Traymore Nursing Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided consistent with professional standards of practice, for 1 of 3 residents (Resident #99) reviewed for respiratory care. The facility failed to ensure that Resident #99's oxygen tubing was bagged in a plastic bag when not used, and the nasal cannula was not dragging on the floor. 2. The facility failed to ensure that Resident #99 was receiving continuous oxygen per physician orders when she was observed without oxygen. These failures could place residents at increased risk of receiving inadequate oxygen support and infections that could result in a decline in health.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure that residents receive adequate supervision and assistance to prevent accidents for one (Resident #2) of seven residents reviewed for falls.1. LVN A failed to remain with Resident #2 when he was in the bathroom, which resulted in the resident having an unwitnessed fall in the bathroom. Resident #2 was found alone on the floor in the bathroom by CNA B. Resident #2's unwitnessed fall in the bathroom on 03/30/26 caused a small laceration, with blood, to his head.2. LVN A failed to ensure he had assistance while transferring Resident #2 from his bed to wheelchair and from wheelchair to toilet, per his hospital discharge paperwork on 03/26/26 and PT Evaluation on 03/27/26. Resident #2 required the assistance of two-persons for ADL care including toileting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 7 residents (Resident #14) reviewed for call light system access. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain clipped to a curtain at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Findings Included: Record review of Resident #14's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II resident review for one (Resident #9) of four residents reviewed for PASRR services. The facility failed to identify a discrepancy between a negative PASRR Level I evaluation and the resident's mental disorder diagnosis during admission. Due to this failure, the facility did not refer Resident #9 for a Level II PASRR Evaluation. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 1 resident's reviewed for CPR. 1. LVN A failed to initiate and perform CPR immediately after finding Resident #1 unresponsive on 05/29/25. 2. LVN A, LVN B and LVN C failed to perform any life saving measures on Resident #1 per his Care Plan, Physician Orders and Advanced Directives. Resident #1 expired in the facility on 05/29/25. The noncompliance was identified as PNC. The IJ began on 05/29/25 and ended on 05/30/25. The facility had corrected the noncompliance before the survey began on 05/31/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 9 residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's medications (Memantine HCL and Carbidopa-Levodopa) were correctly ordered and transcribed on his MAR upon admission on [DATE]. 2. The facility failed to ensure Resident #1 did not miss four doses of Rytary (Carbidopa-Levodopa) 48.75-195 mg 3 capsules each dose between 7/17/24 and 07/18/24 and when Resident #1 received double his dose of Memantine HCL ER 28 mg from 7/20/24 to 7/29/24. [...]

Inspectors wroteBased on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 2 of 8 residents (Residents #31 and #84) reviewed for quarterly assessments. 1. The facility did not ensure Resident #31's Quarterly MDS Assessment, dated 6/3/24, was completed within 92 days of the previous assessment. 2. The facility did not ensure Resident #84's Quarterly MDS Assessment, dated 5/30/24, was completed within 92 days of the previous assessment. These failures could place residents at risk of not having their assessments completed timely.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #9) reviewed for infection control. CNA D did not change her gloves or wash her hands while providing incontinent care for Resident #9. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good oral care for 1 resident (Resident #1) of 5 residents reviewed for reviewed for ADLs. -The facility failed to provide effective oral care to Resident #1, who had a severe dry mouth that caused the skin inside and outside of his mouth to flake and peel off. This failure could place all residents with swallowing issues and required assistance with oral care at risk for not receiving appropriate care to meet their needs.

Inspectors wroteBased on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 2. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the ice machine vent/grate and outer surface was free from dirt and dust. 5. [...]

Inspectors wroteThe facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #56 and #210) of 8 residents reviewed for infection control. 1) The facility failed to ensure CNA A sanitized her hands, put on a gown and gloves prior to entering Resident #56's contact isolation room to get his breakfast meal tray. 2) The facility failed to effectively ensure Resident #210 was not continuing to go outside to smoke cigarettes at the same time the other residents smoked. [...]