Every finding on record at Adelphi Nursing and Rehabilitation Center

Based on complaint, reviews of a clinical record and all pertinent documents, and staff interviews, it was determined that the facility failed to deposit a resident's personal funds, in excess of $50.00, into an individual, interest-bearing account. This was evident for 1 (Resident #1) of 2 residents reviewed during a complaint survey. Findings include: On 08/11/26 at 9:21 AM, the Office of Health Care Quality received a complaint with concerns that Resident #1 may be a victim of suspected financial exploitation. Review of Resident #1's clinical record on 08/12/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, delusional disorder, and bilateral cataracts. On 06/05/26, the staff performed a BIMS test that indicated Resident #1 had a score of 11/15. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. Resident #1 has a physician's order dated 03/03/25 that allows Resident #1 to leave the facility as needed with medications if necessary.In an interview with the facility Business Office Manager (BOM) and Assistant Business Office Manager (ABOM) on 08/12/26 at 1:45 PM, the BOM stated that Resident #1 currently has $5,150.00 dollars in cash that is being held in the facility safe and confirmed that Resident #1's cash was not in an interest-bearing banking account. The BOM stated that Resident #1 refused to have his/her cash placed into an interest-bearing banking account with the facility. The BOM produced a handwritten banking statement of Resident #1's deposits and withdraws that confirmed Resident #1 currently had a balance of $5,150.00 in cash that was being stored in the facility safe.

Based on complaint, reviews of a closed clinical record and all pertinent documents, and staff interviews, it was determined that the facility failed to immediately notify the correct responsible party when Resident #2 needed to be sent to the emergency room after a fall with injury. This was evident for 1 (Resident #2) of 2 residents reviewed during a complaint survey. Findings include: On 08/06/26 at 11:37 AM, the Office of Health Care Quality received a complaint alleging that Resident #2 was sent to a local emergency room on [DATE] at approximately 3:00 pm by the facility nursing staff due to a head injury. The Adult Public Guardian of Resident #2 was not notified of the injury or hospitalization. Resident #2's face sheet was sent to the hospital with him/her that contained the contact information and phone number of Resident #2's Guardian and also listed the phone number of Resident #2's family member. The emergency room staff contacted Resident #2's family member who came to the hospital. At approximately 11:11 p.m. on 07/13/26, Resident #2's family member signed Resident #2's discharge papers and removed Resident #2 from the hospital. Resident #2's family member allegedly informed the hospital of an incorrect home address. The Adult Public Guardianship staff went to the address provided by Resident #2's family member to conduct a welfare check. Local law enforcement assisted in the process. The leasing office of the residence informed the police officer that Resident #2's family member was not known at that address. Telephone calls were also made to Resident #2's family member by the Adult Public Guardianship staff and several police officers. However, Resident #2's family member refused to disclose the location of Resident #2 to the local police or the Guardian staff. A review of Resident #2's closed clinical record on 08/12/26 revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included but not limited to vascular dementia, cognitive communication deficit, and a need for assistance with personal care. Resident #2 was granted a court appointed guardian of person in September 2023. On 06/08/26, the nursing staff performed a BIMS test that indicated Resident #2 had a score of 3/15. This indicates severe impairment. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. In an interview with LPN#1 and the director of nurses (DON) on 08/12/26 at 3:41 pm, LPN#1 stated that S/he had just obtained his/her LPN (Licensed Practical Nurse) license 3 months ago and also started working at the facility 3 months ago. LPN#1 stated that after Resident #2 was identified with a fall with injury on 07/12/26 at approximately 9 pm, s/he reviewed Resident #2's face sheet and saw that Resident #2's family member listed as a contact person. LPN#1 stated that s/he called Resident #2's family member to make them aware of the need to send Resident #2 to the emergency room to be evaluated. LPN#1 stated s/he had to leave a message due to the family member did not answer the telephone. LPN#1 stated that s/he was not aware of what happened to Resident #2 after s/he was sent to the emergency room. A review of Resident #2's long term care facility face sheet on 08/12/26 clearly listed Resident #2's Guardian as Resident #2's Guardian, Health Care Representative, Legal Guardian with an address and telephone number.

Based on investigation into complaints, record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate medical records for residents. This was evident for 2 (Residents #2, #7) out of 7 residents reviewed during the complaint survey.The findings include:1. On 7/31/26 at 9:47 AM, Complaint #3065094 and Resident #2's medical record were reviewed. Review of the physician's orders revealed an order for Amlodipine 10 mg by mouth daily for high blood pressure, with instructions to hold the medication for systolic blood pressure (SBP) less than 110.Review of Resident #2's January and February 2026 Medication Administration Records (MARs) revealed amlodipine was documented as administered on 1/13/26, 1/19/26, 1/29/26, 2/7/26, 2/12/26, 2/21/26, and 2/26/26, despite documented systolic blood pressures less than 110 on those dates. Review of Resident #2's medical record did not reveal documentation indicating amlodipine was held on the identified dates or documentation clarifying whether the medication was administered or held.On 7/31/26 at 12:36 PM, during an interview, Licensed Practical Nurse (LPN) #3 reviewed Resident #2's physician's order for amlodipine 10 mg, the January and February 2026 MAR entries for the identified dates, and the resident's documented systolic blood pressures of less than 110 on those dates. LPN #3 confirmed the identified MAR entries were her documentation and stated, If the systolic blood pressure is less than 110, I do not give the medication.On 8/5/26 at 1:07 PM, during an interview, the Director of Nursing (DON) reviewed the seven identified MAR entries, confirmed a check mark on the MAR indicated the medication was administered, and stated nursing staff are expected to administer medications in accordance with physician orders.On 8/5/26 at 2:35 PM, during a follow-up interview, the DON stated review of Resident #2's medical record did not reveal documentation indicating amlodipine was held on the identified dates or documentation clarifying whether the medication was administered or held. The DON further stated she believed the discrepancy may have been a documentation error by LPN #3.On 8/5/26 at 2:40 PM, during an interview, Unit Manager (UM) #2 reviewed Resident #2's medical record and confirmed it did not reveal documentation indicating amlodipine was held on the identified dates or documentation clarifying whether the medication was administered or held. 2. On 8/5/26 at 10:02 AM, review of Resident #2's physician's orders revealed an order for weekly weights for four weeks with an active order date of 1/5/26.Review of Resident #2's January 2026 Treatment Administration Record (TAR) revealed the weekly weight task was documented as completed. However, review of Resident #2's weight records in the electronic medical record, PointClickCare (PCC), did not reveal the corresponding January 2026 weights. Resident #2's medical record documented a weight of 177.1 pounds on 1/5/26, followed by no documented weight in PCC until 122.2 pounds on 2/16/26 and 123 pounds on 2/18/26.On 8/5/26 at 2:30 PM, during an interview, UM #2 reviewed Resident #2's weight documentation in PCC and stated there was a discrepancy with the documented weights. UM #2 then produced a white binder she kept in her office and referred to as her cheat sheet. The binder contained handwritten January 2026 weights for Resident #2, including 124 pounds on 1/8/26, 124 pounds on 1/9/26, 126.2 pounds on 1/14/26, 128 pounds on 1/20/26, and 128.8 pounds on 1/28/26. UM #2 confirmed the January weights had not been entered into Resident #2's medical record in PCC and stated the weights should have been entered by the nurse and verified by the Unit Manager.On 8/5/26 at 2:45 PM, during an interview, the DON stated the GNA (geriatric nursing assistant) obtains the resident's weight, nursing staff are expected to document the weight in PCC, and the Unit Manager is expected to verify the weights are entered into PCC. 3. On 8/5/26, Complaint #3134594 and Resident #7's medical record were reviewed. Resident #7 was admitted to the facility on [DATE] and transferred to the hospital on 7/21/26 for further evaluation of their medical concerns.Review of Resident #7's weight log revealed two weights documented on 7/20/26 within minutes of each other. A weight of 301 pounds was documented at 11:46 PM, followed by 395 pounds at 11:51 PM. Resident #7's medical record did not indicate which weight was accurate.On 8/5/26 at 3:27 PM, during an interview, the DON reviewed Resident #7's weight log and confirmed the two documented weights were a documentation discrepancy. The DON stated the nurse who documented the weights should have struck out the incorrect weight in PCC.

Based on observations and interviews it was determined that the facility failed to ensure Residents had a dignified existence. This was found to be evident for 5 (Resident #88, #8, #163, #21, and #7) out of 32 Residents observed for dignity during the recertification and compliant survey. The findings include: 1) On 04/02/2026 at 9:54 AM during unit rounds, Resident #88 reported a lack of privacy in the room while staff were providing care to the roommate. The resident stated that staff do not draw the privacy curtain while providing care and do not knock before entering the room. The resident further stated, this happens most of the time. On 04/02/2026 at approximately 10:30 AM while the surveyor was present in Resident #8's room, Licensed Practical Nurse (LPN) #3 entered the room without knocking or announcing his presence. On 04/02/2026 at 10:40 AM the surveyor observed a (LPN) #3 enter Resident #163's room without knocking or announcing his presence. The resident was in bed at the time of entry. On 04/02/2026 at 11:26 AM an interview was conducted with LPN#3, who stated that the expectation is to knock before entering a resident's room and to introduce self to the resident. On 04/03/2026 at 8:15 AM during an interview with Resident #21, the surveyor observed Geriatric Nursing Assistant (GNA) #10 enter the resident's room without knocking or announcing her presence. On 04/03/2026 at 8:30 AM during an interview with Resident #8 in the room, (GNA) #10 entered the resident's room without knocking or announcing her presence. When the surveyor asked GNA#10 about the expectation when entering a resident's room, she stated, I am supposed to knock before entering. She further stated, I was in a rush, so I did not knock. On 04/03/2026 at 9:00 AM during an interview with the Director of Nursing (DON), she stated that the expectation when entering a resident's room is that staff are supposed to knock and introduce themselves to the resident. 2) During an interview conducted on 04/02/2026 at 10:23 AM, The Surveyor observed Geriatric Nursing Assistant (GNA) #13 & #14 enter Resident #7's room. The GNAs opened the door and walked in without knocking, announcing who they were, and asking permission to enter the room. During an interview conducted on 04/02/26 at 10:25 AM, Both GNAs apologized for not knocking, announcing who they were, and asking and waiting for permission to enter the Resident's room. The GNAs stated that they were expected to knock, announce who they are and wait for permission to enter. During an interview conducted on 04/02/26 at approximately 10:45 AM, the Director of Nursing (DON) reported that all staff are expected to knock, announce who they were, and ask and wait for permission to enter the Resident's room.

Based on observations, record review and interview, it was determined that the facility failed to 1) ensure Resident belongings were safe and secure. This was evident for 3 (Resident #30, #38, and #120) of 3 residents and 2) provide a safe comfortable and homelike environment. This was evident for resident 2 (Resident #59, and #10) out of 2 residents reviewed for Resident Rights during the recertification and compliant survey process. The findings include: 1a) During an interview conducted on 04/02/2026 at 9:43 AM, Resident #30 reported that he/she sent clothing to be laundered by the facility however when the clothing was returned a 2-piece outfit was missing. The Resident explained that he/she reported the missing clothing to the facility and a man from Laundry came, got a description, and was able to locate the pants but not the top to the 2-piece outfit. During an interview conducted on 04/08/2026 9:06 AM the Nursing Home Administrator (NHA) explained the facility process is that the Director of Nursing (DON) complete a grievance form for the missing item, the NHA would check the inventory list and would replace the item if the item was listed on the inventory list. During the interview the NHA asked the DON if she had a grievance form for Resident #30, the DON replied that she did not. The NHA reported that she was not made aware of the Resident's missing item but that she would speak with the Resident. The NHA stated that I should have been made aware that the missing item could not be located in laundry. 1b) During an interview conducted on 04/03/2026 at 8:56 AM, Resident #38 reported that when he /she returned to the facility after a recent hospitalization, he/she discovered multiple personal items missing. The Resident stated that he/she reported the missing items to the Nursing Home Administrator (NHA) who advised the Resident to write down the missing items. However, the Resident reported that he/she could not write because of the stroke. Hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction (stroke) on the right dominant side means the left hemisphere of the brain—which controls the right side of the body, language, and logic—is damaged. This causes significant motor, sensory, and cognitive impairments on the right side of the body. A review of the Resident's medical records conducted on 04/03/26 at 9:13 AM revealed a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. During an interview conducted on 04/08/2026 at 8:22 AM the NHA reported that she was not aware that the resident could not write to make a list of the missing items. 1c) On 04/02/2026 at 11:53 AM, Resident #120's Responsible Party (RP) reported that the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The RP stated that since the resident's return from the hospital, all of the resident's belongings have been missing. The RP further stated that they contacted the facility regarding the missing items and were informed that staff would search for them; however, as of the date of interview, no follow-up or update had been provided. On 04/03/2026 at 8:00 AM, record review of Resident #120 revealed the resident was transferred from the facility to the hospital on [DATE], where the resident was admitted . On 04/08/2026 at 7:58 AM, an interview was conducted with the Administrator. When asked about the process for resident belongings when a resident is transferred or admitted to the hospital, the Administrator stated that when a resident is admitted to the hospital, the Geriatric Nursing Assistant (GNA) packs the resident's belongings, labels them with the resident's name and room number, and housekeeping retrieves and places them in storage. The Administrator further stated that when a resident returns, housekeeping retrieves the belongings within 48 hours and returns them to the resident's room, and the GNA arranges them in the room. On 04/08/2026 at 8:45 AM, the Administrator contacted the Housekeeping Director regarding Resident #120's belongings. The Housekeeping Director confirmed that the resident's belongings were still in storage. On 04/08/2026 at 9:43 AM after surveyor intervention, the Administrator reported that housekeeping brought Resident #120's belongings to the resident's room and stated that the process was not followed. 2a) During an interview with Resident #59 on 04/02/2026 at 12:36 PM he/she reported being unable to open the window in his/her room due, no screen in the windows, can't get fresh air. During an observation of the window beside Resident #59 on 04/02/2026 at 12:36 PM the window was observed to have no screen or frame for the screen in place. During an interview with the Administrator on 4/08/2026 at 8:45 AM she advised that Residents can open the windows in their room and confirmed there were rooms that had windows in need of a screen within the facility. She reported that maintenance has been working on replacing screens in the windows and confirmed Resident #59 should have a screen in his/her window so it may be opened. During an interview with the Maintenance Director on 4/08/2026 at 9:21 AM he reported he was working on repairing window screens in the facility before winter came. He advised he has screen to fix the windows but had been waiting for window screen frames. He reported he had made requests for window screen frames from the corporate office but had not received any window screen frames yet. He agreed that Resident #59 needed a screen frame for his/her window. During a review of e-mails on 04/08/2026 at 10:10 AM it was revealed that e-mails requesting window screen frames were sent to the facility's corporate office by the Maintenance Director on 5/02/2025 and a follow-up request was sent on 6/24/2025. The Maintenance Director reported he still had not received any window screen frames. 2b) During an observation of the bedroom for Resident #10 on 4//2/2026 at 9:44 AM it was revealed that three cable outlets and the cable casings had been pulled away from the wall and were dangling from the wall. The cable outlet face plates were hanging off the cable outlet housing. The phone jack for the wired telephone was missing the face plate which exposed the wires and the inside of the wall surrounding the telephone wire housing. In the bathroom for Resident #10 there was an unpainted area where a toilet paper roll dispenser had been located with screws still in place. During an interview with the Maintenance Director on 4/08/2026 at 9:40 AM he reported the maintenance staff does a walkthrough on a regular basis to find things that need to be repaired and depend on other staff to report any issues that need to be repaired. He confirmed the issues found in the room for Resident #10 needed to be repaired but advised he was not aware of the issues and that no one reported the concerns. We have 71 rooms and normally they don't tell me when things go bad. They are supposed to, but they don't.

Based on medical record reviews and interviews it was determined that the facility failed to obtain consent for Psychotropic Medication administration. This was evident for 2 (#9 and #3) of 5 residents reviewed for Psychotropic Medications during the recertification survey. The findings include:Psychotropic medications are prescription drugs that alter brain chemistry to manage mental health conditions, including depression, anxiety, schizophrenia, bipolar disorder, and ADHD. Common types include antidepressants, anti-anxiety agents, antipsychotics, mood stabilizers, and stimulants, which are generally used to reduce symptom severity. These medications are often used in combination with therapy, though they carry potential side effects, such as weight gain, sedation, and sexual dysfunction.1. During a review of medical records for Resident #9 on 4/07/2026 at 12:15 PM it was discovered that the Resident had been taking Buspirone and oxcarbazepine and there was no Informed consent for Psychotropic Medication documented in the Resident's chart for these medications.Buspirone 5 milligrams three times a day was started on 5/13/2025. Oxcarbazepine 75 milligrams two times a day was started on 5/13/2025. Oxcarbazepine was increased to 150 milligrams two times day on 6/09/2025.Oxcarbazepine was increased to 300 milligrams two times day on 8/05/2025.Oxcarbazepine was increased to 300 milligrams three times day on 10/21/2025.During an interview with the Director Nursing on 4/08/2026 at 11:20 AM she reported it was the nursing staff's responsibility to obtain the consent for Psychotropic medications. She confirmed that a consent would have been expected to have been obtained for the Buspirone and Oxcarbazepine, but she was unable to find that the consent was completed. 2. During a review of medical records for Resident #3 on 4/07/2026 at 1:48 PM it was discovered that the Resident had been taking Trazadone and there was no Informed consent for Psychotropic Medication documented in the Resident's chart for the Trazadone.Trazodone 50 MG at bedtime for 30 Days was started on 12/18/2025.Trazodone 50 MG every 24 hours as needed for 14 Days was ordered on 01/29/2026.Trazodone 50 MG at bedtime was reordered on 02/18/2026.During an interview with the Director Nursing on 4/08/2026 at 11:20 AM she reported it was the nursing staff's responsibility to obtain consent for Psychotropic medications. She confirmed that a consent would have been expected to have been obtained for the Trazadone, but she was unable to find that the consent was completed.

Based on medical record review and interviews with resident and facility staff, it was determined that the facility failed to invite a resident to their care plan meetings. This was evident for 1 (Resident #138) out of 2 residents reviewed during recertification survey. The findings include: Residents have the right to be informed of and participate in the development and review of their care plan. The facility must invite the resident and/or representative to care plan meetings, allow participation in person or by phone, and document attendance or refusal. This supports person-centered care and ensures resident involvement in decisions about their care. During an interview conducted on 04/02/2026 at 10:14 AM, Resident #138 reported that he/she has not been invited to a care plan meeting since admission to the facility. A review of Resident #138's medical record, including the Electronic Medical Record (EMR), conducted on 04/06/2026 at 10:50 AM, revealed the resident was admitted to the facility on [DATE].Further review of the EMR identified a care plan conference invitation dated August 26, 2025, addressed to Resident #138 and the Responsible Party (RP). The invitation was issued on the same date as the scheduled care plan meeting. Additionally, review of the care plan attendance sheet (care plan report) dated August 26, 2025, revealed no indication that the resident attended the care plan meeting.On 04/07/2026 at 9:25 AM a review of Resident #138's medical record was conducted with Director of Social Services. The review revealed no documentation indicating that the resident attended a care plan meeting. On 04/07/2026 at 10:07 AM, an interview was conducted in the presence of the facility Administrator, Director of Nursing (DON), and Social Services Coordinator (SSC) regarding the facility's care plan meeting process. SSC stated that care plan meetings are held quarterly, if the resident is capable, the resident is provided with a care plan meeting invitation. If the resident is not capable, the Responsible Party (RP) is notified via phone, email, or mail. SSC further stated that care plan meetings are conducted either in person or via phone conference, and residents attend if able. She stated that the interdisciplinary team (IDT), Responsible Party (RP), and residents are expected to sign the attendance sheet to document participation. Both the Administrator and the Director of Nursing (DON) confirmed that the Resident#138 is capable.On 04/07/2026 at 10:36 AM SSC submitted a care plan meeting attendance sheet dated 08/26/2025 and a care conference invitation dated 08/26/2025 to the surveyor and stated, I do not have any more documentation. It was confirmed that there was no additional documentation indicating that the resident was invited to or attended a care plan meeting since admission to the facility.

Based on observations and interviews it was determined that the facility failed to ensure a Resident's needs were accommodated. This was found to be evident for 1 (Resident #126) out of 8 Residents reviewed for accommodation of needs during the recertification and complaint survey. The findings include: During an observation conducted on 04/03/26 at 12:56 PM, the Surveyor observed Resident #126 lying in a bariatric bed eating his/her lunch. During an interview conducted on 04/03/26 at 12:58 PM, the Resident reported that he/she was bed bound because the facility would not provide a wheelchair although he/she had requested a wheelchair numerous times to the nursing staff. The Resident reported that Nurse Supervisor #15 advised that the facility did not have a wheelchair for him/her. The Resident further explained that a wheelchair company Freedom Mobility gave him/her motorized wheelchair in January 2026 with the understanding that once Medicaid was approved Freedom Mobility would provide a permanent wheelchair. However, since the Medicaid application still had not been approved to date, Freedom Mobility came and retrieved the loaner wheelchair in February 2026, and the Resident had been bed bound ever since. During an interview conducted on 04/08/26 at approximately 9:30 AM, the Nursing Home Administrator (NHA) stated that she did not have a wheelchair to accommodate Resident # 126's size. The Surveyor reported that the Resident stated that he/she had requested a wheelchair from numerous staff. The NHA reported that she would take full responsibility for the staff's failure to notify her of the Resident's request for a wheelchair. The Surveyor observed the NHA make a phone call and requested a bariatric wheelchair be ordered.

Based on record review and interview, it was determined that the facility failed to ensure that residents were free from abuse. This was identified during review of facility-reported incident #2731067 and was evident for 2 (Resident #104 and #161) out of 2 residents reviewed for abuse. The findings include:On 04/03/2026 at 1:03 PM, this surveyor began the record review the facility's investigation related to a facility reported incident #2731067. It was found that the facility verified the allegation, based on the interviews collected and both residents admitted to engaging in an altercation. On 04/03/2026 at approximately 1:30 PM, a record review of the facility-reported investigative file revealed the following:On 01/24/2026 at approximately 9:00 AM, Resident #104 and Resident #161, who were roommates, were involved in a physical altercation. Injuries were documented as [Resident #161] sustained facial swelling and laceration to the right side of forehead, and [Resident #104] laceration on the right side of the cheek. An interview with the alleged victim, Resident #161, stated that his/her clothes were initially placed on a chair by the window. He/she reported that his/her roommate later placed his/her own clothes in the same location. He/she stated that he/she then moved his/her clothes to the foot of his/her bed. According to Resident #161, his/her roommate approached the clothing believing it belonged to him/her. Resident #161 stated that he/she informed the roommate that the clothes were not his/hers. Per Resident #161, the roommate then began using profanity language toward him/her, and after being told not to use such language, his/her roommate subsequently punched him/her in the face, at which point he/she punched him/her back in defense. The resident reported that he/she yelled for help, a GNA responded and removed the roommate from the room, and a nurse later provided first aid. Resident #161 requested to go to the hospital. An interview with the alleged perpetrator, Resident #104, stated that his/her clothes were placed on a chair by the window. He/she reported that the clothing belonging to his/her roommate was also in the same area. Resident #104 reported that he/she approached the clothing believing it belonged to him/her, and when informed otherwise by the roommate, a verbal exchange occurred. Resident #104 stated that a physical altercation then occurred between them, during which both punched each other. A statement from RN Supervisor #15 reported that on 01/24/2026, while serving as the nursing supervisor, a GNA assigned to the residents reported hearing Resident #161 yelling for help while passing breakfast trays. The RN Supervisor reported that upon entering the room, Resident #161 was assessed and found to have facial swelling and a laceration to the right side of the forehead. The RN Supervisor reported that Resident #161 stated that when Resident #104 was taking his/her clothes and he/she refused, Resident #104 struck him/her in the face. A statement from a GNA reported that while passing breakfast trays on 01/24/2026, he/she heard a resident calling for help, entered the room, and observed Resident #104 sitting on the bed and Resident #161 sitting at the edge of the bed with a small amount of blood on the right forehead area. The GNA reported that Resident #161 stated the two residents had argued and that Resident #104 hit him/her in the face. The GNA reported that he/she immediately removed Resident #104 from the room, remained with Resident #104, and contacted the charge nurse.A skin status evaluation completed on 01/24/2026 at 12:58 PM by LPN #16 documented that Resident #161 had a new skin condition, including a laceration to the right side of the forehead and facial swelling.An after-visit summary from Holy Cross Health Hospital for Resident #161 stated, You were seen after an assault. Your CT scan showed a small amount of blood in your brain from being struck in the head. The repeat CT scan did not show any worsening. The summary further stated, you were found to have a small scratch of your eye that will take several days to heal.A psychiatry note dated 01/27/2026 for Resident #161 documented follow-up for patient to patient altercation, noting that the resident required EMS transport to Holy Cross Hospital Emergency Department and that the resident reports feeling safe now that [Resident #161] and [Resident #104] have been placed in separate rooms.A psychiatry note dated 01/27/2026 for Resident #104 documented evaluation following his/her second patient to patient altercation, involving a confrontation with his/her former roommate related to alleged theft of personal belongings. The note further stated that Resident #104 has a documented history of aggressive behavior, including a prior fight and recent start on mood stabilizer medication.On 04/03/2026 at approximately 1:40 PM, record review of Resident #104's care plan revealed documentation stating [Resident #104] has behaviors related to cognitive impairment. He had a physical altercation with another resident. He hit another resident on the face, with a last revision date of 01/11/2026. An additional care plan, revised on 01/24/2026, documented that Resident #104 had a physical altercation with his/her roommate and sustained a laceration on his/her right cheek area.On 04/07/2026 at approximately 11:00 AM, this surveyor conducted an interview with the Director of Nursing (DON), who confirmed that she completed the investigation and submitted the final report. The DON confirmed that the facility verified the allegation based on staff witness statements and both residents' admissions of the physical altercation.On 04/08/2026 at 9:58 AM, this surveyor conducted a follow-up interview with the DON and communicated that, as the facility verified a resident-to-resident physical altercation resulting in injury, there is a concern that the facility failed to ensure residents were free from abuse. The DON acknowledged and confirmed understanding of the concern.

Based on record reviews and interviews it was determined the facility failed to notify the resident in writing of the bed hold policy when the resident was transferred from the facility to a hospital. This was evident for 1 (resident #6) of 2 residents reviewed for hospitalization during the recertification survey.The findings include:During a review of medical records for Resident #6 on 4/06/2026 at 12:37 PM it was discovered that the Resident was sent to and admitted to the hospital on [DATE] and 1/30/2026. Further review of medical records revealed that there was no documentation of the Resident receiving the facility Bed Hold Information after being discharged to the hospital.During an interview with the Medical Records Coordinator on 4/07/2026 at 4:01 PM she reported that the Bed holds policy should be given to any Resident that is sent out to the hospital. She advised that she keeps a copy of all the Bed Hold forms that were given to residents in a binder.During an observation with the Medical Records Coordinator on 4/07/2026 at 4:02 PM she looked through the Bed Hold Binder and could not find any documentation that the Bed Hold Information was given to Resident #6. She confirmed that Resident #6 should have gotten the Bed Hold Information but did not receive one for the dates he/she was sent to the hospital on [DATE] and 1/30/2026.During an interview with the Administrator on 4/08/2026 at 8:10 AM she confirmed that Resident #6 should have received a Bed Hold Information after being sent to the hospital from the doctor's office because he/she is still ours. It was a communication issue and the Medical Records Coordinator wasn't aware she had to send it.

Based on record review and interviews it was determined that the facility failed to ensure that a Resident received an assessment for additional services. This was found to be evident for 1 (Resident #7) out of 1 Resident reviewed for PASRR evaluation during the recertification and complaint survey. The Findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement (often stylized as PASARR) ensuring individuals with serious mental illness (SMI), intellectual disabilities (ID), or related conditions are not inappropriately placed in Medicaid-certified nursing facilities. It requires screening before admission and, if necessary, regular reviews to ensure appropriate care and specialized services.PASRR Level I is a mandatory federal screening process used to identify if individuals seeking admission to a Medicaid-certified nursing facility have a suspected or diagnosed mental illness (MI), intellectual disability (ID), or related condition. It ensures appropriate placement and services, preventing unnecessary institutionalization for those with specialized needs.PASRR Level II is a federally mandated, in-depth evaluation triggered by a positive Level I screen, confirming if nursing facility (NF) applicants have a serious mental illness (SMI) or intellectual disability (ID). It assesses the need for specialized services and determines if a nursing home is the most appropriate, person-centered setting, often looking beyond initial diagnoses. Adult Evaluation and Review Services (AERS) in Maryland provides mandatory PASRR (Preadmission Screening and Resident Review) Level II evaluations for individuals with mental illness or intellectual disabilities seeking Medicaid-certified nursing facility admission. AERS teams (registered nurses/social workers) evaluate applicants to ensure proper care, aiming for the least restrictive environment.During a review of Resident #7's PASRR I conducted on 04/02/2026 10:50 AM, it was discovered section D indicated that the resident should be referred to AERS for a PASRR II evaluation. A further review of the Resident's medical records did not show an AERS evaluation.During an interview conducted 04/07/26 at approximately 11:00 AM. The Social Service Director (SSD) reviewed Resident #7's PASRR with the Surveyor and confirmed that the Resident should have an AERS evaluation. The Surveyor also expressed concern that since admission the Resident had been transferred to the hospital for a psychotic episode and the Surveyor was unable to locate a PASRR. The SSD reported that she would investigate it and get back to the Surveyor. Telligen's PASRR (Preadmission Screening and Resident Review) solution is a comprehensive, electronic tool designed to help state Medicaid agencies and providers ensure individuals with mental illness (MI) or intellectual disabilities (ID) are not inappropriately placed in nursing facilities. It streamlines Level I screenings and Level II assessments through their Qualitrac system. On 04/08/26 at approximately 10:00 AM, the SSD returned and reported that she was unable to locate the AERS evaluation and a PASRR from Telligen for the transfer to the hospital when Resident #7 had the psychotic episode. The SSD stated that there should have been an AERS evaluation and PASRR from Telligen.

Based on record review and interview, the facility failed to initiate a baseline care plan for Resident #163, as required. This was evident for 1 (Resident #163) out of 1 resident reviewed during the recertification survey.The findings include: A baseline care plan is an initial, person-centered care plan developed within 48 hours of a resident's admission that includes instructions needed to provide effective and person-centered care. It is based on admission orders and initial assessments and must address the resident's immediate needs, goals, and preferences to ensure health, safety, and well-being until the comprehensive care plan is developed. On 04/02/2026 at 11:10 AM Resident #163 reported to the surveyor, I have not seen the social worker since my admission to the facility. I have not attended any care plan meeting and would like to discuss my discharge.On 04/06/2026 at 7:45 AM record review of Resident #163 revealed the resident was admitted to the facility on [DATE]. Further review of the medical record found no documentation to support that a baseline care plan had been initiated.On 04/07/2026 at 11:03 AM interview with the Director of Nursing (DON) revealed that unit managers and supervisors are responsible for completing the baseline care plan within 48 hours of admission. The DON stated that the plan of care and medications are reviewed with the resident and/or Responsible Party (RP), signatures are obtained, and a copy is provided. The DON further stated that if the resident is unable to sign, the nurse contacts the RP and two nurses sign to acknowledge the review.On 04/07/2026 at 11:30 AM further review of Resident #163's medical record revealed documentation dated 03/30/2026 that included two nurses' signatures and a list of medications; however, there was no evidence of an immediate plan of care. This was reviewed with the (DON), who confirmed that the documentation did not include the baseline care plan. The DON further stated that she was unsure whether a copy had been provided to the resident or the Responsible Party (RP).

Based on medical record reviews and interview, it was determined that the facility failed to 1) initiate care plans based on medication use. 2) care plan for house acquired pressure ulcer for a resident. This was evident for 2 (Resident# 101 and #120) out of 2 residents reviewed during a recertification survey. The findings include:1) On 04/03/2026 at 11:19 AM during an unnecessary medication review, it was noted that Resident #101 had a physician's order for Fluoxetine HCl Capsule 20 mg, to be administered as one (1) capsule by mouth once daily for depression. Further review of the resident#101's Medication Administration Record (MAR) revealed an active order indicating that the resident received the medication as prescribed during the period under review. On 04/07/2026 at 10:15 AM an interview was conducted with the Director of Nursing (DON) regarding the facility's care plan process. The DON stated that care plans are initiated on the day of admission or within 72 hours and that unit managers incorporate pertinent diagnoses and medications from the transfer summary; she further stated that the interdisciplinary team (IDT), including nurses, nursing supervisors, and unit managers, is responsible for developing and updating care plans, including updates related to new medications. On 04/07/2026 at 10:27 AM, the surveyor and Director of Nursing (DON) reviewed the resident's care plan. The DON confirmed that there was no care plan in place for the resident#101 receiving antidepressant medication. On 04/07/2026 at 10:40 AM a review of the record revealed that, after surveyor intervention, the Director of Nursing (DON) updated the care plan. 2) A facility-acquired pressure ulcer is a pressure injury that develops after a resident has been admitted to the facility and was not present or identified upon admission. It indicates that the skin breakdown occurred during the resident's stay in the facility. On 04/07/2026 at 2:21 PM, a review of the medical record for Resident #120 revealed that the resident developed a facility-acquired right heel pressure ulcer on 10/14/2025. Further review of Resident #120's Treatment Administration Record (TAR) revealed that daily treatment was provided during the period under review; however, review of the medical record indicated that there was no care plan addressing the pressure ulcer. On 04/08/2026 at 9:19 AM, an interview was conducted with the Director of Nursing (DON) and Administrator regarding the process for facility-acquired pressure wounds. The DON stated that when a facility-acquired pressure wound is identified, the nurse completes a comprehensive assessment, including skin, pain, and risk assessments. The DON further stated that the eINTERACT tool is utilized as part of the process and that the care plan is updated accordingly.The DON emphasized that the expectation for nursing staff is to complete all required assessments and ensure the resident's care plan is updated to reflect the resident's current needs.On 04/08/2026 at 9:39 AM the DON and the surveyor reviewed the resident's medical record. The DON confirmed that there was no care plan initiated for the resident's right heel pressure ulcer.

Based on interviews and medical record reviews it was determined that the facility failed to have quarterly care plan meetings with the interdisciplinary team. This was found to be evident for 1 (Resident #15) out of 6 Residents reviewed for care plan meetings during the recertification survey. The findings include:A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse with responsibility for the resident, nursing assistant with responsibility for the resident, dietary services, the resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly.During an interview with Resident #15 on 04/02/2026 at 11:49 AM he/she denied having regular care plan meetings.During a review of medical records for Resident #15 on 4/06/2026 at 11:43 AM it was discovered that he/she had been a resident since 2024. The last three care plan meetings for Resident #15 were held on 12/24/2024, 7/29/25 and 3/31/2026. There were no additional care plan meetings documented between the meetings held on 12/24/2024 and 7/29/2025 or between the meetings held on 7/29/2025 and 3/31/2026.During an interview with the Director of Social Services on 4/06/2026 at 1:23 PM she reported the care plan meeting and the attendance sheet would be documented in the Residents electronic medical record. She confirmed that Resident #15 only had one care plan meeting documented in 2025 which was held in July. She confirmed that care plan meetings were missed for Resident #15.During an interview with the Social Services Coordinator on 04/06/2026 at 1:47 PM she reported she was responsible for the care plan meetings for Resident #15 and reported the Resident had a care plan meeting in March 2026. She confirmed that the Resident only had one care plan meeting in 2025 and confirmed care plan meetings were missed.

Based on observation, interviews, and record review, it was determined that the facility failed to provide ongoing resident-centered activities to meet residents' interests and needs. This was evident for 1 resident (Resident #2) out of 3 residents reviewed for the personalized activities during the annual survey. On 04/02/26 at 2:24 PM, observed Resident #2 was sitting in bed alone in the room. The resident was able to engage in conversation and move her upper extremities freely; however, no activity materials or devices were found at the bedside. During an interview, the resident confirmed that no such materials or device had been provided and expressed an interest in receiving them. A subsequent record review on 04/03/26 at 09:05 AM indicates that Resident #2 was admitted to the facility on [DATE] with the diagnoses include a 2015 cerebral infarction with left lower leg weakness, dysphagia, and chronic kidney disease. Additional observations on 04/03/26 at 09:15 AM and 3:16PM, both lasting over one hour, Resident #2 was noted to be feeding herself and cleaning her bedside table. However, she also repeatedly fell asleep during these periods. Additionally, no activity staff were present at these times. Regarding the interview conducted on 04/07/26 at 2:11PM, Recreation Director Staff #11 stated that the resident was invited to group activities but preferred to remain in their room. The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating had the capacity to make their needs/interests known. Activity Director Staff #11 reported that the resident currently received 1:1 visits daily from activity Staff #12. Requested March & April 2026 daily activity's logs for review. BIMS (Brief Interview for Mental Status) It is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. BIMS Score: 0-7 points indicates Severely Impaired Cognition, 8-12 points indicates Moderately Impaired Cognition and 13-15 points indicates Intact Cognition. A record review of activity logs conducted on 04/07/26 at 3:16PM, identified several documentation gaps regarding Resident #2's interactive contact/1:1 activity. For March interactive contact/1:1 activity: morning greetings, aromatherapy, or spa treatments. This resulted in an overall average below 21%. For April with the same interactive contact/1:1 activity of above 3, the resulting in an average of only 7%. During an interview on 04/07/26, at 3:50 PM, Recreation Director Staff #11 confirmed that the low percentage of 1:1 visits were accurate and no activity materials or devices were provided to this resident. She agreed that the activity staff failed to provide ongoing meaningful activities designed to meet resident-centered daily needs and interests. In the final interview, the Administrator concurred with the above identified deficiency practice concern. It was stated that the activity staff failed to provide ongoing resident-centered activities.

Based on observation, interview and record review it was determined that the facility staff failed to provide sufficient Foley catheter monitoring, standard care and documentation per shift. This was evident for 1 (Resident #11) of 3 residents reviewed for bowel and bladder incontinence during the annual survey.The findings include: A Foley catheter is a semi-flexible plastic tube closed system to empty the urine from the bladder. One end is inserted into the bladder and the other end is attached to a gravity drain bag that collects urine. Observations regarding Resident #11, on 04/02/26, at approximately 10:05 AM and 01:30 PM, it was observed that the Foley catheter drain was not draining. Upon interviewing Resident #11, revealed that pain occurred sometimes (pointed the bladder area). A record review conducted on 04/03/26 at 12:32 PM identified with a new urinary tract infection and physician orders dated 03/20/26 for Foley catheter placement. These orders instructed staff to check the Foley every shift and change it as needed for clinical indications, such as infection, obstruction, or a compromised closed system. Further review revealed a lack of documentation regarding Foley monitoring or standard care for each shift. Additionally, it was noted that the nursing staff did not follow the established Care Plan to provide catheter care on a per-shift basis. Care Plan is a mandatory, personalized document outlining a resident's medical, physical, and social needs, along with specific, measurable goals (SMART goals) to maintain or improve their well-being. Developed by an interdisciplinary team with resident/family input, it serves as a daily roadmap for staff. Interview, on 04/03/26 at 12:50 PM, 1st Floor Unit Manager Staff #19 attempted to locate Resident #11's Foley care shift documentation for her staff but was unsuccessful. She subsequently confirmed that the nursing staff omitted the required documentation regarding insufficient Foley care. The Unit Manager assured that she would address the nursing staff's Foley care and documentation practices. Furthermore, she committed to immediately re-educating her staff on these requirements. The final interview with the Administrator took place on 04/07/26 at 11:55 AM. During the meeting, the previously identified deficient practices were discussed. The Administrator agreed that the nursing staff was not following the established standard of care and Resident #11's resident-centered-care plan .

Based on record review and interview, the facility failed to provide a minimum of 3 hours of bedside care, per occupied bed, per day. This was evident for 3 out of 14 days reviewed during the annual recertification survey.The findings include:Current state regulations require that a nursing home shall employ supervisory personnel and a sufficient number of support personnel to provide a minimum of 3.0 hours of bedside care (PPD) per occupied bed per day, 7 days per week. On 04/07/2026 at 1:22 PM, a review of facility staffing was completed using the provided daily staff assignment sheets and facility census for the period between 03/04/2026-03/17/2026. Review of daily staffing revealed the facility was staffed below the required 3.0 hours per resident per day for 3 out of the 14 days reviewed. PPD below 3.0 was confirmed on the following days:03/07/2026: 2.89 03/08/2026: 2.94 03/17/2026: 2.79 On 04/08/2026 at 8:55 AM, an interview with the Staffing Coordinator confirmed the full building staff listed on the daily staffing schedule is not included in the facility's staffing PPD. She went on to explain that if they are short of nursing staff with call outs, they will call Per diem staff and part time staff to try and fill in staffing gaps. The Staffing Coordinator stated she does not pull nursing staff coverage from the listed full building staff on a daily basis and that the listed full building staff are not routinely on the floor.

Based on observation of medication administration and review of medical records it was determined that the facility failed to ensure a medication error rate of less than 5%. This was evident for 2 medication administration errors out of 27 medication administration opportunities observed which resulted in a medication error rate of 7.41% during the recertification survey.The findings include: During a medication administration observation conducted on 04/02/2026 at 8:40 AM, Registered Nurse #1 (RN) prepared and administered Resident #7's daily morning medications. RN #1 was observed to have pulled and administered the following medications: ARIPiprazole Tablet 10 M; Furosemide Tablet 40 M; Multivitamin-Minerals Tablet; Plavix Tablet 75 MG; Vitamin B6 Tablet 100 MG; BusPIRone HCl Tablet 5 MG; Eliquis Tablet 5 MG; oxyCODONE-Acetaminophen Oral Tablet 10-325 MG. Prior to administering the medications to Resident #7, it was confirmed with RN#1 the medications that were pulled with a count of 8 medications in the cup when administered to Resident #7. On 04/02/2026 at 10:00 AM, a review of Resident #7 Medication Administration Record (MAR) revealed orders for 2 additional medications that were due for medication administration at the time of the observation: Cholecalciferol Tablet 1000 UNIT; Omega-3 EPA Fish Oil Oral Capsule. The medications were documented as administered to Resident #7 and were not observed to be pulled or administered during the medication administration observation with RN #1.

Based on observation and interviews, it was determined the facility failed to ensure medications were properly labeled, stored, and wasted. This was evident for 3 of 3 medication carts observed, 1 of 2 medication storage rooms observed, and 1 Resident (Resident #59) of 5 Residents observed during the recertification survey and complaint survey. The findings include:1)Some medications should be stored in the refrigerator until they are opened because cold temperatures help maintain the stability and effectiveness of their active ingredients. Improper storage can cause these medications to degrade and become less potent, which may make them ineffective. Most insulin vials and pens expire 28 days after opening. The insulin becomes less effective 28 days after opening and can contribute to higher-than-normal blood sugars or diabetic emergencies and should be discarded per facility policy when the expiration date is reached. On [DATE] at 8:40 AM, an observation of Med Cart #1 revealed that there were the following medication storage errors:4 vials of opened Lantus 100 units/milliliter (mL) of liquid that did not have opened date documented on the vials for Resident # 871 vial of opened Lantus 100 units/milliliter (mL) of liquid that did not have opened date documented on the vial for Resident # 1531 humalog pen with no opened date located on the pen for Resident # 751 Novolin 70/30 pen with no opened date located on the pen for Resident # 1261 Insulin Aspart 100units/milliliter (mL) of liquid pen with no open date documented on the pen for Resident # 5 On [DATE] at 8:40 AM, interview with Licensed Practical Nurse #3 (LPN) confirmed that the medications observed on the cart were opened and were not labeled with an open or expiration date on the vials or pens. LPN #3 could not verify the facility process for labeling and expiration monitoring of opened pens and vials. LPN#3 contacted the Director of Nursing (DON) to remove the medication from the cart. 2) [DATE] at 9:00 AM, observation of medication cart #2 revealed that there were the following medication storage errors:2 Lantus 100 units/milliliter (mL) of liquid/ pens that did not have opened date documented on the pens for Resident # 86 [DATE] at 9:00 AM, an interview with LPN #2 confirmed that the medications observed on the cart were opened and were not labeled with an opened or expiration date on the pens. LPN#2 contacted the DON to remove the medication from the cart. 3) On [DATE] at 9:33 AM, an observation of medication cart #3 revealed that there were the following medication storage errors:1 unopened Lantus 100u/milliliter (mL) of liquid pen stored on the cart in a pharmacy bag labeled refrigerate until opened for Resident # 511 unopened ADEMLOG 100u/milliliter (mL) of liquid pen stored on the cart in a pharmacy bag labeled refrigerate until opened for Resident # 881 unopened Novolog 100u/milliliter (mL) of liquid pen stored on the cart in a pharmacy bag labeled refrigerate until opened for Resident # 88 On [DATE] at 9:33 AM, an interview with Registered Nurse #1 (RN) confirmed that the medications observed on the cart were unopened and should be properly stored in the refrigerator until they are opened. RN #1 contacted the DON to remove the medication from the cart. 4)Aplisol should be used within 30 days after opening the vial. Any remaining solution after this period should be discarded due to the potential for oxidation and loss of potency. The integrity of the vial and solution must be maintained to avoid inaccurate test results, which can lead to false negative or positive findings with tuberculosis screening. On [DATE] at 11:25 AM, an observation of the medication storage room on the 1st floor showed 2 vials of Aplisol observed to be in the refrigerator opened without an opened or expiration date recorded on vials. The DON confirmed the vials were not labeled with an open or expired date and removed the vials from the refrigerator. 5) Leaving medication in a cup at the bedside makes the medication accessible to unauthorized individuals, fails to secure the medication, and violates the requirement that drugs be stored properly. This regulation ensures that only personnel authorized to administer medication have access to them, and that medication is stored safely to prevent errors or diversion. On [DATE] at 12:40 PM, a cup of medication containing 3 pills was observed placed on the over bed table next to the bedside of Resident # 59. The resident confirmed that the RN placed them there and he/she does not know what they are for so Resident #59 stated they will not take them. [DATE] 12:43 PM interview with the DON reported it is the facilities process to watch residents take medications and ensure they swallow them before leaving the room. This surveyor showed the DON the cup of pills sitting at Resident #59 bedside on the overbed table. The DON asked the Resident what the pills were and the resident stated she did not know what they were for and would not take them. The DON removed the cup of medications from the resident's room. When asked if that was the facility process to leave medications at the bedside the DON confirmed it is not the facility process, the correct process to administer and watch the resident to make sure they took them.

Based on observations and interviews it was determined that the facility staff failed to maintain the food prepared and storage areas in a sanitary manner, which includes keeping the kitchen free from contaminants and physical hazard free. This was evident for 1 out of 1 kitchen tours during the annual survey and has the potential to affect all residents.On 04/02/2026 at 8:23 AM, in kitchen area personal items of cell phone, keys and drinks were observed on a tray cart outside the refrigerator area. The Kitchen Manager (Staff #13) noted that lockers are available for staff use immediately outside the kitchen. However, subsequent observations on 04/06/2026 at 12:37 PM confirmed that personal items continue to be left in storage and food preparation areas. In a follow-up interview at 1:37 PM with Staff #13 it was confirmed that personal items were repeatedly left in storage and food preparation service areas. Staff #13 agreed that all kitchen staff must use their assigned lockers properly to maintain standards. Furthermore, during a final interview with the Administrator it was concluded on 04/08/2026 at 11:09 AM, regarding the findings identified as a deficiency concern. The Administrator agreed that there is no justification for kitchen staff failing to use their designated lockers for personal items.

Based on review of medical records, review of facility policy and interview with facility staff, it was determined that the facility failed to 1) Ensure nursing staff followed the physician orders [REDACTED]. This was true for 2 out 6 Hospice residents (#117 and #26) reviewed. Due to this failure, on [DATE] 1:00 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to ensure the desired code status of the resident was correctly documented in the resident's chart to ensure that facility staff was able to understand and carry out said wishes and to consistently document the correct code status.An initial plan of action was given to the survey team for review on [DATE] at 5:20 PM and was not accepted. The 2nd plan of action was given to the survey team and the Office of Health Care Quality for review at 6:00 PM. This plan was accepted by the survey team and the Office of Health Care Quality and the immediate jeopardy was removed at 6:10 PM. After removal of the immediacy, the deficient practice remained with potential for more than minimal harm at level D.The findings include:1. On [DATE] at 10:30 AM review of Resident #117's medical records revealed that the resident was admitted from an acute care hospital in [DATE] for long term care. Further review revealed a MOLST form dated [DATE] with a decision made by the resident's legal guardian for an attempt CPR. The second page of the MOLST revealed orders for: the potential use of intubation and artificial ventilation, and may give artificially administered fluids and nutrition (refers to the provision of nutrients and liquids through the use of tubes, intravenous procedures, or similar medical intervention). Review of the resident's hospital records revealed that the resident was a full code. Review of the nurse's notes revealed a note written on [DATE] which stated, Consulted with Hospice. Hospice will follow up today. The resident was admitted to Hospice on [DATE] and review of the nursing comprehensive assessment revealed that the resident was a full code. Review of a [DATE] nursing progress note revealed the following documentation, Continue on Hospice, resident is alert and responsive.Further review of the medical practitioner progress note dated [DATE] revealed that the code status was full code. Review of the resident's medical record in the facility failed to reveal any documentation that the medical order form regarding code status had been reviewed with the guardian since the admission to the facility and admission into Hospice. On [DATE] nursing staff documented, resident noted with yellow sputum in mouth and sounding congestion, physician called and made aware order written to obtain chest x-ray and start resident on antibiotics. Review of the note dated [DATE] revealed, Resident alert and responsive. Continue on antibiotics vital signs temperature 98.7, pulse 91 and blood pressure ,[DATE]. On [DATE] nursing staff documented a change of condition in which the temperature was documented as being 102.4 heart rate 140 and blood pressure was ,[DATE]. The physician was notified and orders were given to provide tylenol and a medication to control the resident's heart rate. Further review of the nursing progress notes revealed that on [DATE] at 11:00 PM, Resident #117 was in bed awake yawning, alert and responsive. Review of the note dated [DATE] at 11:43 PM revealed, resident observed unresponsive, not responding when called, no obvious movement. The hospice nurse was notified of the resident's change in condition. Review of the [DATE] 12:40 AM nursing notes revealed the following, Hospice nurse arrived and assessed the resident. He is resting in bed peacefully. No respiration. No pulse. Hospice nurse notified Dr. (physician name). Resident pronounced dead at 0040 (12:40 AM. There was no evidence that staff performed CPR on the resident at any point between [DATE] at 11:43 PM, when staff observed the resident unresponsive, and [DATE] at 12:40 AM, the time that the resident was pronounced dead. During an interview with Staff Nurse #2 on [DATE] at 11:56 AM, he reported if a resident had no pulse, he would call hospice. Staff Nurse #3 revealed that if a resident was on Hospice he would call hospice first; but if the resident was a full code, he would do CPR and call hospice. During an interview with Staff Nurse #3 on [DATE] at 9:30 AM, he revealed that he doesn't really look at the MOLST if the resident on Hospice. He stated that if the resident is a full code and is receiving hospice services regardless of the MOLST they would not perform CPR on the resident. Further interview with Staff Nurse #3 revealed that because this resident was hospice, he would always call hospice first. 2. On [DATE] Resident #26's medical record was reviewed which revealed that on [DATE] the resident was admitted into Hospice. Review of the MOLST, which was undated, revealed that the resident's code status was attempt CPR in the case of [MEDICAL CONDITION] and to transfer to hospital for any situations. Review of the medical records failed to reveal any additional MOLST which was dated. Further review of the medical record revealed a section for hospice documentation. Review of the Hospice comprehensive nursing assessment within the resident's medical record revealed that the hospice nurse discussed with the resident and/or the responsible party (RP) their preference regarding CPR and hospitalization on [DATE]. The resident/RP indicated that they wanted to have a code status of DNR (do not resuscitate), DNI (do not intubate) and DNH (do not hospitalize). Further review of the hospice emergency phone numbers and instructions revealed that the resident was a DNR.A [DATE] progress note from the facility social worker documented that the resident remains a full code. There was no evidence of documentation that there was a discussion or communication between the facility staff and hospice staff when there were differing orders or notes regarding the resident's code status. On [DATE] the Hospice Director documented a clarification and correction to the hospice documentation in Resident #26's hospice records stating, Admission documentation dated [DATE] DNR status entered in error. At start of care patient was a full code. She went on to document, Resident is a full code with hospital transfer and intubation.An initial plan of action was given to the survey team for review on [DATE] at 5:20 PM and was not accepted. The 2nd plan of action was given to the survey team and the Office of Health Care Quality for review at 6:00 PM. This plan included: an audit of all resident's medical records for the correct MOLST orders, education of the facility's nursing staff on the facility's protocols for MOLST and Hospice residents, education of unit managers, social services staff and licensed nurse on process and completion of the MOLST, education of Hospice staff, and an ongoing auditing plan for quality assurance purposes. This plan was accepted by the survey team and the Office of Health Care Quality and the immediate jeopardy was removed at 6:10 PM on [DATE].Cross Reference F 309 and F 281

Based on medical record review, it was determined that the nursing staff failed to accurately report radiological findings (on 10/15/14) of a possible fracture to a physician; and then after this failure, for more than two months the resident experienced pain and decreased functional status, as she was unable to ambulate. This concern was evident for one (Resident #132) of 46 sampled residents reviewed in Stage 2 Review. The findings included: Resident #132 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This resident was admitted to this facility on 10/11/2014, and was able to ambulate with the use of a rolling walker at admission. The resident also utilized a wheelchair to aid in her mobility. Review of the medical record revealed that on 10/15/2014, this "resident was observed on left lateral position (on floor) beside her wheel chair, stated 'I was trying to go to the bathroom when I lost my balance'." According to the Facility Investigation Report, "Patient complain(ed) (of) left leg pain". Review of the nursing notes revealed that after this resident's fall, the physician was promptly called and ordered X-rays of this resident's left hip, left femur, left tibia and fibula bones. The X-rays were performed and the results were available on 10/15/2014. Specifically, the left hip X-ray result from the radiologist revealed: "There is only a single view of the hip, there are changes suspicious for an intertrochanteric (hip) fracture, additional views are required for confirmation". However, a nursing note dated 10/15/2014 at 10:39 p.m. indicated that "x-ray result received shows no fracture or dislocation seen, Normal left femur" and there was no documented evidence that nursing ever communicated the identified concern of a possible left [MEDICAL CONDITION] to the physician. Further review of the medical record revealed that 9 days later on 10/24/2014, the physician ordered a PT (physical therapy) evaluation due to a decline in functional mobility with moderate pain from the resident's left hip radiating to the left knee. On 10/28/2014, the physical therapy evaluation was performed. The therapist documented that " The resident had been unable to ambulate for the past 2-3 weeks secondary to fall in room with complaints of left hip and knee pain. " The resident continued participation in physical therapy until 12/15/2014, with no improvement in her ability to ambulate. The resident's attending physician documented evaluation of the resident in the medical record on 10/31/2014 and again on 11/14/2014. In addition to the above noted failure of the nursing staff to report the concern about a possible [MEDICAL CONDITION] as was revealed in the radiology report; neither of these two physician progress notes [REDACTED]. On 12/19/2014, resident #132 was transferred to a local hospital for gastrointestinal concerns. While in the emergency room , the resident was assessed to have complaints of left hip pain and swelling with shortening and external rotation of the left leg. The hospital records further stated that the resident had a fall while at the nursing home and the resident reported left leg pain since the fall and had not been ambulatory since. As a result of the emergency room staff assessment of the resident, a left hip X-ray was performed. On 12/19/2014, the left hip X-ray revealed: "Nonacute displaced fracture is seen left femur across the intertrochanteric region, with persisting varus deformity (inward angulation). Visible callus (bone mending) formation is evidence that this fracture is at least 2-3 week of age or more. While at the hospital, surgical repair was performed on this resident's left hip. Nursing staff failed to accurately report significant radiological findings to the physician on 10/15/14 and this failure contributed to resident #132 suffering increased pain and significantly reduced functional status for more than 2 months without an effective assessment, plan, or care to meet her needs.

Based on medical record review, observation and interview it was determined that the physician, nursing, dietician and social worker failed to honor a resident's wishes by continuing to tube feed a resident despite it being clearly against his advance directive in one (Resident #11) of 21 sampled resident records. A feeding tube is a tube that is surgically placed into the stomach via an incision through the abdomen by which nutrition, fluids and medications are administered. A feeding tube is also referred to as a percutaneous endoscopic gastrostomy tube (PEG tube). An Advance Directive is a legal document signed by a competent person to provide future directives for medical and health-care decisions, such as a breathing machine or a feeding tube, in the event the person becomes incompetent to make such decisions. Once a person formulates an advance directive, it remains in effect unless the person revokes it. The findings included: Resident #11 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This nonverbal resident has complete dependence on staff for his care (bathing, dressing, mobility, toileting and feeding), comfort and safety. Interviews were conducted with the nursing staff: Unit Manager on 07/22/2014 at 1:25 p.m., charge nurse #1 on 07/22/2014 at 1:20 p.m. and geriatric nursing assistant #1 on 07/23/2014 at 2:30 p.m. that confirmed this resident has complete physical dependency on staff for his care, comfort and safety. By way of history, this resident while hospitalized in July 2013, had completed an Advance Directive - Health Care Instructions form on 07/07/2013. This resident's advance directive states the following: "If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below." ..."3. If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." After the resident completed his advance directive, the next day on 07/08/2013, he appointed a health care agent, his sister. As a part of the Appointment of Health Care Agent form, it states: "My agent is to make health care decisions for me based on the health care instruction I give in this document and on my wishes as otherwise known to my agent. If my wishes are unknown, or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefits, burdens, and risk that might result from a given treatment or course of treatment, or from the withholding or withdrawal of treatment or course of treatment". Review of the medical record revealed this resident was admitted to this facility on 08/26/2013, after repeated and lengthy hospitalization s where brain surgeries were performed. During one of the hospitalization s, on 07/25/2013, a feeding tube was inserted and the resident was started on artificially administered nutrition and hydration. Upon admission to this facility, the artificially administered nutrition ([MEDICATION NAME] 1.5 formula) and hydration (water) continued through a feeding tube. According to the medical record on 08/27/2013, the social worker met with the resident's sister and completed a Health Care Decision Making Worksheet. This worksheet was used by the attending physician and a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was completed also on 08/27/2013. Also, at this time, the physician certified the resident as incapable of making any health care decision. A Health Care Decision Making Worksheet is a tool used to review and make treatment choices that reflect a resident's wishes about life-sustaining treatments. The worksheet covers the following life-sustaining treatment options: cardiopulmonary resuscitation, artificial ventilation, blood [MEDICAL CONDITION], hospitalization , medical workup, antibiotic use, artificially administered fluids and nutrition, [MEDICAL TREATMENT] and other treatments. A MOLST form is a standardized medical form with orders about life-sustaining treatments. The MOLST form provides a consistent way to order life sustaining treatments bases on exploring and clarifying a resident's key preferences. Ultimately, orders on the MOST form shall be based on several factors, including (but not limited to) the patients goals and wishes as expressed in an advance directive, his or her current medical condition and prognosis, the availability and relevance of potential treatment options, and physician determinations about possible medical ineffectiveness of specific treatment options. An authorized practitioner (physician or nurse practitioner) will complete the MOLST form based on those considerations as well as consultation with an authorized decision maker. Review of the MOLST revealed under artificially administered fluids and nutrition the physician ordered: "May give artificially administered fluids and nutrition, if medically indicated, as a trial. Time limit TBD (to be determined)". The physician ordered on the MOLST for the administration of artificial nutrition and fluid despite this resident having a clear and unambiguous advance directive to the contrary. Further review of the medical record revealed the following social worker note: 08/28/2013 at 12:38 p.m.: "... Social Services met with patient (patient's) sister, she verbalize(d) on 08/27/2013 (hospital name) inserted peg tube 7/26/2013 going against Advance Directive effective 7/7/2013. Patient sister (name) indicates she was made aware of [MEDICAL CONDITION] and was provided information on [MEDICAL CONDITION], but was not given any information about the peg. (Resident's sister) indicates prior to surgery her brother was capable of communicating effectively and making medical decision(s). (Resident's sister) indicates the Advance Directive was completed with his wishes prior to surgery, due to the hospital persistence to have a Advance Directive on file. (Resident's sister) stated after surgery patient remained at (hospital name) for about two weeks and that no other nursing home would accept patient due to his code status. (Resident's sister) indicates the Administrator from (another nursing home) told her (resident) rights have been violated per Advance Directive and that they could not accept him. (Resident's sister) informed Social Service when he transferred to (this facility) she was not notified from the hospital of the transfer. (Resident's sister) indicates she is aware of his Advance Directive and is considering seeking legal advise due to the discrepancies at (hospital) and prior locations at other Nursing Homes. (Name) SW (social worker) consultant was on site to review chart, met with Social Service Dept (department), Admin (Administrator) and DON (Director of Nursing) with recommendation to contact (name,) Corporate Attorney for review. Social Service Director spoke with (name of corporate attorney) assistant (name) who provided fax number. Director of Social Service fax(ed) chart to (numbers). Admin and DON made aware. Admin informed Social Service that there will be a Ethics Review 8/28/13 at 3 pm." An ethics review or an ethics committee involve individuals from diverse backgrounds in health care with three major functions: providing clinical ethics consultation, developing and/or revising policies pertaining to clinical ethics and nursing home policy (advance directive, withholding and withdrawing life-sustaining treatments, informed consent)), and facilitating education about issues in clinical ethics. Often the goals of an ethics committee are: to promote the rights of residents; to promote shared decision making between residents (or their surrogates if decisionally incapacitated) and their clinicians; to promote fair policies and procedures that maximize the likelihood of achieving good, resident-centered outcomes; and to enhance the ethical environment for health care professionals in the health care setting. It is worth noting, the facility did not have any policy or procedures related to ethic review programs. Continued review of the social worker notes: 08/28/2014 at 3:33 p.m.: "Ethic Committee met, in attendance. RDO (Regional Director of Operation's name), Attorney (name), Administrator, DON, Medical Director and Social Service Department. Per review of Documentation and MOLST on file. Patient sister (name) is the decision-maker, nursing home will honor MOLST... ." Once again, despite this resident having a clear and unambiguous advance directive stating: "If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." On 11/16/2013, a second physician certified this resident as incapable of making any health care decision. The physician also certified the resident as end-stage. Again end-stage is a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]. Observation of this resident on 07/21/2014 at 1:30 p.m., 07/22/2014 at 1:20 p.m. and 07/23/2014 at 2:30 p.m., revealed this resident in bed. The resident did not respond to any verbal communication nor did the resident display any spontaneous or purposeful movement. In conclusion, this resident's advance directive completed on 07/07/2013, stated that if he was incapable of making an informed decision regarding his health care and he had an end-stage condition, he directed that his life not be extended by the administration of nutrition and hydration artificially. Since this resident's admission to this facility on 08/27/2013 to the completion of this survey on 07/23/2014, the resident continues to have artificially administered nutrition and hydration. The administration of nutrition and hydration artificially is clearly against this resident's advance directive wishes.