Greenspring Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) for one of thirty-three sampled residents, (Resident #20). The findings include: For Resident #20, the facility staff failed to provide the resident and the resident's representative(s) written notice of the reason(s) for transfer/discharge to the hospital on [DATE], 1/21/25, and 2/24/25. Resident #20's diagnosis list indicated diagnoses that included, but were not limited to, Urinary Tract Infection (UTI), Acute Respiratory Failure with Hypoxia, Repeated Falls, Sepsis, Congestive Heart Failure, Chronic Kidney Disease-Stage 3, and Vascular Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/3/25, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a timely and adequate baseline care plan for one resident (Resident #49) in a survey sample of 33 residents, that includes the instructions needed to provide effective and person-centered care. On 3/4/25 at 9:50 am, Resident #49 (R49) was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. The staff mean well, but they really [NAME] those straps. Everyone does it differently. Even PT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement an accurate comprehensive person-centered care plan for one resident (Resident R49) in a survey sample of 33 residents, that included measurable objectives and timeframes. On 3/4/25 at 9:50 am, resident was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. The staff mean well, but they really [NAME] those straps. Everyone does it differently. Even PT has exclaimed at finding the boot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for three residents (Resident #5- R5, Resident #39-R39, and Resident #49-R49), in a survey sample of 33 residents. The findings included: 1. For R5, who was non-verbal and totally dependent upon facility staff for all activities of daily living, the facility staff failed to review and revise the care plan to accurately reflect the resident's needs for activity programing. On 3/3/25 in the afternoon, on 3/4/25 at 2:55 p.m., and 3/5/25 at 2:32 p.m., R5 was visited in her room. R5 was laying in her bed each of the days, was noted to be non-verbal, and didn't respond when spoken to. There was a sign in the room that indicated Keep the tv on channel 133 EWTN Religious channel. On 3/3/25 and 3/4/25, R5 was in bed without the tv on, no radio was on, and no indication of social, auditory, visual, or other sensory stimulation was observed. On…

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

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident, Resident #104 (R104), out of a survey sample of 11 residents. The findings included: The staff failed to notify the physician when a medication was not available. On 5/13/25 at 2:30 p.m., an interview was conducted with R104. During the tour of the nursing unit, R104 was interviewed by request. R104 stated that she was prescribed a prn (as needed) cough medicine that she could have every six hours if needed. R104 said, I got a dose of the cough medicine during the night but when I asked for a dose this morning, I was told by the nurse there was no more here; it would need to be ordered. R104 stated she asked the nurse to check in the stat (immediate) box and R104 said, The nurse was not even aware of a stat box where you can get medications from if needed. Reportedly, R104 was told that the medication was supposed to be here by 8:00 a.m., and then the time was changed to arrive 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 resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to assess resident, communicate with the provider, and ensure quality of care for one resident, R#104 (R104), out of a survey sample of 11 residents. The findings included: The staff failed to assess R104 prior to being sent out to the emergency room, failed to communicate with the physician before 911 was called by R104, and failed to review the emergency room report for new orders. On 5/13/25 at 2:30 p.m., R104 stated that she had called her pulmonologist (lung specialist) and said, My pulmonologist wants me to go out to the emergency room to get a CT scan and be treated for my cough, since the facility cannot treat me. R104 stated that she had called her pulmonologist and was waiting to be dressed and then she was calling 911 (emergency number) herself. The resident stated that her vital signs were not being checked, and no one had listened to her lung sounds. R104 said, When my oxygen levels are checked, I have to ask for it to be done. On 5/13/25…

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 staff interviews, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent accidents from falls for one resident, Resident #106 (R106) out of a survey of 11 residents. The findings included: On 5/14/25 at 8:30 AM, a clinical record review was conducted, which included the comprehensive care plan. The review revealed that R106 had a fall on 4/29/25, while trying to transfer from wheelchair to bed without assistance. The staff documented a care plan intervention that he was reeducated and was to call for assistance. The record documented another fall on 5/6/25, while he was trying to transfer from the wheelchair to the bed without assistance. The staff again documented that R106 was reeducated on using the call light and to follow him to assist with his needs. The interventions that staff wrote for these falls were interventions that were already in place from previous falls. There was no other entries to indicate that R106 had new interventions put in place to effectively address the required fall prevention,…

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 family interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to implement nutritional interventions to maintain the resident's nutritional status and weight, for one resident (Resident #101- R101) in a survey sample of eleven residents. The findings included: For R101, who had experienced a significant weight loss, the facility staff failed to provide the resident with nutritional interventions identified/implemented to prevent further weight loss. On 5/13/25, a clinical record review was conducted of R101's chart, to include the current care plan, which was kept in the resident's room. According to the care plan, R101 was noted in the nutritional care plan to have interventions of .super soup in a mug at lunch/dinner, and super mashed potatoes at lunch/dinner. Offer magic cup at dinner . According to the weights recorded in R101's chart, on 3/5/25, R101 weighed 146.90 lbs. R101 gained weight and on 3/19/25 had a weight of 154 lbs. On 4/2/25, R101's weight was noted to have 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, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure appropriate dementia care was in place for one resident (Resident #9-R9), in a survey sample of 33 residents. The findings included: For R9, who had dementia, the facility staff failed to develop resident specific interventions and identify target behaviors to ensure the resident received appropriate treatment to maintain the resident's highest practicable well-being. On 3/4/25 and 3/5/25, R9 was observed attending group activities and eating meals in the dining room. R9 was noted to be calm, engaged and no behaviors noted. On 3/5/25, a clinical record review was conducted. This review revealed that R9 was admitted to the facility on [DATE] from assisted living, where her spouse was also a resident. R9's diagnosis included, but were not limited to unspecified dementia, unspecified severity, without behaviors/psych/mood/anxiety; unspecified dementia with behavioral disturbance; 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 resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure medication was available for one resident, Resident #104 (R104) out of a survey of 11 residents. The findings included The staff failed to keep cough medication in stock to be available for the residents. On 5/13/25 at 2:30 p.m., an interview was conducted with R104. During the tour of the nursing unit R104 was interviewed by request. R104 stated that she was prescribed a prn (as needed) cough medicine that she could have every six hours if needed. R104 said, I got a dose of the cough medicine during the night but when I asked for a dose this morning, I was told by the nurse there was no more here it would need to be ordered. R104 stated she asked the nurse to check in the stat (immediate) box and R104 said, The nurse was not even aware of a stat box where you can get medications from if needed. R104 stated that she was told that the medication was supposed to be here by 8:00 a.m., and then the time was changed to arrive at noon. R104 said,…

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

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. There were three errors in 29 opportunities resulting in a medication error rate of 10.3%. The findings include: 1. Resident #33 (R33) was administered a dose of extended-release morphine when the physician's order required immediate release. A medication pass observation was conducted on 3/4/25 at 8:09 a.m. with licensed practical nurse (LPN) #1 administering medications to R33. Included in the medications administered to R33 was morphine 15 mg (milligrams) extended-release. R33's clinical record documented a physician's order dated 2/2/25 for morphine 15 mg immediate release tablets two times per day for pain management. On 3/4/25 at 9:00 a.m., LPN #1 was interviewed about the morphine administered to R33. LPN #1 reviewed R33's clinical record and stated the current morphine order listed immediate release and not extended-release. LPN #1 reviewed R33's medication supply from the locked storage and stated the medication she gave was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for two residents (Resident #108 and Resident #101), in a survey sample of 11 residents. The findings included: 1. For Resident #108 (R108) the facility medical provider failed to complete and accurately document in the clinical record the resident's CPR (Cardiopulmonary resuscitation) wishes and left the information blank. On [DATE], a clinical record review was conducted of R108's chart. This review revealed that R108 signed and executed a durable do not resuscitate (DNR) on [DATE]. On [DATE] the medical provider/doctor completed a Code Status Discussion form and indicated that R108's wishes were for Code B, DNR, but hospitalize. On [DATE], the doctor initiated a National POLST Form: A Portable Medical Order. The POLST form had R108's name, date of birth , gender, R108's signature and the signature of the doctor. Sections A-D, where R108'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.

2. During medication administration, the nurse (licensed practical nurse #4- LPN #4) failed to follow standard infection control practices by not wearing gloves, touching multiple surfaces with contaminated the gloves, and then directly handling the medications with contaminated gloves. On 5/14/25 at 8:31 a.m., LPN #4 was observed to prepare and administer medications to a resident on the 200 unit. LPN #4 donned gloves and with her gloved hands took a set of keys from her pocket, opened the medication cabinet located in the resident's room, removed the medication package cards, and returned to the medication cart, touching the medication cart, computer, computer mouse, etc. LPN #4 was then observed removing/popping medications from the package cards directly into her gloved hands and then placed the pills into a medication cup, which were then administered to the resident. Following the above observations of LPN #4 preparing and administering the above medications, the surveyor asked LPN #4 about wearing gloves during medication administration. LPN #4 stated that she usually wears…

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, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for (1) one of (5) five sampled residents reviewed for immunizations (Resident #1). The findings included: For Resident #1, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal conjugate vaccine 21 (PCV21) at least one year after the pneumococcal conjugate vaccine 13 (PCV13) was administered. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Muscle Weakness, Dementia, Hypertensive Heart Disease, Anxiety Disorder, Occlusion and Stenosis of Bilateral Carotid Arteries, and Chronic Kidney Disease-Stage 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/11/25, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Resident #1 was over the age of 65 years…

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, clinical record review, and facility document review, the facility staff failed to offer updated COVID-19 vaccines for (1) one of (5) five sampled residents reviewed for immunizations (Resident #15). The findings included: For Resident #15, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine and an updated 2024-2025 formula COVID-19 vaccine. Resident #15's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease with Dyskinesia with Fluctuations, Muscle Weakness, Repeated Falls, Cognitive Communication Deficit, Glaucoma, Hypertension, Diabetes Mellitus-Type 2, Dementia, and Atrial Fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/10/25 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities indicating the resident was moderately impaired in cognition. A review of Resident #15's COVID-19 vaccination record revealed resident received a COVID-19 vaccination on 10/7/22. Surveyor…

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 staff interview and clinical record review, the facility staff failed to ensure a Level I PASRR (preadmission screening and resident review) was completed prior to admission for one of 23 residents, Resident #50. Findings include: Resident #50 was admitted to the facility originally on 09/04/21. Diagnoses for Resident #50 included, but were not limited to, diverticulitis, major depression and bipolar disorder. The most recent MDS [minimum data set] was an admission assessment dated [DATE]. This MDS assessed Resident #50 with a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. In Section A1510. Level II Preadmission Screening and Resident Review the section was blank; none had been marked. In Section I. Active Diagnoses, Resident #50 was assessed as having depression and bipolar disorder. The resident's clinical records were reviewed. Resident #50 had an active diagnosis of depression and bipolar disorder. The resident's physician's orders were then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility failed to review and revise a care plan regarding safety/wandering for for one of 23 residents in the survey sample, Resident #19. The Findings Include: Resident #19 was admitted to the facility on [DATE]. Diagnoses for Resident #19 included; Respiratory failure, and muscle weakness, and chronic kidney disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/31/21. Resident #19 was assessed with long and short-term memory problems and severely cognitively impaired. On 10/6/21 Resident #19's current MDS Section E. behaviors, documented a behavior of wandering occurring 4 to 6 days during the MDS look back period. Resident #19's current care plan for Safety and Exploring was then reviewed and documented no wandering throughout the house or community. On 10/06/21 at 2:22 PM, the social worker (other staff, OS #1) was interviewed. OS #1 agreed that she had completed section E of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to follow physician's orders for bladder scan monitoring and fluid intake for one of 23 residents in the survey sample, Resident #26. Findings include: Resident # 26 was admitted to the facility on [DATE]. Diagnoses for Resident #26 included, but were not limited to: atrial fibrillation, coronary artery disease, diabetes mellitus, history of UTI (urinary tract infection) with an indwelling urinary catheter. The most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed in Section H. H0100. Appliances, as having an indwelling catheter. During Resident #26's clinical record review, the resident's physician's orders were reviewed. A physician's order dated 08/23/21 at 8:00 AM documented, .Remove Foley catheter on 08/23/21 at 8 AM .Bladder scan…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on one of 3 units, the 200 unit. The findings include: On 10/6/2021 at 8:15 a.m., medication storage observations were conducted on the 200 unit with Registered Nurse (RN #1). Observed on the 200 unit medication cart, was an opened bottle of Robafen liquid (cough syrup). The opened date on the bottle was 11/19/19 with an expiration date of 7/21. Also on the cart were 3 opened insulin vials. The label indicated an opened date and expiration date of 28 days after opening and were as follows: Humalog opened 4/28/21, Humalog opened 5/23/21, and Lantus opened 7/28/21. On 10/06/2021 at 8:20 a.m., RN #1 was interviewed regarding expired medication. RN #1 said, all of the nurses are responsible for checking for expired medications daily and these medication shouldn't be on the cart. On 10/6/21 at 10:50 a.m., the director of nursing (DON) was informed of the above findings. The DON stated expired medications should not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review the facility staff failed to assess seven of twenty residents for bed rail safety (Residents # 12, 16, 48, 39, 65, 66, and 42). Findings include: 1. Resident # 12 was initially admitted to the facility 8/4/14 with a readmission date of 9/8/16. Diagnoses for Resident # 12 included, but were not limited to: high blood pressure, vascular dementia, depression, muscle weakness, repeated falls, and unsteadiness of feet. The most recent MDS (minimum data set) was an annual review dated 9/1/19 and had the resident scored with severe cognitive impairment with a total summary score of 01 out of 15. On 9/24/19 at approximately 4:00 p.m. Resident # 12's room was observed. The door was partially closed. Moaning was heard coming from the room. Resident #12 was observed with her knees on the fall mat, her upper body across the bed, and her arms entangled in the grab rail. LPN (licensed practical nurse) #2 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 staff interview, and facility document review, the facility staff failed to ensure regular bed inspection of bed frames, mattresses and bed rails for 7 of 79 beds currently with bed rails in use during the survey (Residents # 12, 16, 48, 39, 65, 66, and 42). Findings include: On 9/25/19 at 8:30 a.m. the maintenance staff, identified as OS (other staff) # 4 was interviewed about the bed rail program, and asked if there was any documentation of bed measurements to ensure residents were not at risk for entrapment. OS # 4 stated It's been over a year since we were told not to install bed rails. We are not involved. Anyone with a bed rail still on the bed probably had it prior to us no longer doing it. OS # 4 was asked if there were changes in the resident's weight, or a different mattress was applied to the bed, who would ensure the bed was free from an entrapment risk. OS # 4 stated Any changes like that the floor nurse/nurse manager is responsible to check. On 9/25/19 at 9:52 a.m. the administrator, assistant administrator, and RN # 2 were interviewed about the bed rail…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed, for one of 18 residents in the survey sample, to notify the local Ombudsman of a resident's transfer to the hospital. The findings were: Resident # 2 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included anemia, renal insufficiency, hypothyroidism, Non-Alzheimer's dementia, Parkinson's disease, chronic obstructive pulmonary disease, and history of malignant neoplasm of the prostate. According to the most recent Minimum Data Set, a Significant Change with an Assessment Reference Date of 9/1/19, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. Review of the Nurses Notes in the resident's Electronic Health Record revealed the following entry: 6/17/19 - 4:10 p.m. - Resident is alert and oriented to self, observed with confusion and forgetfulness, cognition is not within his usual…

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 clinical record review, facility staff failed to review and revise comprehensive care plans (CCP) for two of 20 residents in the survey sample, Residents #42 and #39. Neither resident's care plans were reviewed by a complete interdisciplinary team (IDT). Resident #42's care plan did not include fall interventions, or use of siderails. Resident #39's care plan did not include interventions for weight loss. Findings included: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses including, but not limited to: multiple pelvic fractures, osteoporosis, dementia and depression. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/05/2019. Resident #42 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine (09) out of 15. Progress notes reviewed on 09/24/2019 at 10:15 a.m. included documentation of falls on 05/30/19, 08/28/19, and 09/23/19. Subsequent 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 observation, facility document review and staff interview, the facility staff failed to ensure expired medications and biologicals were not available for use in one of two medications rooms (Evergreen 2nd floor). The findings include: On 9/24/19 at 1:25 p.m., accompanied by licensed practical nurse (LPN #1), the medication room on the Evergreen second floor unit was inspected. A bottle of Lidocaine viscous medication labeled as expired on 9/13/19 was stored in the medication refrigerator. Also stored in the medication room were three expired vacutainer blood collection tubes. One tube had a manufacturer's expiration date of 1/31/19. Two additional tubes had expiration dates of 7/31/19. LPN #1 was interviewed at the time of this observation about the expired medication and collection tubes. LPN #1 stated the Lidocaine viscous was for a current resident and should have been discarded. LPN #1 stated the blood collection tubes were used by nursing for stat emergency labs. LPN #1 stated all nurses were responsible for monitoring the drug storage room and discarding expired…

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.