Every finding on record at Alice Byrd Tawes Nursing Home

Based on record review and interview, it was determined the facility failed to report an allegation of seclusion/abuse immediately or no later than 2 hours after the allegation was made aware to the facility's Administration team. This was evident for 1 (#4) out of 1 resident reviewed for allegations of abuse during the complaint survey. The findings include the following:Intake # 2964422 was reviewed on 5/20/26 at approximately 10:30AM for seclusion/ abuse allegations involving Resident #4.During an interview on 05/20/2026 at 11:40 AM with the Director of Nursing she stated, On 03/19/2026 there was an allegation of seclusion/abuse involving Resident #4, the facility investigated and the allegation was not substantiated. The facility provided the survey team with a copy of the investigation.Review of the investigation records on 05/20/2026 at 12:40 PM revealed that the facility was made aware of an allegation of seclusion/abuse involving Resident #4 on 03/19/2026 at 7:30 PM. Further review of records revealed that the facility did not report allegation to the Office of Health Care Quality and other appropriate agencies. During a subsequent interview with the DON 05/20/2026 at approximately 1:00 PM, stated that after reviewing the records, the information should have been reported to the state agency.All concerns were discussed with the Administration team at the exit conference on 5/20/26.

Based on random observations it was determined that the facility failed to maintain a homelike environment for the residents of the 3rd floor. This was evident for 1 of 2 units ( 3rd floor). The findings include:Upon entering the 3rd floor on 3/3/26 at 9:00 AM and entering the open sitting area, this surveyor observed that the television was on, however, there was a black bar covering half of the screen on the left side. The tour of the unit and observations continued throughout the morning. Returning to the unit at approximately 11:50 AM on 3/3/26 to review medical records, the same observations were made of the television on in the sitting room with the black bar covering half of the screen on the left side, with the same television game show on.Observations of the 3rd floor unit on 3/4/26 at 10:09 AM revealed the same observations of the television on with the black bar covering the left half of the screen, with the same television game show on. This surveyor sat in the sitting area to complete observations at this time. A popular game show was on, however, only the host could be seen and not the contestant due to the back bar. A closer look at the television and the black bar looked revealed it to be an option menu from a button that was pushed on the remote, and the screen was just left up. During this observation, this surveyor noted staff interacting with residents that were placed in front of the television-that was still not fully displaying the show. At 10:31 AM, 22 minutes after this surveyor sat down and 26 hours after initially walking onto the floor and making observations, the television channel was changed and adjusted to a full screen that could be viewed and enjoyed by the residents. This ongoing observation and concern for a homelike environment for the residents was reported to the DON and NHA on 3/4/26 at 12:43 PM. The DON stated that she herself had been on the 3rd floor and had not identified the concern, but acknowledged that at times you become complacent and need other eyes to pick up on things.

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status. This was found to be evident for 1out of 5 residents (R # 4) reviewed during the investigative stage of the survey.The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.A review of the medical record on 3/4/26 at 4:50 PM for Resident #4 revealed a completed MDS on 1/17/26 identifying Resident #4 as receiving an insulin injection for 7 days during the lookback period. A concurrent review of the medication administration record (MAR) failed to reveal that Resident #4 received any insulin injections for this most recent look back period for the coded MDS completed on 1/17/26. Interview on 3/5/26 with staff #8 revealed that she was the one that completed the MDS for Resident #4 in January 2026. She reviewed the MDS that was submitted concurrently with the MAR in the presence of the survey team. She verbalized that there was a discrepancy and would complete a modification.

Based on observation, medical record review and interview, the facility failed to monitor a resident's nutrition status and failed to recognize a resident's need for feeding assistance and inform the dietitian/physician. This was evident for 1 of 2 residents (Resident #8) reviewed for nutrition. The Findings include: On 3/3/26 at 8:00am, the surveyor observed Resident #8 during breakfast attempting to feed him/herself. The resident was having difficulties with putting the food in his/her mouth due to tremors in the hands. The surveyor attempted to interview the resident, but the resident was lethargic and difficult to understand. On 3/3/26 at 8:35am, the surveyor interviewed GNA #12 regarding Resident #8's status and his/her ability to feed him/herself. GNA #12 stated that the resident was able to feed him/herself. The surveyor pointed out that the resident was observed having trouble feeding her his/herself due to tremors in the hands. GNA #12 stated that the resident normally picks at (his/her) food and requires no assistance with feeding. On 3/4/26 at 8:20pm, the surveyor observed Resident #8 during breakfast. The surveyor observed for a 2nd time that the resident was having trouble feeding him/herself due to tremors in the hands. On 3/4/26 at 10:30am, the surveyor reviewed Resident #8's medical record. The resident's diagnosis stated that he/she had Parkinson's disease with tremors. The resident was being treated for tremors, and the treatment was noted to be successful. Progress notes revealed that the dietitian assessed the resident as being malnourished on 1/15/26. Further review of progress notes found the resident was receiving nutritional supplementation, but the resident was eating a portion of the supplement or refusing to take the supplement. Review of the resident's care plan revealed that the facility had no interventions for reduction in the resident's intake. On 3/5/26 at 10:48am, the surveyor interviewed medical director #7 regarding Resident #8's nutritional status. The surveyor explained that the resident was observed having difficulty feeding his/herself breakfast on 3/3/26 and 3/4/26. Medical director #7 stated that he/she was unaware of feeding issues and he/she was aware that the resident had a reduction in intake. Medical director #7 also stated that he/she expected the GNAs to provide feeding assistance when the resident is observed to have difficulties feeding him/herself or when the resident has decreased intake at meals. The surveyor pointed out that this expectation was not known to the GNA's. On 3/5/26 at 9:30am, the surveyor interviewed Dietitian #13 regarding Resident #8's nutritional status. The surveyor asked Dietitian #13 about treatments/supplementation to assist with mitigation of weight loss. Dietitian #13 stated that supplementation is given for snacks and after dinner as well as protein supplementation was ordered during medication administration. The surveyor asked about issues with tremors causing difficulties with the resident feeding him/herself. Dietitian #13 stated that he/she did not observe the resident having difficulties with feeding him/herself. The surveyor pointed out the resident was observed having difficulties feeding him/herself during breakfast due to tremors. Dietitian #13 admitted that he/she normally observed the resident later in the day and did not observe the resident's tremors. On 3/5/26 at 10:00am, the surveyor informed the Director of Nursing (DON) of surveyor observations of Resident #8 having difficulties feeding him/herself during breakfast on 3/3/26 and 3/4/26. The DON stated that he/she was unaware of the resident's issues feeding him/herself. The surveyor also informed the DON that interviews with medical director #7 and dietitian #13 revealed that both providers were unaware of the issues with the resident feeding him/herself but GNA #12 was aware of the resident's feeding difficulties.

Based on medical record review, staff interview and review of facility policy, it was determined that the facility failed to maintain ongoing communication with the dialysis facility. This was evident during the review of 1 of 1 Residents (#11), (all residents) who currently attend dialysis. The findings include:Review on 3/3/26 of the medical record for Resident #11 revealed that s/he currently received dialysis and according to the matrix provided to the survey team s/he is the only resident currently receiving dialysis.A review of the dialysis communication pages in the binder revealed inconsistencies in the completion of the assessments for each visit to dialysis and the return to the facility from dialysis. Interview with LPN #17 on 3/5/26 at 11:00 AM regarding the dialysis communication book, and process revealed that the assigned dialysis book goes with the resident to the dialysis center. LPN #17 was asked about the form with the 3 sections, she reviewed the book and said that dialysis needs to fill out the middle section, and the night shift does the top, she was not familiar with filling out the bottom portion. Interview on 3/5/26 at 11:02 AM with RN staff #16 verbalized that the night shift fills out the top section, dialysis completes middle and the facility does its own vitals upon the residents return. She was then asked if the form is incomplete, what do you do? She stated that you are supposed to call the dialysis center back but 'I don't think that they do.' She was shown all the blank pages in Resident #11's dialysis book. She verbalized that she was not surprised. The facility NHA was interviewed on 3/5/26 at 11:12 AM and the surveyors' concerns were shown to her regarding the blank dialysis forms. The NHA stated that the team knows what to do with the forms and when the dialysis center fails to complete their portion. Facility policy on dialysis communication was reviewed on 3/5/26 revealed the basics for completing the dialysis communication form, to be completed prior to leaving the facility, at dialysis center and upon return. The policy also addresses the procedure if any area is missing. The concerns were followed up on with the facility DON and NHA throughout the remainder of the survey and again on exit 3/6/26.

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed and safe food handling practices were followed to reduce the risk of foodborne illness. This was evident during the initial tour of the kitchen and only 1 observation. The findings include:During the tour of the kitchen and observation of staff practices, this surveyor observed the following at 3/3/26 at 8:16 AM: On the cold prep table a large metal container holding milk was sitting unattended. Within arm's reach of the container of milk was an open bottle of water, a coffee cup and a personal black thermos with red hearts on it. Additionally, there was a white rag sitting next to and touching the metal pan of milk with orange, brown and black stains and flecks of debris.At 8:18 AM staff #9, the lead cook was notified of the observations and concerns and directed the staff to discard the container of milk, he had already removed the personal drinking items when he saw this surveyor making observations and notations. On 3/4/26 at 1:21 PM this Surveyor met with the Kitchen Manager, staff #10 and was able to update him with the observations and concerns.

Based on record reviews and interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 1 (Resident #5) of 1 Residents reviewed for complete and accurate medical record documentation.The findings include:During a review of the Task Administration Record (TAR) for Resident #5 on 3/06/2026 at 7:51 AM it was discovered that Resident #5 had orders for wound care that was not signed off as being completed. The orders include:An order for Clean left buttock open area with Normal Saline Solution and cover with AG and dry sterile dressing was not signed off as completed on 2/23/2026.An order for Clean right calf open area with Normal Saline Solution, pat dry and cover with damp AG and dry sterile dressing every dayshift for wound care was not signed off as completed on 2/23/2026.An order to Clean wound to right outer elbow with Normal Saline Solution, pat dry, cover with Xeroform and dry sterile dressing was not signed off as completed on 2/23/2026.During an interview with the Director of Nursing (DON) on 3/06/2026 at 9:05 AM she confirmed that wound care should be completed if there is an order and when wound care is performed on a Resident it should be signed off in the TAR. She reported she can't confirm that wound care was completed on Resident # 5 on 2/23/2026 because it was not signed off as completed and it's unacceptable that it was not documented.

Based on observation and facility staff interview, the facility staff failed to protect and value resident's dignity (Resident #38). This was evident for 1 out of 1 resident reviewed for dignity. The findings include: On 3/3/26 at 7:40am, the surveyor observed Resident #38 sitting in a wheelchair in front of the 2nd floor's nursing station attempting to get nursing staff's attention by stating excuse me repeatedly. The resident manually moved his/her wheelchair closer to the 2nd floor's nursing station and stated excuse me to LPN #17 which he/she was on the phone. LPN #17 ignored the resident. Infection Preventionist (IP) #14 walked past LPN #17 and the resident while the resident stated excuse me again. IP #14 also ignored the resident. The resident continued to attempt to get nursing staff's attention by excuse me without success. The closest nursing staff member to the resident was LPN #17 and LPN #17 continued to ignore him/her. When IP #14 re-entered the 2nd floor nursing station, the surveyor informed IP #14 that Resident #38 was requesting assistance. IP #14 asked the resident what he/she wanted and the resident requested something to drink. IP#14 provided the resident with a drink. Interview with the Director of Nursing (DON) on 3/4/26 at 12:30pm, the surveyor informed the DON of the interaction between Resident #38 and the 2nd floor nursing staff on the morning of 3/3/26. The DON stated that he/she was unaware of issues with residents being ignored by nursing staff. The DON stated that he/she would speak to the nursing staff about the incident.

Based on observation and interview it was determined the facility failed to post required staffing information. This was evident for 3 out of 3 floors of the facility during the recertification survey. The findings include: On 11/12/24 at approximately 10:15AM surveyors entered the building for the facility's recertification survey and upon entering, no staffing information was observed posted on the first floor. On 11/12/24 at 11:47AM the surveyor conducted a tour of the facility's second floor nursing unit. Observation of a dry erase board on the unit revealed there was no facility name displayed, the following date was observed: November 1, 2024, there was no total number of staff displayed, and no actual hours worked listed by category for 7 out of 11 nursing staff. No other postings of staffing information were observed to be present on the unit. On 11/12/24 at 12:04PM the surveyor conducted a tour of the facility's third floor nursing unit. Observation of a dry erase board on the unit revealed there was no facility name displayed, there was no total number of staff displayed, and no actual hours worked listed by category for 10 out of 13 nursing staff. No other postings of staffing information were observed to be present on the unit. On 11/19/24 at 3:35PM the surveyor conducted an interview of the facility's Director of Nursing (DON) who stated the following information in response to the surveyor's sharing of the concern: We have a staffing binder on the second floor nursing station that is supposed to be on the counter. At this time, the DON confirmed with the surveyor that there were no postings of staffing information in the building occurring except on the dry erase board, and one was located on each unit (2nd and 3rd floors). On 11/19/24 at 3:36PM the surveyor conducted an interview of Front Desk Receptionist #26 who confirmed that there was no staffing information that was posted on the first floor. On 11/19/24 at 3:38PM the surveyor conducted an observation of the second floor nursing station and staffing schedule sheet binders were observed to be out of reach behind the nursing counter, in the office area. At the time of the observation, the surveyor again interviewed the DON who reported the following information to the surveyor: We have these binders and the staffing board on the units, no paper copies are posted anywhere, just the boards and binders. The surveyor subsequently shared the concern with the facility Administrator who acknowledged and confirmed understanding of the concern. On 11/20/24 at approximately 4:15PM during the exit conference, the surveyor again shared the concern.

Based on review of reporting data, clinical records and interview it was determined that the facility staff failed to ensure assessments were sent to the Centers for Medicare and Medicaid Services as required. This was evident for 4 (#11, #51, #56, and #69) out of the 7 residents reviewed for late reporting. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of seven residents' clinical records was conducted secondary to the survey process triggering this task for missing resident assessments. Records for Residents #11, #51, #56, #62, #63, #67, and #69 were reviewed on 11/20/24. The electronic health records revealed that some of the residents had an assessment that was listed as in progress. The MDS director was interviewed on 11/20/24 at 9:39 AM. She was provided with the names of the residents and the survey team requested the validation report for the submission of the MDS assessments. She wrote down the names of the residents and said she thought most of the assessments were late then added that she knew a couple of these were definitely late. A review of the Validation report revealed that Resident #11's discharge MDS was still in Progress and not transmitted. Resident #51 had a discharge MDS that is also in Progress and not transmitted. Resident #56 had a discharge MDS that is in Progress and not transmitted. Resident #69 had a discharge MDS that was in progress but not transmitted. The facility administrative staff were informed of the deficiency at the exit conference.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents and/or resident's representative within 48 hours after admission. This was evident for 6 (#57, #8, #19, #36 # 30, and #10) out of 12 residents reviewed for baseline care plans during the recertification survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP as well as a list of the resident's current medications must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. 1.) On 11/18/24 at 3:15PM the DON was asked for a copy of Resident # 10's Baseline Care Plan along with Resident #30 and Resident #36. On 11/19/24 05:00PM The DON was asked to provide documentation to show that the resident/resident representative were presented with their Baseline Care Plan and given a written copy of their Baseline Care Plan within 48 hours of admission. The DON acknowledged that they do not have any documentation to verify that the resident/resident representative were presented with a written copy of their Baseline Care Plan within 48 hours of admission. On 11/19/24 at 6:00PM a paper copy of their Baseline Care Plan was reviewed and showed that Resident #36 was admitted on [DATE] and their Baseline Care Plan was completed on 8/15/2024. Further record review showed that the Baseline Care Plan had no signature for staff and no signature for the resident/resident representative that acknowledged that they had been given a written copy of their Baseline Care Plan within 48 hours after being admitted On 11/19/24 06:07PM a paper copy of the Baseline Care Plan was reviewed and showed Resident #30 was admitted on [DATE]. Further record review showed that the Baseline Care Plan had no signatures for staff or for when the Baseline Care Plan was completed and no signature for when the Baseline Care Plan was reviewed with the resident/resident representative and when the resident/resident representative received a written copy of their Baseline Care Plan. On 11/19/24 6:12PM a paper copy of the Baseline Care Plan was reviewed and showed that Resident #10 was admitted on [DATE] and the Baseline Care Plan was completed on 6/21/2018. Further record review showed that the Baseline Care Plan had no signature for staff and no signature for the resident/resident representative that acknowledged that they had been given a written copy of their Baseline Care Plan within 48 hours after being admitted . 49304 2.) On 11/15/24 at 10:54 AM, review of Resident #57's medical record revealed an admitted [DATE]. Further review of the medical record revealed the first care plan initiated for this resident was dated 4/25/23, however there was no documentation that the resident received a BLCP summary including a summary of the resident's medications. The surveyor requested a BLCP summary for Resident #57. On 11/15/24 at 11:04 AM, the SW was interviewed. During the interview, she stated that all residents should be given copies of their BLCPs within 48 hours. On 11/15/24 at 12:38 PM the Director of Nursing (DON) provided a copy of Resident # 57's BLCP dated 4/25/23. The field where it stated Resident signature and date on page 8 of 9 was blank/empty. The surveyor requested documentation that the resident received a summary of his/her BLCP including a list of his/her medications. On 11/15/24 at 1:05 PM in an interview with the DON she stated, No, there is no documentation that Resident #57 received his/her BLCP, including a list of their medications. We do have residents sign their Baseline Care Plans now, but no, there is no documentation Resident #57 received his/her BLCP summary. 3.) On 11/15/24 at 12:15 PM Resident #19's medical record was reviewed. The review included an admitted [DATE], however, no note or other documentation could be found that stated the resident had received a summary of his/her BLCP. The surveyor requested documentation that the resident received a summary of his/her BLCP including a list of their medications. On 11/15/24 at 1:05 PM in an interview with the DON she stated, no, there is no documentation that Resident #19 received their BLCP summary, including a list of their medications. 4.) On 11/15/24 at 11:52 AM review of Resident #8's medical record revealed an admitted admitted [DATE]. Upon further review, there was no documentation that the resident received a BLCP summary. The surveyor requested documentation that the resident received a summary of his/her BLCP summary including a list of their medications. On 11/15/24 at 1:05 PM in an interview with the DON she stated, no, there is no documentation that Resident #8 received their BLCP summary, including a list of their medications.

Based on observations and interviews, it was determined that the facility failed to properly store, date, and label food items to prevent food from being served that may be unsafe to eat and to prevent cross contamination. This was evident by the initial kitchen observations of the facility's dessert freezer during the recertification survey. The findings include: On 11/12/24 at 10:55 AM during the initial kitchen observation the surveyor entered the kitchen and spoke with the Food Service Supervisor (FSS) #22. Together a walkthrough of the refrigerator and freezers was conducted. During the inspection of the freezer, which had frozen desserts inside, the surveyor noticed a large full bag of brownies in a clear Ziplock bag and a large full bag of cookies in a clear Ziplock bag. This was brought to FSS #22's attention and they removed the bags of brownies and cookies and placed them on a stainless-steel counter in front of the dessert freezer. When asked how long the brownies and cookies had been in the freezer, FSS #22 said: I am not sure. FSS #22 then called over Dietary Aide #23 in charge of desserts, and asked Dietary Aide #23 about the Ziplock bags with brownies and cookies with no date and label. Dietary Aide #23 said the cookies and brownies were from yesterday and proceeded to label and date the Ziplock bags of brownies and cookies. During the initial kitchen observation, a blue rag in a clear Ziplock bag was also observed in the dessert freezer on the middle shelf. This blue rag in the clear Ziplock bag was shown to FSS #22 and the surveyor asked them what this was, and FSS #22 stated they were not sure. FSS #22 then asked Dietary Aide #23 what the blue rag in the Ziplock bag was doing in the dessert freezer. Dietary Aide #23 stated: I do not know. FSS #22 removed the blue rag in the clear Ziplock bag from the dessert freezer. On 11/19/24 at 12:00 PM the Food Receiving and Storage policy was received from the Food Service Director #30. Their facility policy stated that all foods stored in the refrigerator or freezer are covered, labeled and dated with a (use by date).

Based on resident interview, review of the medical record, and interview with facility staff, it was determined that the facility failed to hold care plan meetings for residents and/or their representatives at the time of their admission. This was evident for 1 (Resident #18) out of 33 residents reviewed during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 11/13/24 at 11:49 AM in an interview with Resident #18 she stated she had attended a care plan meeting since her admission to the facility. On 11/13/24 at 12:08PM review of the resident's paper chart did not reveal any documentation that care plan meetings had occurred. On 11/14/24 at 10:07AM review of Resident #18's medical record revealed the resident was admitted on [DATE] and that the resident had an admission MDS assessment completed on 2/12/24. Further review of the medical record revealed 2 care plan meeting notes. One was dated 5/29/24 and the other note was dated 8/29/24. There was no evidence in the medical record that a care plan meeting had been held with the resident and/or resident representative and the interdisciplinary team around the time of the admission MDS assessment. The surveyor interviewed the MDS Coordinator #11 on 11/14/24 at 11:49AM. During the interview, the MDS Coordinator #11 stated, yes, she was the staff member responsible for coordinating care plan meetings with residents and/or their resident representative. During the interview she stated, no, there was not a care plan meeting held in February 2024 for Resident #18. In addition, she stated, she looked in her calendar and saw she did not schedule it, and that it looked like it just got missed. The surveyor requested that the MDS Coordinator #11 provide the survey team with any evidence that a care plan meeting had taken place for Resident #18 around the time of the admission MDS assessment in February 2024. No such records were provided to the survey team by the time of survey exit.

Based on observation, interview and record review it was determined the facility failed to: 1) ensure and monitor the implementation of fall interventions, and 2) monitor for effectiveness of fall interventions. This was evident for 1(Resident #25) out of 2 residents reviewed for accidents during the facility's recertification survey. The findings include: On 11/13/24 at approximately 9:18AM the surveyor observed Resident #25, who was awake and laying in their bed. Upon interview of Resident #25 they expressed to the surveyor that they wanted to get up out of their bed and did not understand why they ate breakfast in their room instead of in the dining area. On 11/19/24 at 12:20PM the surveyor reviewed the medical record of Resident #25 which revealed they had extensive fall history, including four recent falls in October 2024. Review of the resident's care plan revealed the resident was at high risk for falls, and after a fall on 10/15/24 and a fall on 10/18/24, the following intervention was not implemented until 10/24/24 and was to currently be in place: low bed with mat when in bed. Review of the resident's medical record additionally revealed, that after 10/24/24, the resident had sustained two falls on 10/31/24 in which they were found on the floor. Observation by the surveyor of the resident's room on 11/19/24 at 12:24PM revealed there was no fall mat in place. On 11/19/24 at 12:25PM the surveyor observed the second floor nursing unit dry erase board information which documented that Registered Nurse (RN) #31 was assigned to the care of Resident #25 for the current shift. At this time, the surveyor inquired to RN #31 as to if they were familiar with Resident #25, and what fall precautions were currently supposed to be in place for them, to which they responded: I don't know the resident well, I would have to ask my supervisor. When the surveyor inquired to RN #31 as to if they were assigned to the care of Resident #25, they reported to the surveyor that they had to check and see if the resident was assigned to them. The surveyor observed RN #31 check their computer system, who then confirmed with the surveyor that they were assigned to the care of Resident #25. At this time, the surveyor shared their concern with RN #31 who observed and acknowledged the surveyor's concern, and the surveyor requested for the Director of Nursing (DON) to conduct a dual observation of the concern. On 11/19/24 at 12:30PM the surveyor conducted an interview with Licensed Practical Nurse #32 who confirmed with the surveyor that a fall mat should be in place and remain on the side of the bed that is not next to the wall, and that staff do not have to go retrieve a mat from anywhere when they put a resident who requires a fall mat into bed. On 11/19/24 at 12:33PM the surveyor conducted a dual observation with the facility's DON who observed the concern. The surveyor observed the DON look through the room to ensure there was no fall mat anywhere. At this time, the surveyor conducted an interview with the DON who acknowledged and confirmed understanding of the surveyor's concern and stated the following: There's no fall mat, it should be within the room and it's not. On 11/19/24 at 12:36PM the surveyor conducted an interview with Geriatric Nursing Assistant #33 who reported the following to the surveyor regarding fall mats: I don't usually deal with that, I think maintenance gets it for us, usually they're just on the floor. On 11/19/24 at 12:38PM the surveyor continued to observe there was no fall mat in place in the room of Resident #25. On 11/19/24 at 2:14PM, after surveyor intervention, review of the medical record revealed the pre-existing medical order dated as beginning on 10/24/24 for the fall mat was now discontinued, and a new order for a fall mat to be in place was ordered beginning 11/19/24. Additionally, a nursing note created on 11/19/24 at 12:54PM was observed documented by RN #31 which did not include information regarding intervention by the surveyor. Until surveyor intervention, sign off documentation was observed to be signed off on the October and November treatment administration records indicating the fall mat had been in place for the resident. The surveyor subsequently shared the concern with the facility's Administrator who acknowledged and confirmed understanding of the concern. On 11/20/24 at approximately 4:15PM during the exit conference, the surveyor again shared the concern.

Based on observation, interview and record review it was determined the facility failed to ensure the implementation of a nutrition intervention for a resident to prevent further weight loss. This was evident for 1 (Resident #53) out of 3 residents reviewed for nutrition during the facility's recertification survey. The findings include: On 11/12/24 at 12:07PM the surveyor observed Resident #53 to be laying in bed awake, positioned at approximately a thirty degree angle with their lunch meal on the bedside tray table which was positioned over the bed. On 11/13/24 at 11:35AM the surveyor reviewed the medical record of Resident #53 which revealed that upon admission on 9/11/2024, they weighed 114.2 lbs. and on 11/07/2024, they weighed 103.9 lbs. indicating weight loss of the resident. Review of the physician's documentation revealed the resident had been losing weight prior to admission to the facility. On 11/15/24 at 9:31AM during review of the medical record of Resident #53 the surveyor reviewed section GG of the admission minimum data set (a standardized assessment tool used to evaluate residents) which revealed documentation dated 9/18/24 which coded the resident as needing partial/moderate assistance for eating upon admission to the facility. Review of a nutrition note dated 10/11/24 by Dietician #19 revealed they documented the following information: Nursing reports resident ate 100% when s/he was fed, Communicated with DON (Director of Nursing) and s/he will be continued to be fed by staff at mealtimes. Further review of the medical record revealed a quarterly nutrition assessment dated [DATE] which documented the following regarding the resident's feeding ability: Unable to feed self and must be assisted or supervised throughout the meal/snack. Review of the resident's care plan revealed the following intervention was documented on 9/11/24 upon their admission: S/he is dependent on staff for bathing and dressing, setup meals and assist to max intake as needed. On 11/18/24 at 12:15PM the surveyor conducted an observation of Resident #53 who was observed to be laying in bed repeatedly attempting to bring a cup and then a container (magic cup) to their mouth without eating or drinking the contents. Closer observation of the resident revealed the cup was empty and the container had a paper lid on it. Liquid was observed to be spilled adjacent to the bed. As the resident was picking up the magic cup container (nutritional supplement) they stated the following to the surveyor: Can't get it open, gosh, can't do that, I'll soon give up, it would be easier to try to get into this. The resident was observed raising their drink cup to show the surveyor and verbalized the following information: Can't get anything out of here. The surveyor observed that the resident had not yet consumed any of the lunch food items on their tray. On 11/18/24 at 12:23PM the surveyor conducted an interview with Registered Nurse (RN) #4. When the surveyor inquired as to the process of how staff ensure all residents receive feeding assistance at mealtime, they reported to the surveyor: The geriatric nursing assistants (gna's) are each assigned a group of residents, this group is heavy, they just figure it out amongst themselves, if I see somebody that needs to be fed I'll jump in today. RN #4 further reported that staff look and make sure the residents have been fed at clean up time. On 11/18/24 at 12:26PM the surveyor requested a dual observation of Resident #53 with RN #4. Upon entry to the room, RN #4 observed and verbalized that the resident's tea was spilled and was observed obtaining supplies and cleaning up the spill and retrieving another tea for the resident to drink. At 12:28PM Resident #53 was observed grabbing their magic cup and packaged cookies, however, they were unable to open the packaging. The surveyor shared their concerns with RN #4 who acknowledged and confirmed understanding of the concerns. On 11/18/24 at 12:32PM the surveyor observed Resident #53 accepting food while being provided with physical assistance for feeding by RN #4. On 11/18/24 at 12:37PM the surveyor reviewed the medical record for Resident #53 which revealed that documentation had not yet been recorded on the task list for either the breakfast or the lunch meal for 11/18/24. On 11/18/24 at 12:39PM the surveyor conducted an interview with Geriatric Nursing Assistant #28 who confirmed with the surveyor that the facility's expectation for documentation of amounts eaten and the resident's level of feeding assistance provided was expected to be documented at each meal, prior to the next meal occurring. On 11/18/24 at 12:53PM the surveyor conducted an interview of RN #4 who reported to the surveyor that Resident #53 had consumed all supplements including the ensure and magic cup, ate their cheeseburger, and some of their cookie. On 11/18/24 at 12:55PM the surveyor observed the resident's food tray in the food cart which confirmed the resident had eaten 100% of their supplements and 100% of their cheeseburger. On 11/18/24 at 12:58PM during an interview with the Director of Nursing (DON) they stated to the surveyor that the staff are provided with a paper cheat sheet that is updated by them after risk meetings are held. The DON observed the current cheat sheet and reported that it directed the staff to cue and feed as needed, but this was not the most current recommendation. The DON stated the following: I'm going to edit this right now. When the surveyor inquired as to the resident's care plan intervention which did not reflect the most current level of feeding assistance required, the DON reported the intervention should be updated on the care plan at the time of the change.

Based on observations, interviews and medical record reviews it was determined that the facility failed to 1) label the oxygen tubing and humidifier bottle and 2) failed to follow the physician's orders to label the oxygen tubing and humidifier when changed. This was evident for one (Resident #30) of one resident reviewed for respiratory care during the recertification survey. The findings include: A nasal canula is a plastic tube that delivers oxygen into a resident's nostrils. On 11/13/24 at 12:00 PM the surveyor observed Resident #30 with oxygen 2 Liters nasal cannula in her nose. It was observed that the oxygen tubing and the humidifier bottle had not been labeled with the date and time it was placed. On 11/14/24 at 11:32 AM the surveyor observed Resident #30 with oxygen 2 Liters nasal cannula in her nose. It was observed that the oxygen tubing and the humidifier bottle had not been labeled with the date or time it was placed. On 11/14/24 at 11:35 AM Staff #24, Licensed Practical Nurse (LPN), was interviewed regarding who changes the oxygen tubing and humidifier and when is it changed. LPN #24 replied that the night nurse changes the oxygen tubing and humidifier and stated, I am not sure how often the tubing is changed, but I think it is monthly. But you can ask a regular staff nurse. At the time of the interview LPN # 24 was shown that the oxygen tubing and humidifier bottle had not been labeled with the date and time. LPN #24 acknowledged that the oxygen tubing and humidifier bottle were not labeled. On 11/14/24 at 11:40 AM Staff #25, LPN Charge Nurse for the second and third floor, was interviewed about when oxygen tubing and humidifiers are changed. LPN #25 replied that the oxygen tubing gets changed every Sunday night by the night shift nurse along with the nebulizer or concentrator. When a resident is on oxygen there should be an order for the oxygen and when to change the oxygen tubing. When the tubing and humidifier have been changed by the night nurse, the nurse signs off that the oxygen tubing was changed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). On 11/14/2024 01:00 PM the TAR was reviewed. The order on the TAR was to change oxygen tubing and humidifier every 2 weeks and PRN (as needed) on Sunday nights 7P-7A. Label O2 (oxygen) tubing and canister with the date and time. Start date of order was 8/26/24.

Based on observation, record review, and interview with facility staff, it was determined that the facility 1) failed to ensure monthly Medication Regimen Reviews were completed by the pharmacist and 2) failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #18) out of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: A Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen (plan) of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. The MRR includes review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. 1) On 11/14/24 at 9:49AM, the surveyor reviewed the medical record for Resident #18 which revealed on 8/29/24, Pharmacist #17 documented in the Chronological Record of MRR in the resident's paper chart, TSH low: decrease levothyroxine. On 11/14/24 at 10:56AM the surveyor requested copies of the last three months of medication regimen reviews and pharmacy recommendations for Resident #18 from the Director of Nursing (DON.) On 11/15/24 at 8:58AM the surveyor noted the above documentation requested was not received and made a second request to the Licensed Nursing Home Administrator (LNHA). On 11/15/24 at 9:35AM in an interview with the LNHA she stated she did not see a pharmacy recommendation for August for Resident #18. On 11/15/24 at 10:12AM in an interview with the LHNA she stated we have no formal recommendations (and she clarified formal recommendation to be the document titled Note to Attending Physician/Prescriber) for Resident #18 for August 2024 from Pharmacist #17. When showed the Chronological Record of MRR and asked why there is not a formal recommendation for Resident #18 from the month of August, she stated we do not have one because she [Pharmacist #17] never sent it to us. She [Pharmacist #17] comes to the facility, reviews all the residents' medications, makes recommendations (if necessary), inputs them into her software which generates a Note to Attending Physician/Prescriber, and then emails them to myself and the DON. On 11/15/24 at 11:02AM, the DON provided the surveyor with a screenshot she said she received from Pharmacist #17 showing her history of recommendations made and sent to the facility for Resident #18. There was no recommendation for the month of August 2024. On 11/18/24 at 12:33PM in an interview with Pharmacist #17 when asked if she made any recommendations for Resident #18 in August 2024, she stated she does not have an entry for Resident #18 for August 2024. During the interview when asked for an explanation, she stated she does not know why. On 11/18/24 at 3:29PM in an interview with the LNHA, when asked what process/system was in place to ensure the facility received all the pharmacy recommendations from the consulting pharmacist for a specific month, she stated there is not currently a system for knowing which pharmacy recommendations we should be receiving monthly. During the interview she stated, starting next month and moving forward Pharmacist #17 will send a monthly summary report to ensure we are aware of all the pharmacist's recommendations we should be receiving for a given month. 2) The medical record for Resident #18 was reviewed on 11/14/24 at 9:49AM. The review revealed on 9/29/24, Symbicort dose: increase puffs. On 11/14/24 at 10:37AM in an interview the DON when asked about the facility's MRR process, she stated, the pharmacy consultant, Pharmacist #17, comes to the facility monthly, reviews residents' medications and medical records, make any necessary recommendations, emails those recommendations to the LNHA and DON, and then we print them out. The Clinical Supervisor #3 gives the recommendations to the doctors and rounds with them. The doctors either agree or disagree with Pharmacist #17's recommendations and if they disagree, they must document their reason. During the interview, she stated it is the expectation that the provider checks one of the boxes (agree, disagrees, or other) and provides a rationale if they disagree with the pharmacist's recommendations. On 11/14/24 at 10:56AM the surveyor requested copies of the last three months of medication regimen reviews and pharmacy recommendations for Resident #18 from the Director of Nursing (DON.) On 11/15/24 at 8:58AM the surveyor noted the above documentation requested was not received and made a second request to the Licensed Nursing Home Administrator (LNHA). On 11/15/24 at 9:43AM in an interview with the LNHA she stated the September 2024 pharmacy recommendation was not addressed. The surveyor made a third request for the documentation. On 11/15/24 at 10:12 AM in an interview with the LHNA she provided a copy of the Note to Attending Physician/Prescriber, for Resident #18 with a documented MRR date of 9/29/24. The note stated, Dear Dr. [Physician #15], Resident is on Symbicort Inhalation Aerosol 160-4.5mcg- 1puff orally twice daily for bronchiectasis. Manufacturer recommends administration of 2 puffs not one for appropriate therapy in both asthma and COPD. Please change to Symbicort Inhalation Aerosol 160-4.5mcg- administer 2 puffs twice daily. Under the Physician/Prescriber Response heading, none of the 3 response boxes [agree, disagree, other] were checked and the Signature and Date fields were blank. The LNHA was interviewed on 11/18/24 at 12:21PM. When asked the facility's timeline for the physician/provider to respond to the pharmacist's recommendations she stated within 7-14 days. During the interview when asked why the 9/29/24 pharmacist's recommendation to increase Resident #17's Symbicort had not been responded to, she stated she could not say but could find out now if Physician #15 wanted to act upon that recommendation. On 11/18/24 at 1:11PM in an interview with the LNHA she stated there was no documentation anywhere else in Resident #18's medical record that the 9/29/24 pharmacist recommendation was addressed by Physician #15, so he did respond, sign, and date it today, 11/18/24. During the interview the LNHA provided a copy of the pharmacy recommendation with the disagree box checked, a rationale for the disagreement, and the doctor's signature and date (11/18/24). When asked if the 9/29/24 pharmacy recommendation was responded to within the facility's timeframe, she stated, no, it was not. The 9/29/24 pharmacy recommendation was not addressed until surveyor intervention, 82 days after the recommendation was made.

Based on observation, interview and record review it was determined the facility failed to ensure advance directives for a resident were maintained and readily retrievable by any facility staff in their medical record. This was evident for 1 (Resident #50) out of 4 residents reviewed for advanced directives during the facility's recertification survey. The findings include: On 11/13/24 at 8:51AM the surveyor observed and reviewed the medical record which included both the hard chart and electronic health record for Resident #50 which revealed that a living will and power of attorney was documented for the resident, however, no evidence of the living will or power of attorney documents could be found within the medical record of the resident. The surveyor noted upon review of the resident's Maryland Medical Orders for Life Sustaining Treatment form that it referred to the resident as having a healthcare agent, however, no advanced directives were present within the resident's medical record. On 11/14/24 at 10:43AM the surveyor reviewed the medical record which revealed a physician's note dated 2/26/24 which notated advanced directives counseling/discussion had occurred. On 11/14/24 at 11:33AM the surveyor conducted an interview with Social Worker (SW) #6. When the surveyor inquired during the interview as to why the resident's advanced directives were not located within their medical record, SW #6 stated the following to the surveyor: It was an oversight. SW #6 confirmed with surveyors that they had checked, and the resident's advanced directive was not in their medical record. At this time, the surveyor shared their concern with SW #6 who acknowledged and confirmed understanding of the concern. On 11/20/24 at approximately 4:15PM during the exit conference, the surveyor again shared the concern.

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to document in the medical record when the determination was made that a resident met the criteria for a Significant Change in Status Assessment (SCSA). This was evident for 1 (Resident #24) out of 33 residents reviewed during the recertification survey. The findings include: A Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed within 14 days after the Interdisciplinary Team (IDT) has determined that a resident meets the guidelines for significant change for either major improvement or decline. On 11/18/24 at 8:09AM review of the facility's Change in a Resident's Condition or Status policy revealed, A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b.Impacts more than one area of the resident's health status; c.Requires interdisciplinary review and/or revision to the care plan; and d.Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument (a process to ensure residents receive the highest quality of care and can maintain the highest quality of life). The policy also indicated that, the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. On 11/18/24 at 4:38PM review of Resident #24's medical record revealed a SCSA dated 10/11/21. There was no evidence in the medical record indicating when the IDT determined that the resident met the criteria for a significant change. On 11/18/24 at 4:58PM in an interview with MDS Coordinator #11, when asked to show documentation where Resident #24 met the criteria for significant change, she asked if the surveyor was referring to the 10/11/2021 SCSA and stated she could not find anything to determine Resident #24 met the criteria for a significant change assessment. On 11/19/24 at 12:19 PM in an interview with the Director of Nursing she stated there is no documentation showing the resident met the criteria for a significant change on 10/11/2021.

Based on observation, record review and interview it was determined the facility failed to ensure a resident's care plan was comprehensively developed and person centered. This was evident for 1 (Resident #50) out of 1 resident reviewed for activities during the facility's recertification survey. The findings include: On 11/12/24 at 11:27AM the surveyor observed residents of the unit engaged in the community area, however, Resident #50 was observed to be in their bed awake with no activity materials observed within reach of the resident. On 11/13/24 at 9:18AM the surveyor observed Resident #50 in bed sleeping, and no activity materials were observed within reach of the resident. On 11/14/24 at 10:59AM the surveyor reviewed the medical record which revealed the resident had the following incomplete care plan intervention dated as initiated beginning on 3/14/24 for activities: Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: (SPECIFY). On 11/14/24 at 11:01AM the surveyor conducted an interview with Activities Coordinator #27 who confirmed that Resident #50 prefers specific individual activities rather than participating in group activities. At this time, the surveyor shared their concern with Activities Coordinator #27 who observed the resident's incomplete care plan intervention and acknowledged and confirmed understanding of the concern and further reported that they would be revising the care plan intervention to include the resident's individualized preferences. The surveyor subsequently shared their concern with the facility's Administrator who confirmed understanding of the concern. On 11/20/24 at approximately 4:15PM during the exit conference, the surveyor again shared the concern.

Based on medical records review and interview with staff it was determined that the facility staff failed to notify the physician when there was an acute change in the resident's condition after a fall. This was found to be true for 1 out of 22 residents (Resident #4) reviewed during the investigation stage of the long-term care survey process. This failure resulted in actual harm to Resident #4. The findings include: On 9/19/19 Resident #4's medical records were reviewed. This review revealed the resident was admitted to the facility in (MONTH) (YEAR) for rehabilitation and with [DIAGNOSES REDACTED]. Review of the medical records revealed on 4/5/19 the resident was found on the floor beside the bed. Review of the investigative reports revealed that the resident's nurse, licensed practical nurse (LPN) #22 indicated that the resident was assessed and put back into the wheelchair. Review of LPN #22's notes revealed no injury noted, no bruising or complaints of pain and the doctor and the resident's family were notified of the fall. Review of the comprehensive evaluation note completed by LPN #24 documented the following: Resident in bed, no bruises noted at this time. Resident appears to be in pain with guarding R (right) leg and moaning. vs (vital signs) stable. Assisted geriatric nursing assistant (GNA) to change resident noticed bruise R hip, resident in pain guarding, restless, body stiffening signs. Tylenol given. Further review of the medical records failed to reveal any documentation that the physician was notified of the resident's change in condition of the bruising and increased pain. Review of the statements from the GNAs (#23, #25, #26 and #27) that provided care to the resident after the fall revealed the following: -GNA #23- when providing care to the resident I noticed a bruise on her/his right hip and that the resident was in a lot of pain than usual, just from moving the bed up for care the resident moaned and grabbed her/his right hip. -GNA #26 indicated that she noticed the resident in more pain than usual. -GNA #27's written statement revealed that the resident seemed in more pain than usual on the right side and that the resident had less movement on the lower extremity. GNA #27 also reported that the resident had more pain when he/she moved the head of the bed and that the resident winced when the head of the bed was put down. Further review of the physical therapist notes for 4/5/19 revealed that when she approached the resident to put on her/his brace, the resident presented with increased tone and hip flexion and apparent discomfort with facial grimacing. Review of the nursing notes from 4/6/19 thru 4/7/19 failed to reveal any documentation indicating that the resident was having pain. The nursing note dated 4/8/19 documented that the resident was having pain and discomfort, hurts with movement, wincing stiffening and grabbing right hip. The physician was notified and ordered an x-ray of the right hip. Review of the radiology report revealed the following: 3 days post fall, there is an acute right femoral neck fracture ([MEDICAL CONDITION]). During an interview with the Assistant Director of Nursing (ADON) on 9/17/19 while reviewing the nurses notes and the GNA statements it was presented that the GNA was saying the resident was having pain and nursing was documenting that the resident denied pain. The Assistant Director of Nursing (ADON) was asked for an explanation. The ADON stated that the pain mainly came with movement, and if the resident was still, he/she was comfortable, but any movement caused pain. During an interview with LPN #22 on 9/17/19 at 10:40 AM she reported that they put the resident back in the wheelchair after the fall. Review of the written statement from LPN #22 revealed that the resident was given [MEDICATION NAME] for pain the LPN #22 revealed that the resident was having a little more pain, but that the resident denied hip pain. On 9/17/19 12:13 PM during an interview with GNA #23 she stated that she provided care for the resident. She further reported that when she had to move the bed or the resident, she/he seemed to be in pain. The surveyor asked her if she told anyone, she replied, I told the nurse that the resident was having pain. During an interview with the physical therapist on 9/18/19 at 1:37 PM the therapist revealed that the resident was still on her caseload when she/he had the fall. She further reported that the resident was being seen to place a brace on the left leg. The therapist stated that when she attempted to place the brace the resident flexed her/his hip in response to being touched and that the resident also winced as if pain was present. The surveyor asked if she went to see the resident the next day she replied no, because she wanted to make sure the hip was okay before therapy proceeded. During a telephone interview with LPN #24 on 09/19/19 at 11:46 AM the surveyor asked if when the resident had a change in condition with the bruising and increased pain was the physician notified. She revealed that she did not call the doctor. She further stated that when she saw the bruising and increase in pain, she should have called the doctor. Staff #24 stated, I do not know why I did not call the doctor; I really should have. During an interview with the Medical Director (MD) on 9/19/19 at 4:30 PM the surveyor asked him if he was familiar with the resident and he indicated that he was the resident's primary physician. The surveyor asked if he was aware of the fall and he replied, yes and that he saw the resident that morning. He further revealed at that time the resident did not appear to be in any distress. The resident was sitting in her/his wheelchair. The surveyor asked if he was aware that later that evening there was a change in the resident's condition, and that the resident was complaining of increased pain, guarding the right side and that staff had noticed bruising. The MD informed the surveyor that he was not made aware of the change in the residents' condition. During the same interview with the MD, the surveyor asked him if he had known about the resident's symptoms of guarding the hip, moaning and wincing from pain and bruising and knowing that the resident had fallen, would he have done anything different. He replied he would have ordered an x-ray sooner.

Based on medical record review, facility investigative reports and interviews, it was determined that the nursing staff failed to protect a resident from abuse when staff involuntarily secluded a resident, used abusive language, and inappropriately utilized a sheet to confine the resident's arm movements while in a wheelchair. In addition, nursing staff who witnessed the events failed to intervene to stop the abuse and failed to report the incidents of abuse promptly to the appropriate entities. These deficient practices jeopardized the health and safety 1 (Resident #1) of 13 residents reviewed and had the potential to affect others with behavior issues. These findings constituted an Immediate Jeopardy situation at 3:15 PM on October 23, 2014. A plan of correction was submitted, with new policy development and Elder Abuse & Neglect training was conducted with the staff. The involved nurse was terminated and reported to the Maryland Board of Nursing (MBON). The Police were also notified of the incident and other entities as well. The Immediate Jeopardy was abated at 6:25 PM on October 23, 2014. The findings included: Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident's care plan dated 9/30/14 (for problem onset) indicated that the resident had wandering behaviors, urinates in public and/or inappropriate places, masturbates in public areas, is confused, and is not redirectable. This resident is dependent upon staff for his care, comfort and safety. Review of the medical record revealed that according to a nursing note dated 10/12/14 at 2:46 AM, the resident consistently got out of bed and urinated on the floor and the resident was combative. The nursing staff attempted on two occasions to put him/her back to bed and were unsuccessful and noted that the resident did not follow instructions. Resident #1 was put into his wheelchair by staff and brought out to the nurses station. The note further indicated that the resident was difficult to understand, remained agitated and the nurse "cannot allow" him/her "to enter other residents' rooms." Registered Nurse (RN) #1 placed furniture around Resident #1's wheelchair to prevent him from wandering. The nursing note also stated that she administered [MEDICATION NAME] (narcotic pain reliever) to Resident #1 in an attempt to calm the resident down. No pain assessment was done. The October 12, 2014 medication administration record (MAR) documented the resident received the medication at 3:00 AM. The October 2014 MAR and physician's orders [REDACTED]. The facility's narcotic sheet for Resident #1 showed Tramodol signed out on 10/12/14 but no time was recorded. The nursing note reflected that the nurse had attempted to contact the on-call physician for guidance however, there were no documented attempts to contact the Medical Director or Director of Nursing. Review of the facility's investigation, according to a statement provided by RN #1, was that the Resident #1 was brought to the nursing station and kept rolling away in his wheelchair. RN #1 took 4 chairs and a table and placed the furniture around the resident to confine him. RN #1's statement went on to state that she wrapped a sheet around his waist and tucked it into the back of his brief to prevent him access to his body. The statement indicated that the resident would not keep the gown on and was inappropriate touching his/her body parts. RN #1's statement also included that she administered [MEDICATION NAME] with the intention of having some sedative effect on the resident. The resident was confined based on the statement for approximately an hour until he/she started to "nod off." Lastly, RN #1's statement included that she attempted to contact the on-call physician for guidance however; she never attempted to notify the Medical Director of the facility. Further review of the facility's investigation also revealed a statement from a second nurse, RN #2. RN #2's statement revealed that she observed Resident #1 at the nursing station with several chairs around him. RN #2 by her own account observed Resident #1 confined with furniture, involuntarily secluding him. RN #2 did not report the what she had witnessed at the time of the occurrence. Continued review of the facility's investigation revealed a statement from a geriatric nursing assistant, GNA #1. GNA #1's statement revealed she also observed Resident #1 with chairs around him so he could not self-propel his wheelchair about the unit. GNA #1 by her own account observed Resident #1 confined with furniture. GNA #1's statement went on to state also that she observed Resident #1 with a sheet tied around him, preventing him access to his body. An interview was conducted with GNA #1 on 10/24/2014 at 11:30 a.m., confirming that she witnessed Resident #1 confined with furniture and attempting to wheel his wheelchair through the barricade. GNA #1 went on to state, she also observed Resident #1 with a sheet tied around his waist and secured behind the resident's wheelchair. Additionally, during this interview GNA #1 stated she heard RN #1 speaking to the resident in a loud tone and using profanity. GNA #1 did not report the incident at the time it occurred. The Director of Nursing was not made aware of the incident until 9:45 AM on 10/12/14 which was at least 6 hours after the incident. Although, some actions were taken by the facility once discovered, the MBON was not notified until 10/20/14 of RN #1's actions, the facility's Policy & Procedure on Abuse was revised 10/23/14, the Elder Abuse & Neglect training for staff was done 10/23/14.