound care for Resident #200. RN #33 prepared her materials on the bedside table for the dressing, set up, performed hand hygiene, put on clean gloves, removed the old dressing, and removed the gloves. Without performing hand hygiene, she put on a new pair of gloves, proceeded to clean the wound, and apply the treatment…

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, policy and procedure review, and staff interviews, it was determined that the facility staff 1) failed to document that the residents and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent, 2) failed to develop the policies and procedures to ensure that residents or RPs receives education regarding the benefits and potential side effects of Influenza and pneumococcal immunizations. This was evident for 5 (#21, #22, #57, #59, and #71) of 5 residents reviewed for Immunization during the survey. The findings include: Pneumococcal vaccine help prevents pneumococcal disease, which is any illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through 64 with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is 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 the walk in freezer was functioning in a manner that prevented ice build up, which included ice frozen to the floor; and failed to ensure unit refrigerators were maintained in a manner to keep items at safe temperatures. This was found to be evident for the one walk in freezer in the kitchen; and one of the six unit refrigerators used for storing food items. The findings include: 1) On 6/6/22 at 10:00 AM, during a tour of the kitchen with the executive chef, (#43) the walk in freezer was observed to have small frozen mounds observed on the ceiling in front of the compressor, and an approximately 1.5 inch in diameter mound of ice was stuck to the floor where staff would walk. On 6/16/22 at 11:30 AM, observation of the walk in freezer again revealed ice build up on the ceiling in front of the compressor, similar to the observation on 6/6/22. The food service director (FSD #25) indicated that she was aware of the surveyor's observation on 6/6/22. She reported she had not yet received a final…

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 resident and staff interviews, surveyor observation and record reviews, it was determined that the facility failed to have sufficient nursing staff to assist residents in the dining room at mealtime, to provide restorative services to residents and failed to provide geriatric nursing assistant with yearly evaluations. The findings include: 1) On 10/15/18 at 12:00 PM, during an interview, Resident # 54 stated that residents from the Canal Side Terrace B unit werenot allowed to dine in the Fireside dining room at lunch or dinner when there were not enough nursing staff working on the unit. The resident stated that, when there are 4 GNA's working, the residents can dine in Fireside dining room, and when there are only 3 GNAs, the residents must stay on the floor. Resident #54 stated that 2 GNA's are required to be present with the residents during any meal at the Fireside dining room and 2 GNA's are required to be on the unit. Resident #54 stated that the residents only get to go to the Fireside dining room about once every 3 weeks. Resident #54 stated that, in the Fireside…

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 Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months, for 6 out of 6 personnel files reviewed. The findings include: 1) A review was conducted of Staff #17, #21, #22, #12, #23 and #24's personnel files on 10/19/18. There were no yearly evaluations for 2018 found in the files. he Director of Nursing (DON) stated they were done and in her office. The DON brought the surveyor evaluation forms that were dated June 2018 evaluation at the top of the form. The evaluation form had a rating scale of 1 to 5 with an average overall rating. There was management feedback written on the evaluation form, however, there was no employee feedback. The form was signed by the DON, however, there was no date signed. The words declined meeting were written where the employee signatures were located. This was for all 6 GNA evaluations reviewed. An interview was conducted with the DON on 10/19/18 at 1:30 PM. The DON stated that the staff declined…

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 of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor was responsible for oversight of food preparation and daily kitchen operation. The findings include: An initial tour of the facility's kitchen, on 10/12/18 at 11:10 AM, revealed that the full time Director of Dietary service (Staff #26) was not clinically qualified, as per Federal and state regulations. The Director of Culinary services indicated that he/she had not completed all the course work required prior to taking the certification exam to become a Certified Dietary Manager. The Director of Culinary Services revealed that his/her position has been effective since October 9, 2017. Ongoing conversations with the Director of Culinary Services during the survey revealed that the facility had a part-time dietitian. The current registered dietitian was providing coverage to the the facility 12 hours a week. Review of the requested consultant dietitian's reports for the past 12 months did not reveal any consultation services to the Director 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 staff interview, surveyor observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance program. This was evident during the survey process and review of the Quality Assurance Program. The findings include: Review of the facility's prior surveys and plans of correction revealed that the facility failed to implement effective corrective measures to correct deficient practices related to notification, developing, implementing and revising care plans, nurse aide performance reviews, dignity and medication storage resulting in recurrence of the same deficient practice. These findings were discussed with Staff #1 on 10/19/18 at 3:33 PM.

Based on observation and resident interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by 1) failing to serve all residents at the same table at the same time during dining observations, and 2) failing to cover a urinary drainage bag. The observations were noted during 2 of 2 lunch time dining in the Canal Heights dining room. The findings include. 1) A lunch time dining observation was made on 10/17/18 at 12:35 PM in the Canal Side Heights dining room. Residents #40 and #15 were sitting next to each other at a table in the dining room. At 12:41 PM, resident #40 was served her/his meal tray. Resident #40 indicated/stated that she/he would like to eat at the same time as her/his table mate. Staff were observed serving other tables. Resident #15 was served her/his tray at 12:49 PM. At another table of 8 residents, 5 residents were observed to be eating by 12:45 PM, with three residents waiting. One (resident #33) of the three residents was served her/his lunch tray at 12:56 PM. The next resident #29 was served her/his lunch tray at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to develop comprehensive and implement comprehensive, resident-centered care plans to meet the residents medical, nursing, mental and psychosocial needs. This was evident for 7 (#97, #63, #103, #102, #72, #78, #16) of 38 residents reviewed during the investigation phase of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident#97's medical record was reviewed on 10/16/18 at 2:38 PM. The resident had been hospitalized from [DATE] - 9/6/18 and returned with a Cholecystostomy tube (a temporary tube inserted through the abdominal wall to drain the gall bladder) in his/her abdomen. No plan of care was developed to direct the resident's care and treatment related to the drainage tube. The resident had plan of care for Chronic Pain with the goal: The resident will…

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 interview with facility staff it was determined that facility staff failed to revise resident plans of care to reflect residents' current status. This was evident but not limited to 7 (#60, #34, #41, #43, #100, #16, #73) of 38 residents residents reviewed during the investigative phase of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of Resident #60's medical record revealed a care plan The resident uses antidepressant medication Remeron r/t (related to) depression. The goal was The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The care plan was initiated on 6/26/18. Documentation for this plan of care revealed that the goal was revised on 9/25/18 as the target date for the goal was changed to 12/20/18. Interview of the MDS assessment coordinator (staff #6) revealed that she had simply changed the goal date. Staff #6 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 resident family and staff interview and medical record review, it was determined the facility failed to provide the necessary care and follow-up to ensure that residents received the appropriate treatment and services to maintain, and/or improve ambulatory status. This was evident but not limited for 2 (#9, #30) of 2 residents reviewed for restorative. The findings include: 1) Interview of resident #9's daughter, on 10/12/18 at 3 PM, revealed a concern that resident #9 was to be walked daily. Resident #9's daughter indicated that there was not enough staff to assure her loved one was routinely walked. Review of resident #9's care plans revealed care planning for limited physical mobility r/t weakness, history of left distal femur fracture, pain related to chronic left leg cellulitis, impaired vision and hearing. The goal for this plan of care was The resident will maintain current level of mobility (able to walk with a walker and one assist) through next review. This plan of care was initiated on 6/23/16. One intervention was written as Ambulation the resident requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. This was evident for 1 (#97) of 11 residents reviewed for Nutrition. The findings include: During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost about 4 pounds since his/her last weight and added that he/she gets Redi care supplements with meals. Review of the residents record, on 10/17/18 at 10:28 AM, revealed a physician's order for Renal diet, regular texture with thin liquid consistency. There was no physicians order for nutritional supplements. The residents weight record revealed that he/she weighed 122.2 lbs. (pounds) on 8/3/18. The resident was hospitalized from [DATE] - 9/6/18 and upon return from the hospital, his/her weight on 9/8/18 was 111 lbs. reflecting a 9.17% (11.2 lb.) weight loss in 1 month. A 5% loss in 1 month or 10% loss in 6 months is considered…

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

Based on medical record review, observation and staff interview, it was determined the facility failed to 1) ensure that a resident that was placed on oxygen had a physician's order for oxygen with the amount of oxygen to be administered, 2) failed to develop a respiratory, resident centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) who was placed on oxygen, 3) failed to label oxygen tubing when initiated and 4) failed to ensure that oxygen was administered at the rate ordered by the physician. This was evident for 1 (#103) of 3 residents reviewed for discharge and 1 (#78) of 3 residents reviewed for respiratory care. The findings include: 1) Review of the medical record for Resident #103 on 10/17/18 revealed a nursing admission note written on 9/10/18, which stated that the resident had an oxygen saturation level of 92% on 2L (liters) of oxygen. The resident's admitting diagnosis was CHF (congestive heart failure) along with hypertension, MI (myocardial infarction - heart attack), COPD and renal failure, requiring dialysis 3 times per week. 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 review of the medical records, it was determined that the facility staff failed to ensure that each residents medication regimen was free from unnecessary drugs by failing to hold medications when the residents' vital signs were below the physician prescribed parameters. This was evident for 1 (#100) of 6 residents reviewed for unnecessary medications. The findings include: Resident #100's medical record was reviewed on 10/19/18 at 10:17 AM. The residents prescribed medications included but were not limited to: Lisinopril 10 mg (milligrams) 1 tablet by mouth in the morning for hypertension. Hold for SBP (systolic (upper) blood pressure) < (less than) 130, DBP (diastolic (lower) blood pressure) <55. Isosorbide Mononitrate 10 mg give 1 tablet by mouth in the morning for chronic angina pectoris (chest pain). Hold if apical pulse (pulse obtained by listening to the heart with a stethoscope) <60, Hold for SBP <130. Metoprolol Tartrate 25 mg give 1 tablet by mouth every 12 hours for hypertension. Hold if SBP less than 130, DBP <55, AP <60. Lasix (a fluid pill) 20 mg by mouth one…

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 review of facility narcotic logs, it was determined the facility staff failed to ensure that narcotic counts were performed with dual signatures, that opened refrigeratable medication was labeled with its open date and that medication carts were not left unlocked and unattended. This was evident on 1 (Terrace [NAME] Wing) of 4 hallways observed. The findings include: 1) A review of the 1st floor med cart in the Terrace west wing nursing unit was performed on 10/18/18 at 9:07 AM. During the review, it was found that there was only one signature for the 10/8/2018 7am reconciliation and for the 10/19/18 3pm reconciliation. Change-of-shift reconciliation involves the oncoming and off-going charge nurses simultaneously accounting for all narcotic blister packs on their unit. The nurses conduct the review simultaneously to maintain accountability and then sign in a controlled substance log to represent their participation. Entries with only one signature suggest that the review did not take…

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 residents' medical records and interview with facility staff, it was determined that the facility failed to maintain accurate and complete medical records. This was true for 5 (#114, #103, #97, #216, #77) of 45 residents reviewed during the investigation phase of the survey. The findings include: 1) Resident #114's medical record did not reflect the resident's weight loss. Resident #114's medical record was reviewed on 10/17/18 at 11:19 AM. The resident was admitted to the facility on [DATE] with an admission weight of 181.0 lbs. The Resident's most recent weight was 164.8 lbs and it was taken on 10/17/2018. This was a loss of 8.95% over 2 months. Intervening weights also demonstrated a downward trend. There were 7 weights taken since 10/1/2018 and all of them had an associated weight warning that triggered as part of the electronic medical record system. Progress notes were searched by type and there were no weight change notes. There were also no nutrition/dietary notes. A nutritional…

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 4) Resident #49 was observed sitting in his/her wheelchair in the Canal Side Height's dining room during the lunch-time meal on 10/18/18 at 12:50 PM. The resident had a urinary catheter (a bag connected to a tube which drains urine from the bladder.). The catheter bag was lying on the floor underneath the wheel-chair. Additionally, the content of the drainage bag was not covered to maintain the resident's dignity. The director of nursing was notified of the findings on 10/19/18. Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to: 1) properly label and store resident care items, 2) ensure that a resident's urinary catheter bag was properly kept off the floor and 3) ensure that nursing staff maintain proper hand hygiene practices during medication administration. The findings include: Resident room [ROOM NUMBER] was observed on 10/15/18 at 11:13 AM. 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 the medical record and interview with the resident and staff, it was determined that the facility failed to notify the Physician and Dietician when a resident had a significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition. The findings include: During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost a few pounds since his/her last weight. A review of the resident's medical record on 10/17/18 revealed that Resident #97's weight was recorded on his/her weight record as 122.2 lbs. (pounds) on 8/3/18. He/She was hospitalized [DATE], returned to the facility on 9/6/18 with a readmission weight on 9/8/18 of 111 lbs. this reflected a 11.2 lb., or 9.17% weight decrease from 1 month prior. Further review of the record failed to reveal that the Physician or Dietician had been notified when Resident #97 was assessed to have had the significant weight loss. On 10/18/18 at 8:26 AM, Staff #1 (the Director of Nursing) was made aware of the…

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

Based on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff it was determined that the facility staff failed to provide 1 (#268) of 3 Medicare beneficiaries reviewed with a written notice of Medicare Provider Non-Coverage. The findings include: The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 10/19/18 at 2:00 PM, a review of the SNF Beneficiary Protection Notification Review worksheet completed by the facility indicated that Resident #268 was discharged from skilled services on 5/2/18 with benefit days remaining. The worksheet indicated that a SNFABN form and NOMNC form had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that facility staff 1) failed to protect a resident's medical record from public view and 2) failed to take steps to provide a resident privacy during an interview. This was evident for 1 of 3 medication carts observed during the survey and for 1 (#78) of 8 residents in Canal Side Terrace-B observed for the initial pool process of the survey. The findings include: Observation was made, on 10/19/18 at 1:59 PM, of an unattended medication cart which was sitting outside of room [ROOM NUMBER]. There was a laptop computer sitting on top of the medication cart that was open. The screen displayed Resident #366's medication administration record (MAR) which displayed what medications Resident #366 was prescribed. Also sitting on the side of the medication cart was an opened Controlled Substance Tracking Form which displayed the names of 6 residents. Staff #18 walked up to the medication cart at 2:01 PM and completed a task. The surveyor walked away from the medication cart and…

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

Based on medical record review and staff interview it was determined that he facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 2 (#16, #78) of 10 residents reviewed for hospitalization. The findings include: 1) On 10/12/18 at 2:30 PM, a review of Resident #16's medical record revealed documentation that, on 5/14/18, the Resident #16 was transferred to the emergency room for an acute change in condition related to hematuria (blood in urine) and vomiting blood. Review of Resident #16's medical record did not reveal any documentation that the resident had received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding. 2) On 10/15/18 at 3:20 PM, a review of Resident #78's medical record documented that on 9/29/18, Resident #78 was transferred to the hospital emergency room for evaluation of shortness of breath and an increased heart rate. Review of the resident's medical record did not reveal any documentation that the resident had received an…

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

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#72) of 4 residents reviewed for dental. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 10/15/18 at 11:47 AM, an observation of Resident #72 revealed that the resident was edentulous (did not have any natural teeth). On 10/18/18, review of Resident #72's medical record revealed that on 9/8/18 in a Nursing Admission/readmission Assessment, the nurse documented the resident did not have his/her own teeth. Review of Resident #72's admission assessment MDS with an 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 medical record review and staff interview, it was determined the facility failed to have a discharge summary written and available to go with a resident to another facility upon discharge. This was evident for 1 (#43) of 3 residents reviewed for discharge. The findings include: Review of Resident #43's medical record on 10/17/18 documented that, on 10/5/18, resident discharged today to another facility. {name} arrived at 3:00 PM to take resident and belongings to new facility. The noted ended, d/c (discharge) packet sent with EMTs. Further review of the medical record revealed the physician's discharge summary that was in the medical record was dated 10/14/18 which was 9 days after Resident #43's discharge. Discussed with the Director of Nursing (DON) on 10/18/18 at 10:50 AM. The DON stated, the discharge summary should have gone with the resident.

Based on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. This was evident for 1 (#8) of 1 residents reviewed for activities. The findings include: On 10/15/18 through 10/19/18 of the survey, daily, intermittent observations of Resident #8 were made at various times of the day. Resident #8 was never observed in an activity or having a 1:1 (one on one) activity with facility staff. On each observation, Resident #8 was observed in the resident's room, in bed or in a wheel chair located in the hall outside of the resident's room. On 10/19/18, review of Resident #8's medical record revealed that the resident was cognitively impaired and dependent on the facility staff for activities of daily living. On 10/19/18 at 11:02, during an interview, when asked if Resident #8 participated in activities, Staff #11 (Life Enrichment Assistant Director), stated that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, it was determined the facility failed to ensure that a resident who received dialysis services 1) had fluids monitored, 2) had the fistula site monitored and 3) had a resident centered care plan for dialysis. This was evident for 1 (#103) of 3 residents reviewed for discharge. The findings include: Review of the medical record for Resident #103 on 10/17/18 revealed the resident was initially admitted to the facility on [DATE]. A social service note, written on 9/11/18 at 10:01 AM, stated, goes to dialysis 3x a week, family transports. The 9/17/18 physician's progress note documented that the resident had end stage renal disease (ESRD), on HD (hemodialysis) and had multiple comorbidities. The resident was sent out to the hospital on [DATE] and re-admitted to the facility on [DATE]. Review of October 2018 physician's orders for Resident #103 revealed that the resident was monitored for intake and output every shift prior to being sent to the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a physician, physician assistant, nurse practitioner or clinical nurse specialist supervised the immediate care and needs for a resident with significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition. The findings include: During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost about 4 pounds since his/her last weight and added that he/she received Redi care supplements with meals. Review of the residents record on 10/17/18 at 10:28 AM revealed a physician's order for Renal diet, regular texture with thin liquid consistency. There was no physicians order for nutritional supplements. The residents weight record revealed that he/she weighed 122.2 lbs. (pounds) on 8/3/18. The resident was hospitalized from [DATE] - 9/6/18 and upon return from the hospital his/her weight on 9/8/18 was 111 lbs. reflecting a 9.17%…

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 staff interview, it was determined that facility failed to provide the correct consistency of a diet as prescribed by a physician. This was identified for 1 (#29) of 11 residents reviewed for nutrition and during 2 of 2 meal time observations. The findings include. On 10/17/18, Observations of the lunch time meal service in the Canal Side Heights dining room revealed that resident #29 was served Salisbury steak that was chopped. The resident's tray/meal ticket indicated both chopped meats and ground meat. A speech language pathologist (Staff #25) was in the dinning room at the time working/observing another resident. Upon interview of the speech language pathologist (SLP), she confirmed that Resident #29 was to receive ground meat and Resident #29 did not receive the correct texture of meat. The SLP acknowledged working with Resident #29 and due to swallowing difficulties and subsequently, the resident's diet was changed to a ground meat consistency. Review of Resident #29's medical record later in the day revealed a change to the prescribed diet 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.