Courtland, LLC

Inspectors wroteBased on record review, facility reported incident #2703327 and interviews, it was determined that the facility failed to report allegations of abuse to The office of Healthcare Quality (OHCQ) in a timely manner. This was evident for 1 of 1 Facility Reported Incident (FRI) reviewed during the survey process. Findings Included:On 07/09/2026 at 3:42 PM, a review of the FRI #2703327 initial report form revealed that on 12/24/2025 at 9:20 PM, the facility was notified by Resident #74 that he/she was assaulted by a relative; however, a review of the facility's internal incident report revealed that on 12/24/2025 at 7:50 PM staff heard loud yelling coming from Resident #74's room. As the nurse approached, the female relative was observed by staff exiting the room. The nurse then checked on the resident, who stated that he/she was struck in the head with a TV remote by the female relative. [...]

Inspectors wroteBased on observations, and interviews, it was determined that the facility failed to provide a safe sanitary environment related to sewage water backup. This was found on 1 of 8 days of the survey. The Maryland Office of Health Care Quality (OHCQ) determined that concern met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 3:25 PM on 7/15/25.

Inspectors wroteBased on record review, and interview it was determined that the facility failed to provide a Resident's Representative the right to be involved in the vaccination consent process. This was found evident in 1 (Resident #73) of 5 residents reviewed for vaccinations.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide a resident with a reasonable accommodation of need. This was found evident during one random observation on the survey for Resident #77.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of facility investigation, resident medical records, and interviews, it was determined that the facility failed to ensure that a resident remained free from abuse. This was true for 1 (Residents #2) of 16 residents reviewed for abuse during the annual re-certification survey.

Inspectors wroteBased on medical record review, interview and policy review it was determined that the facility failed to acquire and document the appropriate consents and procedures prior to the implementation of a restraint. This was evident during the review of 1 of 3 residents (R-165) reviewed for restraints.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to conduct a thorough investigation for an incident of abuse. This was evident for 1 (#176) resident reviewed for 1 of 16 reports of abuse.

Inspectors wroteBased on record review, and interviews, it was determined the facility failed to 1) notify the Ombudsman of resident's transfers, 2) provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer. This was found evident of 2 (Resident #10 & #141) of 4 residents reviewed for hospitalization 3. Failed to provide the resident/family/RP with discharge instructions. (#161) This was evident for 1 of 3 discharge records reviewed during the survey.

Inspectors wroteBased on interview, observation and record review, it was determined that the facility failed to develop/revise a comprehensive person-centered care plan specifically including measurable objectives-ideal healthy weight and timeframes to meet residents' significant weigh change concern. This was evident for 1 (Resident #64) out of 132 residents reviewed for care plan development to meet medical and psychosocial needs during an annual survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow the facility's standard of oxygen care consistently. This was found evident of 1 out of (Resident #12) residents reviewed for respiratory care during an annual survey. Observation, on 07/15/2025 at 3:04 PM, Resident #12 was found on 2 liters of oxygen with nasal cannula in use and there was no label on the humidifier water bottle nor the oxygen nasal cannula tubing with a change date/time. Nasal cannula- a tubbing used to provide supplemental oxygen. Record review, on 07/16/2025 at 1:08 PM, of this resident's record indicated 1/18/25 the resident was admitted to this facility after a complicated hospitalization with diagnoses of new seizure disorder, heart attack, hypoxia, dysphagia and post medical diagnoses: intellectual disability, end of renal disease on hemodialysis MWF. [...]

Inspectors wroteBased on the review of a complaint, medical record review and interview with facility staff, it was determined that the attending physician failed to review the full program of care at each visit, ensuring the medication ordered and documented in the progress notes were accurate. This was evident for 1 of 3 residents (161) reviewed for physician services.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication without adequate monitoring. This was evident for 1 (Resident #14) of 5 Residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and medical record review, it was determined that the facility's staff failed to track proper diet orders, to process the repeat insufficient proportion requests from residents and to honor residents' right to meet personal dietary proportion needs. This was evident for 1 (Resident #12) out of 2 residents reviewed for food during an annual survey.

Inspectors wroteBased on medical record, review of a complaint, and interview of facility staff, it was determined that the facility's Medical Director failed to ensure adequate implementation of resident care intervention and/or policy review. This was found evident for 1 (Resident #98) of 1 resident reviewed for insulin use.

Inspectors wroteBased on record review and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records by:1) Failing to document the disposition of a discharged residents personal property. This was evident for 1 (#163) of 1 resident reviewed for Misappropriation of Property. 2) Failing to document resident behavior. This was evident for 1 (#176) resident reviewed for 1 of 16 abuse reports reviewed.

Inspectors wroteBased on observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 out of 3 observations of the laundry area.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, and interview it was determined that the facility failed to document the rationale for non-administration of the influenza and pneumococcal immunization. This was found evident of 1 (Resident #66) of 5 residents reviewed for vaccinations during an annual survey. Influenza (flu) immunizations are usually offered during the flu season, which is considered October 1 through March 31 annually.

Inspectors wroteBased on observations, interviews, and reviews of facility documents and medical records, it was determined that the facility staff failed to 1) ensure that the dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, and 2) store food in accordance with professional standards for food service safety, and 3) ensure meals were provided in a manner that maintained safe quality control temperatures to meet the individual needs of dialysis residents. This was evident for 2 (Residents #51 and #111) of 17 residents reviewed during an LTCSP recertification survey for food quality and kitchen practices. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen.

Inspectors wroteBased on observations, reviews of medical records, and staff interviews, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by;1) failing to screen tuberculosis (TB) for new admit residents, this was evident for 2 (Resident #125 and #142) of 5 residents TB screening reviewed; 2) failing to order contact precautions for a resident who diagnosis E. coli infection, this was evident for 1 (Resident #343) of 6 residents review for infection disease; 3) failing to follow infection control practices in residents' rooms, this was evident for 2 (Resident #2 and #205) of residents reviewed; [...]

Inspectors wroteBased on surveyor observation and interview with staff it was determined the facility staff failed to treat each resident with respect and dignity by 1) ensuring residents were treated with respect and dignity by labeling residents who required physical assistance with meals as feeders and this was evident for 11 residents listed on 2 of 3 posted staffing assignment boards in the facility, 2) identifying, labeling and posting the residents level of dependency on others on 1 of 3 nursing units in the facility, and 3) failing to have an effective process in place to assist the residents to obtain and wear personal clothing for 2 (#70 and #137) of 78 residents reviewed during an LTCSP recertification survey.

Inspectors wroteBased on observation, medical record reviews, and staff interviews, it was determined that facility staff failed to develop and initiate comprehensive, resident-centered care plans with measurable objectives and goals for residents residing in the facility. This was evident for 6 (#14, #30, #131, #52, #51, #35) of 78 residents reviewed during the LTCSP recertification survey.

Inspectors wroteBased on medical record reviews and interviews with facility staff, the facility failed to update residents' care plans after each assessment and failed to consistently conduct quarterly care plan meetings. This was found to be evident for 4 (Resident #48, #131, #23, #35) of 78 residents reviewed during an LTCSP recertification survey.

Inspectors wroteBased on complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure staff followed physician orders as evidenced by failing to apply Multi Podus boots and hand splints to a resident, and 2) to ensure ordered consults were addressed, 3) follow a consult physician's dressing change orders, 4) provide care for a resident who had shortness of breath, including failing to ensure the resident's x-ray was taken STAT (immediately) per the Physician's order, and 5) delay care regarding critical lab results. This was evident for 5 (Resident #53, #199, #297, #403, #405) of 78 residents reviewed during an LTCSP recertification survey. This noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected.

Inspectors wroteBased on observation, reviews of medical records, and staff interviews, it was determined that the facility staff failed to 1) initiate nursing interventions to prevent further falls, and 2) implement measures to minimize the residents' risk of injury. This was evident for 2 (Residents #65, and #129) of 11 residents reviewed for accidents during an LTCSP recertification survey.

Inspectors wroteBased on reviews of the medical records and interviews with staff, it was determined that the facility staff failed to 1) conduct accurate ongoing assessments and oversight of the resident before and after dialysis treatments, and also failed to develop a resident-centered plan of care for a resident receiving dialysis. This was evident for 2 (Residents #51, and #297) of 5 residents reviewed for Dialysis during an LTCSP recertification survey.

Inspectors wroteBased on observation, record review, administrative policy review, and interviews, it was determined that the facility failed to have a system in place to ensure that appropriate alternatives are attempted prior to installation of side rails, assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #30, #48, #131) of 3 residents reviewed for accident hazards during the annual survey.

Inspectors wroteBased on record review and interview it was determined that the Physician failed to 1) review the resident's total plan of care as evidenced by the physician continuing to write orders related to a condition no longer existed, and 2) reconcile the correct dose, or the amount of the medication the resident received per day, of Depakote. This was evident for 2 (Resident's #35, #49) of 5 residents reviewed for Unnecessary Medications during an LTCSP recertification survey.

Inspectors wroteBased on reviews of medical records and staff interviews, it was determined that the facility staff failed to 1) have a process to ensure the clinical pharmacist's monthly medication reviews were reviewed by the physician with a documented response in the resident's medical record, 2) to ensure that monthly medication regimen review was completed by the facility pharmacist, and 3) ensure the physician reviewed and addressed irregularities identified by the clinical pharmacist. This was evident for 6 (Residents #48, #30, #93, #35, #129, and #33) of 6 residents reviewed for unnecessary medications during an LTCSP recertification survey.

Inspectors wroteBased on observation, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication carts locked when unattended, 2) discard multi-dose vials which have been opened or accessed (e.g., needle-punctured) within 28 days, 3) label medications upon opening, and 4) dispose of expired medications. This was evident in 2 of 3 nursing units observed during the annual recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent, and document residents' vaccination consent form including agree to receive the vaccine or refuse it. This was evident for 4 (Resident #51, #128, #133, and #142) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents. This was evident for 2 (Resident #51 and #128) of 5 residents reviewed for COVID-19 vaccination during the annual survey.

Inspectors wroteBased on documentation review and interview, it was determined that the facility failed to ensure nurse aide competency training (including dementia management and resident abuse prevention training) occurred no less than 12 hours per year. This was evident for 3 (GNAs #48, #49, and #50) of 3 employee training records reviewed and had the potential to affect all residents.

Inspectors wroteBased on observation and interview with staff it was determined the facility staff failed treat residents with dignity and respect by failing to encourage and assist residents to dress in their own clothing. This was evident for 1 (#90) of 78 residents reviewed during the survey.

Inspectors wroteBased on reviews of a medical record and staff interview, it was determined that the facility staff failed to 1) notify a resident's physician and family member when a significant weight loss was identified, and 2) notify a resident's Surrogate Decision Maker when changes were made in the residents' psychotropic medications. This was evident for 2 (Resident #35 #93) of 78 residents reviewed during an LTCSP recertification survey.

Inspectors wroteBased on interview and record review it was determined the facility staff failed to 1) have an effective process in place to protect resident's property from loss or theft. This was evident for 1 (#43) of 3 residents reviewed for Personal Property, and 2) failed to have a safe clean and comfortable environment on 1 of 3 units observed throughout the survey.

Inspectors wroteBased on complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued, and 2) promptly resolve resident grievances. This was evident for 2 (Resident #131 and #43) of 3 residents reviewed for the grievance process during the LTCSP recertification survey.

Inspectors wroteBased on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 1 (Resident #9) out of 16 residents reviewed for abuse during an LTCSP recertification survey.

Inspectors wroteBased on complaint, reviews of the facility investigation, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, 2) immediately initiate an investigation into the allegation of resident abuse, and 3) report an allegation of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 1 of 16 (Resident #57) residents reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on 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 (#48) of 14 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to screen a resident to determine if the resident had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 1 of (Resident #9) of 2 residents reviewed for pre-admission screening and resident review (PASSR) requirements during an LTCSP recertification survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission. The facility did not have records to show the Preadmission Screening and Resident Review (PASARR) Level 1 screening was completed prior to admission. This is evident for 2 (#30, #9) of 34 residents in the initial sample of the annual survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide residents and or residents' responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 1 (#131) of 1 resident interviewed about baseline care plans during the annual survey.

Inspectors wroteBased on complaints, medical record reviews, and interviews with residents and facility staff, it was determined that the facility failed to provide a resident with a shower during the past four weeks of his/her stay. This was evident for 2 (Residents #52, and #195) of 6 residents reviewed for activities of daily living (ADL) during an LTCSP recertification survey.

Inspectors wroteBased on complaint, reviews of a medical record, and interview, it was determined that the facility failed to provide treatment/services to maintain vision (Resident #52). This is evident for 1 out of 5 residents reviewed for vision/hearing during the annual LTCSP recertification survey.

Inspectors wroteBased on complaints, observation, reviews of medical records, and interviews, it was determined that the facility staff failed to 1) cleanse a wound with the prescribed solution, 2) implement measures to minimize the residents' risk of injury, 3) ensure a wound consult was completed timely, and 4) monitor and document treatments and services to promote healing of pressure ulcers. This was evident for 2 (Residents #65, #401, and #405) of 10 residents reviewed for pressure ulcers during an LTCSP recertification survey.

Inspectors wroteBased on medical record review, and staff interview, it was determined facility staff failed to follow up on Podiatry consultation report recommendations. This is identified for 1 (resident #131) of 1 resident reviewed for foot concerns.

Inspectors wroteBased on a medical record review and staff interview, it was determined that the facility failed to monitor a resident's body weight, who had potential nutritional risks due to tube feeding. This was evident for 1 (Resident #33) of 14 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on review of residents medical records and interview with staff, it was determined that the facility failed to develop a plan of care that addressed the needs of a resident with dementia. This was evident for 1 (#129) of 2 residents reviewed for dementia care.

Inspectors wroteBased on record review and interview with staff it was determined the facility staff failed to ensure adequate rationale for increasing antianxiety and antidepressant medications and monitoring of behaviors, behavior interventions and effectiveness for a resident receiving psychotropic medications for anxiety and depression. This was evident for 1 (#35) of 5 residents reviewed for Unnecessary Medications.

Inspectors wroteBased on medical record review and staff interviews, it was determined that facility staff failed to ensure residents were free from significant medication errors, as evidenced by administrating overdose of psychotropic medication with the same ingredient but different forms (tablet and sprinkles capsule) for two days. This was evident for 1 (#49) of 5 residents reviewed for an unnecessary medication review during the annual survey.

Inspectors wroteBased on a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to obtain a STAT urine sample when a resident was observed with a change in condition. This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey.

Inspectors wroteBased on observation and interview with staff it was determined the facility failed to have sufficient dietary support personnel to provide social dining services in the dining room. This was evident throughout the survey and had the potential to affect all residents.

Inspectors wroteBased on complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to develop, prepare, distribute, and serve menus that reflect a resident's nutritional wishes. This was evident for 1 (Resident #96) of 78 residents reviewed during the recertification survey.

Inspectors wroteBased on complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to provide food that accommodates resident preferences and/or appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. This was evident for 2 (#96, #342)) of 78 residents reviewed during the recertification survey.

Inspectors wroteBased on a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to correctly evaluate and provide a resident with a full cognitive workup as recommended by a speech-language pathologist (SLP). This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey.

Inspectors wroteBased on observations, record review and interview it was determined the facility staff failed to ensure 1) accurate documentation of oxygen administration for 1 (#111) of 1 resident reviewed for respiratory care, and 2) failed to maintain complete and accurate inventory of belongings for 3 (#70, #137, and #90) of 78 residents reviewed during the survey.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift, and failed to have the staff data requirements available in an accurate, clear and readable format. This was evident for the initial 4 days of the annual survey beginning on 1/23/23.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility staff failed to ensure the information used to complete the Annual and Quarterly Minimum Data Set (MDS) assessment for 1) Functional Status; Activities of Daily Living and 2) Bladder and Bowel were accurate. This was found to be evident for 3 out of 4 residents (Resident #119, Resident #44 and Resident #26) reviewed for activities of daily living and 1 out of 1 (Resident #26) reviewed for bladder and bowel during the investigation stage of the survey.

Inspectors wroteBased on observation, resident interview, record review, and staff interview it was the determined that the facility staff failed to provide a resident-centered care plans to address: 1) the the resident's choice to not have facial hair shaved and 2) the care of a resident's Permacath (a catheter used for dialysis). This was found to be true with 2 of 2 residents (Resident #31 and Resident #96) reviewed for patient centered care plans during the survey.

Inspectors wroteBased on observations, medical record review and interviews with facility staff it was determined the facility failed to update care plans to 1) meet the specific needs for a resident with a history of falls and 2) a resident diagnosed with anemia (a condition where the patient does not have enough red blood cells to carry oxygen to parts of the body). This was found to be evident for 2 of 30 residents (Resident's #109 and #131) that were investigated during the facility's annual survey.

Inspectors wroteBased on observation, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that food and beverages are healthy and satisfying to residents. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review, resident and staff interviews it was determined the facility failed to: 1) follow resident's meal tickets and 2) provide foods that are consistent with the resident diet plan and 3) provide meals on time 4) put a system in place to provide food and drink that was attractive, appetizing, at acceptable temperatures, and assure that food is stored in a way to maintain its nutritional value for residents. This was found to be evident for 3 out of 3 residents (Resident #41, Resident #95 and Resident #110) investigated for food concerns and has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that residents meals and snacks were offered at scheduled times. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review, and staff interview it was determined that the facility staff failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, medical record review and interview with facility staff, it was determined that the facility staff failed to: 1) promote care for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect by failing to provide a privacy cover to a resident with Foley drainage bag and 2) failure to knock and wait for permission to enter a resident room. This was found to be true for 2 out of 4 residents (Resident #44 and Resident #31) reviewed for dignity.

Inspectors wroteBased on observations and staff interview it was determined the facility failed to promote care for a resident in a manner that would ensure the resident's dignity. This was found to be evident for 1 out of 44 residents (Resident #44) reviewed during the survey.

Inspectors wroteBased on observation, record review and interview with staff and family members, the facility failed to ensure that resident bathing areas were free of hazards that may cause injury to the residents. This has the potential to affect any resident that utilized the shower in Hall 1A. The facility also failed to provide reasonable accommodation of resident needs and preferences for Resident #2. This was evident for 1 out of 45 Residents reviewed during the survey.

Inspectors wroteBased upon resident interviews, record review and staff interview it was determined that facility staff failed to consider or act upon Resident Council's grievances regarding food service. This deficient practice has the potential to affect all residents receiving food/meal services in the facility.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that residents and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for hospitalization during the investigative stage of the survey.

Inspectors wroteBased on administrative manual review, medical records review and interview with staff and residents, it was determined that the facility failed to provide residents and or their resident representative (RP) with the documentation of the facility's bed-hold policy. This was evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for planned and unplanned hospitalizations during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to develop a care plan for a resident at risk for pressure ulcers. This was found to be evident for 1 of 4 residents (Resident #99) reviewed for pressure ulcers.

Inspectors wrote2. Blood glucose level is the amount of glucose (sugar) in the blood. The amount of glucose in the blood is measured in units of mg/dl or mmol/l. Blood sugar levels that are too high or too low can be a dangerous condition and without immediate treatment can cause serious complications. A review of the medical for Resident #96 was conducted on 12/10/18 at 10:00 AM. Review of a physician order dated 10/17/18 stated to check the resident's blood sugar level twice a day and notify the physician if the resident's blood sugar level was below 80 mg/dl or above 250 mg/dl. However, review of the October 2018 Treatment Administration Record (TAR) conducted on 12/13/18 indicated that the order was started on 10/22/18. [...]

Inspectors wroteBased on record review, staff and family interview, it was determined that the facility failed to adequately monitor behaviors for a resident who was prescribed antipsychotic medication. This was evident for 1 out of five residents (Resident #2) reviewed for unnecessary medications.

Inspectors wroteBased on interviews with a resident and facility staff, it was determined the facility failed to provide what was on the menu for a resident who was served lunch. This was found to be evident for 1 resident (Resident # 41) while observing lunch being served during the facility's annual survey.

Inspectors wroteBased on observation, and staff interview it was determined that the facility staff failed to 1) follow infection control practices and guidelines while performing duties and caring for residents and 2) provide sanitary storage conditions to prevent the development and transmission of disease by not providing proper storage of resident mattress and fall mats after disinfection by central supply. This deficient practice has the potential to affect all residents in the facility. 1a. During an observation of the 1A Unit on 12/11/18 at 01:26 pm, surveyor noted Geriatric Nursing Assistant (GNA) (Staff #33) enter room [ROOM NUMBER] with a white Styrofoam cup labeled Rm #120 and placed on top of a dispenser to care for a resident in the room. The GNA exited the room, sat the cup on a nearby medication cart, poured water into cup from a pitcher and took it to room [ROOM NUMBER]. [...]