Every finding on record at Allegany Health Nursing and Rehab

Based on record review and interview it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received the required 12 hours of annual training. This was evident for one (Staff #14) of two GNAs reviewed for annual training.The findings include:On 4/02/26 at 9:00 AM the Director of Nursing (DON) was interviewed and asked to provide training records for GNA #14. The DON reported that there were no training records for GNA #14. On 4/02/26 at 9:50 AM an interview was conducted with the DON and she was asked to provide any additional evidence of training for GNA#14. On 4/02/26 at 3:57 PM in an interview with the DON, she confirmed the finding that GNA #14 did not have 12 hours of annual training. No additional evidence was provided by the end of the survey on 4/3/26.

Based on observations and interviews, it was determined that the facility failed to ensure that the call system was accessible to meet resident needs. This was evident for 1 (Resident #46) of 1 residents observed for call system accessibility. The findings include: On 03/30/2026 at 11:22 AM, Resident #46 motioned for the surveyor to enter the room while holding a nasal cannula and requested assistance to place it back on. At that time, the surveyor observed that no call bell was within Resident #46's reach, and further observation of the room revealed the call bell was located on the floor under Resident #46's bed.On 03/20/26 at 11:26 AM, after the surveyor stood in the doorway to obtain staff attention, Geriatric Nursing Assistant (GNA) #17, who identified themselves as the assigned staff member for Resident #46, entered the room and retrieved the call bell from under Resident #46's bed. GNA #17 stated they had previously placed the call bell within the resident's reach on the bed during their last check of Resident #46. GNA #17 further indicated the call bell was not clipped, and the resident was seated in a wheelchair next to the bed at the time of observation.On 04/01/26 at 11:00 AM, the Director of Nursing acknowledged the concern regarding the accessibility of the call bell for Resident #46.

Based on observation, interview, and record review, it was determined that the facility failed to use infection prevention strategies. This was found to be evident during two out of two observation of the laundry facility; the review of the water management plan to prevent Legionella; and review of one (Resident #16) out of three residents reviewed for pressure ulcer care.The findings include: 1) On 3/31/26 at 1:13 PM an observation of the facility laundry rooms was conducted. A laundry aide (Staff #10) was observed as she held and folded a flat sheet which touched the floor as she held it up to fold it. There was a metal table in the room that was partially covered with supplies, and about 3 feet of the table was clear. The overall table length appeared to be shorter than the length of the flat sheet that was being folded. When interviewed, Staff #10, described the process for sorting, washing, drying, folding, storing and stocking linens for the facility. When she described how she sorted dirty linens and how she placed dirty linens in the washer, she said she wore gloves but did not wear a gown or an apron. On 3/31/26 at 1:40 PM an interview was conducted with the Maintenance Director (Staff #9) who said his responsibilities included management of housekeeping and laundry. When he was informed of the observation and interview of Staff #10 who was observed to allow clean linen to touch the floor when she folded it, and that she said she did not wear a gown or apron when she sorted dirty linens, he acknowledged the deficient practice and said he would talk to his staff that day. On 4/01/26 at 9:12 AM another observation of the dirty laundry room was conducted. Laundry aide (Staff #7) was observed and interviewed. She took dirty linens from a reusable cloth bag and sorted the white linens from resident clothing and dark colors and place them in separate dirty linen carts. Some of the linens appeared to be wet and smelled of urine. Staff #7 wore gloves but did not wear an apron or gown over her personal clothing while she sorted the dirty laundry. When asked, she said she did not wear an apron or gown when she sorted dirty linens or when she put dirty linens in the washer, and that she processed the linens in the way that she was taught. On 4/01/26 at 9:19 AM an interview was conducted with the Nursing Home Administrator (NHA) regarding the observation that Staff #7 was observed and interviewed and failed to wear the proper personal protective equipment (PPE) to sort dirty linens and failed to describe the proper process. The NHA said that staff had been re-educated yesterday, but she acknowledged the observation of deficient practice that day despite the facility's staff education. 2) On 3/31/26 at 1:25 PM an interview was conducted with the Maintenance Director (Staff #9) to review the facility's water management plan to prevent Legionella. He explained that the facility's water supply was from the city and that he checked the city's water report annually. When asked he said the facility did not test for Legionella. When asked about water temperature monitoring, he said he sometimes did random testing and said he would provide a report. On 3/31/26 at 1:40 PM the Nursing Home Administrator joined the interview and when asked about the facility's water management plan, she replied that it is something they have talked about, but she could not cite a professional reference they used or explain any process in place to monitor the water. On 3/31/26 at approximately 2:00 PM, a water temperature log document was provided and reviewed. The review revealed that the log was for the month of May 2025 and listed random resident rooms and corresponding water temperatures. No other evidence of resident room water temperature monitoring was provided. On 3/31/26 at 2:12 PM the NHA brought a copy of the facility policy titled Water Systems, Safety and Management which referenced Center for Disease Control (CDC) guidelines for the process to monitor and control water for Legionella. The NHA confirmed that the facility failed to have a program for Legionella management and did not follow their policy which referenced the CDC guidelines. 3) On 4/01/26 at 9:40 AM, Resident #16 was identified as having a stage 4 pressure ulcer on their lower back. Physician #12, the facility's contracted wound care provider, and Wound Care Registered Nurse (RN) #13 were completing the dressing change for Resident #16 at that time. According to the Centers for Disease Control and Prevention (CDC), Enhanced Barrier Precautions (EBP) in long-term care are infection control measures that require gowns and gloves during high-contact resident care and target multidrug-resistant organisms (MDROs) when standard precautions are insufficient. They apply to residents with chronic wounds, indwelling devices, or known MDRO infections to prevent transmission without completely isolating residents. This strategy, which applies to residents with unhealed wounds, bridges the gap between Standard and Contact Precautions without requiring room isolation. On 4/01/26 at 9:46 AM, the surveyor completed an observation of Resident #16's stage 4 pressure ulcer on the resident's lower back. Physician #12 and RN #13 provided the care to the resident. During the observation, Physician #12 prompted RN #13 to put on Personal Protective Equipment (PPE), including a gown. However, during the observation, Physician #12 did not properly don the gown, leaving it untied and unsecured, which caused it to drape off their arms and cuff around their hands while assessing and redressing Resident #16's stage 4 pressure ulcer. On 4/01/26 at 10:10 AM, the medical record revealed Resident #16 had an order for EBP; however, the order specifically stated that it was for a Foley Catheter dated 02/06/26. There was no evidence of an active order on Resident #16's record to reflect EBP for the Stage 4 pressure ulcer on the resident's lower back. On 4/01/26 at 11:30 AM during an interview with both the Nursing Home Administrator and the Director of Nursing, they acknowledged concerns about not providing proper EBP for Resident #16.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the accuracy of clinical records, specifically the electronic medication administration record (eMAR). This deficient practice was identified for 1 (Resident #15) of 3 resident medication administration observations. The findings include: On 04/01/26 at 9:30 AM, during a medication administration observation, Registered Nurse (RN) #11 was observed preparing to administer medications to Resident #15.Resident #15 had diagnoses that included, but were not limited to, Parkinson's disease, Repeated falls, and Muscle weakness. Resident #15 had an order for amantadine, a dopaminergic medication used to manage symptoms of Parkinson's disease. Failure to administer this medication as ordered may result in increased rigidity, decreased mobility, and impaired functional status. Review of the resident's eMAR revealed that the resident's amantadine HCl 100 mg, scheduled for 8:00 AM, was documented as administered.On 04/01/26 at 9:32 AM, during the observation, RN #11 confirmed that the medication had not yet been administered, despite being documented as given in the eMAR.On 04/01/26 at 9:35 AM, with surveyor observation, RN #11 administered the medication at approximately 9:40 AM and corrected the eMAR entry to reflect a late administration prior to delivering the medication to Resident #15.During an interview at the time of the observation, RN #11 stated they were unsure how the medication was documented as administered prior to giving it.On 04/01/26 at 11:00 AM, both the Nursing Home Administrator and Director of Nursing acknowledged the concern that a medication for Resident #15 had been documented as administered in the eMAR prior to actual administration.

Based on observation and interview, it was determined that the facility failed to ensure the accuracy and integrity of controlled substance reconciliation records. This deficient practice was identified in 1(3rd floor south cart) of 3 medication storage areas observed. The findings include: On 04/02/26 at 11:45 AM, during an observation of the 3rd floor medication storage room and 3rd floor south medication cart, Licensed Practical Nurse (LPN) #16 provided the narcotic count verification sheet utilized for shift-to-shift reconciliation of controlled medications. Review of the narcotic reconciliation documentation revealed the following: The 6:00 AM shift reconciliation for 04/02/26 contained signatures of two licensed nurses; however, there was no documented evidence that an actual count of controlled medications was performed, including: total number of narcotic blister pack cards total number of medication bottles, including refrigerated medications total number of transdermal patches The reconciliation record did not demonstrate that controlled substances were verified by two licensed nurses at the time of shift change, and signatures alone do not constitute evidence of an actual count. The 2:00 PM shift reconciliation for 04/02/26 was signed in advance of the shift change by LPN #16, prior to the required reconciliation time and prior to completion of a narcotic count with another licensed nurse. On 04/02/26 at 11:45 AM, during the surveyor's observation, LPN #16 confirmed that the 2:00 PM reconciliation had been pre-signed and stated this was done due to working a 16-hour shift. LPN #16 further confirmed that the narcotic count for the 2:00 PM shift change had not yet occurred at the time the signature was entered. This practice resulted in narcotic reconciliation documentation that did not reflect verification of an actual count at the time of shift change, and did not ensure that controlled substances were accurately accounted for by two licensed nurses. On 04/02/26 at approximately 1:30 PM, the Nursing Home Administrator and Director of Nursing acknowledged the concern related to narcotic count reconciliation practices.

Based on record review and interview it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) had their performance evaluated. This was evident for 2 (Staff #14, #15) of 2 GNAs reviewed for performance evaluation.The findings include: On 4/01/26 another surveyor requested the employee files for Staff #14 and Staff #15.On 4/02/26 at 9:08 AM a review of the employee files for Staff #14 and Staff #15 failed to reveal any evidence that they had performance evaluations.On 4/02/26 at 3:57 PM an interview was conducted with the Director of Nursing and she confirmed the deficiency that the facility did not complete performance evaluations for either Staff #14 or Staff #15.

Based on interview, and record review it was determined that the facility failed to ensure nursing staff were evaluated for competence. This was evident for 2 of 2 Registered Nurses (Staff #11, #13) employee files reviewed for skills and competency.The findings include: On 04/02/26 at 10:25 AM an interview was conducted with the Human Resources Coordinator (Staff #19). When asked how staff performance was monitored she said that this was done annually and that she gave a form to the Director of Nursing (DON) who would then give them to the corresponding unit manager and that the form included a section for skills/competencies. She was then asked to provide employee files for 2 Registered Nurses (Staff #11, Staff #13). On 4/02/26 at 10:47 AM an interview was conducted with the DON and a review of Nurse #13's employee file was done together but the review failed to reveal any skills/competency for the nurse. The DON said Nurse #13 was part time and was hired only to do wound care, so she may not have had a skills checklist done. During the interview the Facility Assessment was also reviewed with the DON and she confirmed that the assessment indicated multiple resident care activities for which staff were expected to demonstrate competence. On 4/02/26 at 11:06 AM a review of Nurse #11's employee file was conducted and revealed 2 competencies dated 3/18/21, one for Blood Glucose Monitoring and one for Medication Administration. No more recent competencies were found in the file. On 4/02/26 at 12:01 PM, in another interview with the DON, she said that nursing staff should have competencies done during orientation and annually. She confirmed that Nurse #11 and Nurse #13 did not have their skills/competence evaluated.

Based on medical record review and interview it was determined that the facility failed to develop a care plan to address the resident's needs related to the use of an indwelling urinary catheter and failed to ensure that a resident was assessed for the possible removal of the urinary catheter. This was found to be evident for one (Resident #6) out of two residents reviewed for indwelling urinary catheter usage.The findings include:On 4/1/26 review of Resident #6's medical record revealed the resident has resided at the facility for more than a year and was sent to the hospital in late December 2025. Review of the discharge Minimum Data Set (MDS) assessment for the December discharge to the hospital revealed the resident was frequently incontinent of urine (unable to control their bladder) and did not have an internal or external urinary catheter in place. The resident was re-admitted to the facility from the hospital in early January 2026.An internal urinary catheter is a medical device consisting of a tube that is inserted through the urethra into the bladder to empty urine. A Foley catheter is an indwelling urinary catheter that remains in place after insertion for continuous drainage of urine. The Foley catheter is held in the bladder by a water-filled balloon which prevents it from falling out.The MDS is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. Review of the hospital Discharge summary, dated [DATE], revealed that the resident was noted to have urinary retention during the hospitalization and that a Foley catheter was placed by urology. The note also indicated that the catheter would remain in place at discharge and the resident would follow up in the outpatient setting with urology.Review of the facility's policy regarding Catheter - Urinary Catheter, Cleaning and Maintenance revealed it consisted of a reference to Lippincott Nursing Procedures 9th Ed. (a nursing text book), pages 432 - 435. The facility did not have a facility specific policy regarding catheter use or addressing a plan to discontinue catheters when no longer needed. Review of the referenced [NAME] pages did reveal: Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection (CAUTI). Complications associated with indwelling urinary catheter use include CAUTI, genitourinary trauma, bladder fistula (an unusual opening between the bladder and another part of the body), bladder stone formation and incontinence.Continued review of the medical record on 4/1/26 revealed the resident had current orders, in place since January 2026, for an indwelling foley catheter and for catheter care to be provided every shift. Review of the progress note, written by primary care provider physician assistant (PA #23) for a visit on 1/3/26, revealed in the history of present illness section: .Foley catheter placed for Urinary retention. Urology had to placed it due to atrophy and difficult placement. [S/he] is to follow with urology outpatient.Review of a progress note, written for a visit completed by primary care physician (PCP #24) on 1/5/26, revealed in a section titled Interval History, which addressed events that had occurred during the recent hospitalization, included: .[S/he] also had a Foley catheter placed with difficulty and to follow with urology.On 4/1/26 at 10:31 AM review of Resident #6's medical record revealed an MDS, with an assessment reference date of 1/9/26. This assessment included documentation that the resident had an indwelling urinary catheter.Review of the care plan, on the morning of 4/1/26, failed to reveal documentation to indicate the presence of a urinary catheter or interventions to address the resident's needs related to catheter use. Further review of the medical record on 4/1/26 failed to reveal an order for a urology appointment or documentation to indicate the resident was seen by a urologist since the re-admission in January. No documentation was found to indicate there was an attempt to discontinue the use of the indwelling urinary catheter since the resident's re-admission.Review of a progress note written by primary care provider nurse practitioner (NP #25) for a visit on 3/2/26 revealed the resident was seen that day due to a report by nursing of hematuria (blood in the urine). The note revealed an indwelling Foley catheter was in place and some bloody urine was observed in the tubing.On 3/2/26 there was an order to flush the foley catheter with 60 cc sterile water every 6 hours for 24 hours. On 3/3/26 there was an order for an antibiotic to be administered twice a day until 3/10/26 for cystitis with hematuria. Cystitis is inflammation of the bladder due to an infection.Further review of the resident's care plans, on the morning of 4/1/26, revealed a plan for occasional bladder and bowel incontinence, which was last reviewed/revised on 3/11/26 by Registered Nurse #21. The 3/11/26 update failed to address the use of the indwelling urinary catheter or that the resident had recently been treated with an antibiotic for a possible urinary tract infection and blood in the urine. On 4/01/26 at 12:34 PM the Director of Nursing (DON) was interviewed about the process when a resident returns from a hospitalization with an indwelling urinary catheter still in place. The DON reported that they look to see if the resident was seen by urology while in the hospital, if there is an appropriate diagnosis for the use of the catheter, and any follow up to see if it should be removed. The DON also reported that they are able to complete bladder scans at the facility.After removal of an indwelling urinary catheter there are often orders to complete a bladder scan after the resident voids to assess if the resident is continuing to retain significant amounts of urine.Further review of the current order for the indwelling foley catheter revealed it was for Obstructive and reflux uropathy, unspecified. Obstructive uropathy is a blockage that makes it difficult or impossible to urinate. However, further review of the January hospital discharge summary and the primary care provider progress notes for 1/3/26, 1/5/26 and 3/2/26 failed to reveal documentation of a diagnosis of obstructive uropathy.During the 4/1/26 interview with the DON the surveyor reviewed the concern that there was no documentation found to indicate there was an attempt to remove the catheter after the January re-admission or that the continued use of the catheter was addressed in the care plan.On 4/02/26 at 8:40 AM, after reviewing the section of the hospital discharge summary that addressed the need for urology follow-up with the surveyor, the DON reported that the resident does have an appointment with urology in May. The DON also reported that the resident has had an indwelling urinary catheter in the past that was removed.On 4/02/26 at 8:50 AM the Appointment Coordinator (#22) reported that the appointment with the urologist was just scheduled the day before. She went on to report that it appears it was missed during the resident's re-admission by nursing.On 4/2/26 at 10:34 AM surveyor reviewed the concern with the corporate nurse (#26) that in addition to the hospital discharge summary, the primary care notes from January 2026 also indicated the need for follow up with urology.On 4/2/26 continued review of the medical record revealed that a care plan to address indwelling catheter use was initiated on 4/1/26. Registered Nurse #18 documented that this plan was reviewed/revised on 4/1/26 at 2:31 PM.

Based on medical record review and interview it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. This was found to be evident for one (Resident #28) out of three residents reviewed for pressure ulcers.The findings include:The Minimum Date Set (MDS) is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. Review of Resident #28's medical record revealed a wound specialist note, dated 3/11/26, that documented the presence of an unstageable deep tissue injury (DTI) on the resident's right lateral foot. A DTI is a pressure injury resulting from intense and or prolonged pressure and shear forces at the bone-muscle interface. It presents as intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue. Review of the Minimum Data Set (MDS), with an assessment reference date of 3/13/26, revealed staff documented in Section M0210 that the resident had no unhealed pressure ulcers or injuries. On 3/31/26 at 2:15 PM surveyor interviewed the MDS Nurse #18 about the 3/13/26 MDS assessment regarding the presence of pressure ulcers. After looking up the information in the electronic health record, Nurse #18 reported that the resident has a DTI on the foot and stated: I'll have to modify that in regard to correcting the MDS assessment. Later in the survey, Nurse #18 provided documentation to indicate a correction was submitted that included documentation that the resident has a one unhealed, unstageable pressure injury presenting as a deep tissue injury.

Based on medical record review, observation and interview it was determined that the facility failed to ensure the provision of activities to meet the needs of residents with dementia. This was found to be evident for 2 (Resident #122 and #9) out of 5 residents reviewed for dementia care.The findings include1.Review of Resident 122's medical record revealed the resident has resided at the facility for more than 6 months, was legally blind and had dementia. The resident resided on the secured unit, in which a code was required to gain access to the elevator to leave the unit. On 3/30/26 at 11:09 AM Resident #122 was observed ambulating in the hallway, dressed for the day. There was no formal activity occurring at this time on the nursing unit.On 3/30/26 at 12:40 PM, Resident #122 was observed standing in his/her room alone, leaning over the foot of the bed. Surveyor did not observe the television or music to be on in the resident's room. On 3/31/26 at 1:39 PM, observation made on Resident #122's unit failed to reveal an organized activity at this time. Resident #122 was not in the hall at this time. At 1:42 PM, the resident was again observed in his/her room.On 3/31/26 at 2:02 PM, Resident #122 was sitting in the hallway near the nursing station. Bingo was being called at this time in the hallway, but Resident #122 was not participating. The resident was drinking a container of milk at this time.On 4/01/26 at 1:57 PM, Resident #122's door was shut. After entering the room, Certified Medicine Aide (CMA #5) and surveyor observed the resident reclining on the bed crossway. CMA #5 assisted the resident with a position change and asked the resident if s/he would leave the door open.Further review of the medical record revealed an interview was conducted with Resident #122 for the Minimum Data Set (MDS) assessment, dated 7/17/26, related to activity preferences. According to this assessment it was very important for the resident to have books, newspapers and magazines to read; listen to music s/he likes; be around animals such as pets; keep up with the news; to do things in groups; go outside to get fresh air when the weather is good and to participate in religious services.Review of Resident #122's care plan revealed the resident was independent after set up assistance for meeting emotional, intellectual, physical and social needs related to being legally blind. The interventions reflected the MDS assessment and included but not limited to offer resident audiobooks of thriller and mystery stories; staff to offer assistance with reading mail and other information sheets; and staff will offer one-to-one visits for socialization and assistance with audio equipment.Review of a Care Conference note, dated 1/14/26 revealed the resident's representative would like for [her/him] to be more engaged with activities.On 4/2/26 at 3:38 PM, interview with the Activity Director (#27) revealed that prior to COVID she had a full-time activity person for the secured unit. Currently she has one full-time staff member plus two part-time staff, and she also supervises the bus driver, who when not driving the bus can assist with activities as needed. She reported the full-time person conducts the activities on the Activity Calendar and that one of the part-time staff conducts the one-on-one visits. She confirmed that the residents on the secured unit are able to attend any of the activities in the facility and that they do have documentation of activity participation.In regard to Resident #122, the Activity Director reported that the resident goes to some music activities and that a church lady comes in on Wednesdays. She confirmed that the resident would have to leave the unit in order to attend most activities offered.Review of the Activity Participation sheet for January 2026 revealed self directed active socialization on 29 out of 31 days reviewed and two days were documented as passive. There was documentation of walking in the halls as an activity for 30 out of 31 days. Interview with the Activity Director on 4/2/26 at 4:22 PM revealed that the socialization documented is not a 1:1 intervention; and that the walking in the halls is an independent activity. Further review of the January participation log revealed the resident attended Bingo on one occasion, attended two socials; and participated in snacks/hydration on two occasions. There was only one instance of the resident refusing to participate in an activity but was found to be unable to participate on five occasions. There was one notation about the resident receiving mail, but staff documented that the resident was asleep, so they did not get a chance to read the mail to the resident. No further documentation was found to indicate the mail was read to the resident at a later date.Review of the Activity Participation sheet for February 2026 revealed self-directed active socialization on 26 out of 28 days reviewed, and two days were documented as passive socialization. There was documentation of walking in the halls on 7 days and actively participating with snack/hydration on one day, and one occasion that the resident was unable to participate with the pet visit. No documentation was found to indicate the resident attended a party, a religious event, or had staff read to her/him or otherwise engage with the resident during the month of February. There was no documentation to indicate activities were offered and the resident refused.Review of the Activity Participation sheet for March 2026 revealed self-directed active socialization on 29 out of 31 days reviewed and two days were documented as passive. Walking around was documented as an activity on 30 out of 31 days reviewed. There were four occasions when the resident actively participated in an activity: once with fresh baked cookies; once with the snack/beverage cart; once with some mail; and once went to the barber/beauty shop. The resident refused to participate on one occasion when offered an arts and crafts activity, no other refusals were documented. Staff documented that the resident was unable to participate with the snack & beverage cart on five occasions and the movie & popcorn on one occasion. No documentation was found to indicate the resident attended, or was offered to attend an entertainment event, religious activity or had staff read to him/her or engage in a one-on-one activity.2) Review of Resident #9's medical record revealed the resident had resided at the facility for more than one year and had a diagnosis of dementia with severe cognitive impairment as evidenced by a March 2026 Brief Interview for Mental Status (BIMS) score of 1/15. The resident resided in the secured unit.Review of the 8/4/25 MDS assessment for activity preferences revealed the resident was interviewed in regard to his/her preferences. This assessment revealed it was very important to the resident to go outside to get fresh air when the weather is good; and somewhat important to have books, newspapers and magazines to read. The resident indicated it was not very important to listen to music, keep up with the news, participate in religious activities or to do things in groups.Review of the care plan addressing activities revealed Resident #9 was dependent after set up assistance for meeting emotional, intellectual, physical and social needs. The most recent evaluation of this care plan was completed by the Activity Director on 2/18/26 and included the following: .has been offered pet visits, up front in reclining chair, guessing games, television up front. Interventions include, but are not limited to: Staff will invite, make arrangements, offer materials, or assistance to facilitate participation in music interests such as country; staff will offer to read mail and other materials to [name of resident] as s/he is not able to see well.Review of the activity participation logs for January 2026 revealed Television upfront was included as an activity and there was documentation of active participation for this activity on 23 out of 31 days reviewed.Observations made throughout the survey revealed there was a large television located at the back of the nursing station which had a movie playing throughout the day during the course of the survey. Several residents were frequently observed sitting near the nursing station while the movies were playing. However, residents sitting in the hallway needed to look past the nursing station counter, and any staff at the nursing station, in order to actually view the movie that was playing. Additionally, there was a room at the end of the unit that appeared to be a dining room; however, no observations were made during the survey of this room being utilized for dining or activities. During an interview with Nurse #16, she reported that there was no specific activity person assigned to the secured unit. She reported that the room at the end of the hall is currently a staff training room and that the residents are never taken down there for activities. Nurse #16 did report that they always have music or a movie, referencing the tv playing at the nursing station.Further review of the January activity participation log revealed active self-directed socialization on 29 out of 31 days, with passive socialization documented on two dates. The resident did participate in a guessing game on one occasion and had mail read to her/him on two occasions, attended one party and had one pet visit over the course of the month. The daily chronicle was provided on 8 days.Review of the February 2026 participation documentation revealed Television upfront was documented as an activity on 27 out of 28 days reviewed. No documentation was found to indicate the daily chronicle was provided to the resident during February. Self-directed socialization was documented for all 28 days. The mail was read to the resident on one occasion, and a pet visit also occurred on one occasion; the resident refused to participate in a word game when offered on one occasion. Five family visits were also documented as activities. No additional documentation was found to indicate other individualized activities were offered to the resident in February.Review of the March 2026 participation documentation revealed self-directed socialization was documented for 25 days and passive socialization on 6 days. The resident had the mail provided on one occasion; attended a movie & popcorn on one occasion and had fresh baked cookies on one occasion. The staff documented two family visits as activities. The resident refused the offer of music on one occasion, but no other refusals were documented. Staff documented the resident was unable to participate in the pet visit on one occasion and was unable to participate with snacks & beverage cart on 6 occasions. No documentation was found to indicate the daily chronicle was offered or read to the resident; no documentation to indicate the resident was offered to participate in any games or other activities.During the interview with the Activity Director on 4/2/26 at 4:22 PM surveyor reviewed the concern regarding the provision of activities. The Activity Director acknowledged the concern.

Based on interview and medical record review it was determined that the facility failed to ensure an interdisciplinary care plan meeting was held to review and revise the resident's care plan after the completion of a Minimum Data Set (MDS) assessment. This was found to be evident for one (Resident #6) out of two resident's reviewed for urinary catheter use.The findings include: Care Conferences, also known as care plan meetings, are interdisciplinary team meetings that are to occur following the completion of Minimum Data Set (MDS) assessments. The MDS is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. On 3/31/26 at 2:19 PM social worker (SW) #6 was interviewed in regard to the process for scheduling care plan meetings. SW #6 reported that the MDS nurses send out a schedule and that social work usually schedules the meeting 14 days after the assessment date. She went on to report that there is documentation of these meetings in the electronic health record. On 4/1/26 at 10:31 AM review of Resident #6's medical record revealed a MDS, with an assessment reference date of 1/9/26. On 4/1/26 further medical record review revealed documentation that a care conference had occurred on 10/15/25, but failed to reveal documentation to indicate a care conference had occurred after the 1/9/26 assessment was completed. On 4/1/26 at 11:51 AM SW #6 was asked if there was documentation to indicate that a care conference had occurred since October 2025. At 12:32 PM SW #6 and the Nursing Home Administrator (NHA) confirmed that there was no care plan meeting since October. The NHA indicated this was due to the resident transitioning from long term care to skilled care. Cross reference to F 690.

Based on reviews of a facility-reported incident, a closed medical record and all pertinent information, and staff interviews, it was determined the facility staff failed to provide adequate supervision and follow the resident's plan of care to: 1) prevent a fractured humerus during a transfer, and 2) to prevent a cognitively and functionally impaired resident from sliding out of bed onto the floor and receiving bilateral fractured hips. This was evident for 2 (Residents #909, #906) out of 11 facility-reported incidents resulting in harm to both residents reviewed during the survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 07/11/23. The findings include: 1) A review of the facility-reported incident MD00178281 was reviewed on 01/23/2025 at 1 PM. The facility's investigation revealed that on 05/14/22 at 9:30 PM Resident #906 had fallen out of bed during care and that subsequent assessments and X-rays determined that Resident #906 had suffered bilateral femoral neck fractures. Resident #906 had been admitted to the facility on [DATE] with cognitive impairment and was totally dependent upon the staff for all aspects of his/her care needs. The facility investigation indicated that on 05/14/22 GNA #5 entered Resident #906's room to provide incontinence care. The investigation indicated that GNA #5 informed staff that S/he turned Resident #906 onto his/her left side, away from him/her, and then Resident #906 rolled out of bed. GNA #5 then informed the nurse. A review of Resident #906's activities of daily living care plan on 01/23/25 revealed nursing interventions dated 06/11/21 that instructed staff members to use two staff members when performing for bed mobility (turning and repositioning) for Resident #906. In an interview with GNA #5 on 01/24/25 at 5:15 PM, GNA #5 stated that prior to the start of Resident #906's bed bath on 07/09/24, GNA #5 stated S/he obtained all the equipment and clean linen supplies to provide Resident #906's bed bath. GNA #5 stated that S/he then raised Resident #906's bed up to his/her hip level. During the bed bath, GNA #5 stated that S/he turned Resident #906 away from him/her, onto Resident 906's left side, which placed Resident #906 closer to the edge of the bed away from him/her. GNA #5 stated that this was when S/he realized that S/he needed more incontinent wipes. GNA #5 stated that S/he then turned away from Resident #906 lying in bed to ask another staff member if they could bring him/her more incontinent wipes. GNA #5 stated that this is when Resident #906 jerked up and rolled out of bed onto the floor. After the Resident #906's fall, GNA #5 stated that other staff members had informed him/her that Resident #906 was a one-staff member assist for baths. GNA #5 stated that S/he had reviewed Resident #906's plan of care that day but could not say why S/he performed the bed bath by himself/herself. The facility administrator and director of nurses were made aware of the findings at the exit conference on 01/24/25 at 6 PM. 2) The facility's investigation of the reported incident MD00194149 was reviewed on 01/23/2025 at 10:00 AM. The facility's investigation revealed that on 07/09/23 Resident #909 was being transferred by 2 GNA's to a shower chair during the evening shift when they heard a pop and called the floor nurses for assistance. Resident #909 was sent to the local emergency room via 911 for evaluation. The 2 GNA's were suspended pending the investigation. Resident #909 was scheduled for a shower on 07/09/23. Resident #909 was admitted to the facility on [DATE] with a history of a fractured hip, dementia, and metabolic encephalopathy. Resident #909 is alert to person only and has a BIM's score of 7. Resident #909 was scheduled for a shower on 07/09/23. A review of the facility investigation revealed that GNA #3 requested assistance from GNA #4 to transfer Resident #909 from the bed to the shower chair. GNA #3 and GNA #4 stated that they each got under one arm of Resident #909 and were transferring him/her to the shower chair when they heard a popping sound. GNA #3 and GNA #4 then lowered #909 to the floor. While GNA #3 stayed with Resident #909, GNA #4 alerted the nurse to the incident. Upon assessment by the nurse, Resident #909 was noted to have an abnormal range of motion in the left arm. Resident #909's physician and family were notified of the incident and orders to transfer Resident #909 to the emergency room for eval and treat. The hospital obtained an X-ray of Resident #909's left arm which revealed a fracture of the left humerus with osteopenia/osteoporosis. Resident #909 was sent back to the facility with an order for a splint to the left arm until seen by an Orthopedic physician for a possible cast. The Medical Director and Resident #909's family were made aware of plan of care and both were in agreement. The facility investigation determined that Resident #909 obtained a fracture to his/her left humerus as a result of GNA #3 and GNA #4 failure to follow the plan of care for Resident #909. Both GNA #3 and GNA #4 received counseling and were educated on checking a resident's profile for safe transfer status and plan of care. The facility staff were educated to review a residents' profile for safe transfer status and plan of care. All resident care plans were reviewed and updated. A review of Resident #909's admission fall and injury prevention care plan dated 07/20/21 revealed a nursing intervention that indicated to transfer Resident #909 by the use of lifting device as ordered. In a telephone interview with GNA #3 on 01/24/25 at 3:43 PM, GNA #3 stated that S/he recalled the incident with Resident #909. GNA #3 stated that Resident #909 was to receive a shower that day had asked GNA #4 for assistance transferring Resident #909 from the bed to the shower chair. GNA #3 stated S/he thought Resident #909 was a 2-person assist for transfers. GNA #3 stated that during the transfer both S/he and GNA #4 grabbed Resident #909 under each arm. GNA #3 stated S/he was on the left side of Resident #909 during the transfer. GNA #3 stated that we heard a snap and immediately stopped the transfer and lowered Resident #909 to the ground. When asked, GNA #3 stated that S/he had transferred Resident #909 under his/her arms frequently in the past. GNA #3 stated that S/he had not reviewed Resident #909's plan of care for transfers. GNA #3 stated that after the incident S/he then learned that Resident #909 was to be a Hoyer transferred. GNA #3 stated that S/he was not aware that Resident #909's care plan had been changed regarding transfer status to a Hoyer lift. GNA #3 stated that S/he received education after the incident to check a resident's transfer status prior to the transfer. In an interview with GNA #4 on 01/24/25 at 3:52 PM, GNA #4 stated that S/he recalled the incident and that GNA #3 had asked for assistance to get Resident #909 out of bed. GNA #4 stated that S/he was not assigned to Resident #909 on 07/09/23. GNA #4 stated that S/he did not review Resident #909's care plan regarding transfer status prior to assisting GNA #3. GNA #3 stated that S/he was standing on Resident #909's right side before the transfer. GNA #4 stated both S/he and GNA #3 grabbed Resident #909 under the arms and lifted the resident up from the bed and this was when they heard Resident #909's arm snap. GNA #4 then stated to GNA #3 they needed to lower Resident #909 down. GNA #4 stated that S/he went and got the nurse. GNA #4 stated that S/he and GNA #3 were suspended after the incident. GNA #4 stated that S/he received education on how to determine a resident's transfer status. The Director of Nursing (DON) was interviewed on 01/24/25. During the interview, the DON demonstrated and provided Quality Assurance (QA) material that s/he maintained in which the entire nursing staff were educated on 07/11/23 on how to access a resident's care plan and correctly identify the number of staff needed to provide care to each resident. The QA plan was to be reviewed monthly in QAPI for 3 months. Based on the above actions taken by the facility and verified by the nurse surveyor on site, it was determined that the facility's deficient practice was past noncompliance with a compliance date of 07/11/23.

Based on reviews of a facility-reported incident, a closed medical record and all pertinent information and staff interview, it was determined that the facility staff failed to identify a newly admitted Resident who was admitted without clear physician's order for end-of-life care and failed to follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This was evident for 1 (Resident #902) of 11 facility-reported incidents reviewed during an annual recertification survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of [DATE]. The findings include: Review of facility-reported incident (FRI) MD00174662 on [DATE] revealed allegations that Resident #902 was admitted to the facility from the community on [DATE] at 1:15 PM. Resident #902 was being evaluated in the emergency room earlier in the day. On [DATE], Resident #902 was assessed by his/her physician and deemed incapable of understanding any information and that a third party should make the decisions for Resident #902. Reviews of the facility investigation and Resident #902's closed medical record revealed that on [DATE] at 1:30 AM, Resident #902 was observed lying on a floor mat by the bed with nonskid socks on. Resident #902 was assessed by the nursing staff with no evidence of injury and placed back in bed. At 3:40 AM on [DATE], a GNA staff member alerted LPN #4 that Resident #902 had changes in his/her breathing pattern. LPN #4 assessed Resident #902 and notified RN #5 that Resident #902's eyes were observed rolled back into his/her head and Resident #902 was not breathing. LPN #4 alerted 911/EMS and applied oxygen by non-rebreather mask to Resident #902. No other life-sustaining procedures were started at this time. In an interview with LPN #4 on [DATE] at 11:30 AM, LPN4 stated that s/he was alerted by a staff member that Resident #902 was not breathing well and also had trouble finding a pulse. LPN #4 stated that s/he notified 911/EMS and the RN supervisor (RN #5). LPN #4 stated that s/he asked RN #5 what to do. LPN #4 stated that s/he and RN #5 both looked at Resident #902's medical record and could not find a completed MOLST form. LPN #4 stated s/he then asked RN #5 what should they do and RN #5 stated to wait for 911/EMS to arrive. LPN #4 then stated that s/he stayed with Resident #902 until 911/EMS arrived. LPN #4 stated that CPR was not performed on Resident #902 and that 911/EMS pronounced Resident #902 at that time. LPN #4 stated that s/he has had education in the past regarding CPR/MOLST forms and what staff should do if a resident does not have a completed MOLST form and codes. LPN #4 stated that if s/he identified a resident now without any vital signs and without a completed MOLST form, that s/he would start CPR immediately. In an interview with the former Social Work Director on [DATE] at 9:05 AM, the former Social Work Director stated that S/he first visits a newly admitted resident to complete a social history. Also, during the first interview the former Social Work Director stated that S/he speaks to the residents and or the family members about advance directives and reviews the MOLST form. The former Social Work Director stated that if a resident is admitted to the facility without a complete Maryland Order for Life Sustaining Treatment (MOLST) form the resident would be considered a full code in an emergency. The Maryland MOLST form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The nurse surveyor reviewed the former Social Work Directors' [DATE] 6 PM progress note with him/her. The former Social Work Director was asked why there was nothing documented about a set of advanced directives or a MOLST status in the [DATE] 6 PM progress note. The former Social Work Director stated that s/he could not recall why there was nothing in the [DATE] 6 pm progress note about advance directives or the resident's code status or MOLST form. A review of the facility's Social Services Policies and Procedures on [DATE] revealed a statement that indicated: In the absence of appropriate DNR identification or orders, the Facility Staff will respond to medical emergencies with CPR measures and a full code will be instituted. On [DATE], a total of 18 residents closed and active medical records were audited by the nurse surveyor. In these audits, a completed MOLST form was located. All of the MOLST forms clearly indicated whether or not CPR should be performed if the resident was found in an emergency situation. The Director of Nursing (DON) was interviewed on [DATE]. During the interview, the DON demonstrated and provided Quality Assurance (QA) material that s/he maintained in which the entire nursing staff were educated on [DATE] on ensuring the resident had a completed MOLST form, what to do if the resident is not admitted with a completed MOLST form, and what to do if a resident codes in the facility and does not have a completed MOLST form or physician order for CPR. Also, the facility medical director had given Resident #902's primary care physician education on the timeliness of completing a resident's end of life wishes on the MOLST form and if a resident is admitted without a completed MOLST form the resident will be a full code. An Ad Hoc Quality Assurance Performance Improvement meeting was held on [DATE] regarding the contents of the plan. Data was to be reviewed monthly in QAPI for 3 months. Based on the above actions taken by the facility and verified by the nurse surveyor on site, it was determined that the facility's deficient practice was past noncompliance with a compliance date of [DATE].

Based on reviews of the facility investigation and all pertinent administrative documents, a closed clinical record, and staff interview, it was determined that the facility failed to ensure that a resident remained free of abuse. This was true for 1 (Residents #901) of 11 facility reported incidents reviewed during an annual recertification survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facilitie's plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 09/10/20. The findings include: The facility's investigation related to the facility reported the incident MD00157948 in which GNA2 was witnessed kicking Resident #901 on the right lower leg on 09/04/2020. This incident was reviewed by the survey team on 01/21/2025 at 1 PM. In the investigation, the facility substantiated through witnesses that GNA2 kicked Resident #901 on the right lower leg and created a skin tear. Resident #901 was attempting to remove food and meal trays from the food cart located at the third-floor nurses' station. The facility suspended GNA2 immediately upon report of the incident and began the investigation that substantiated the allegation. GNA2 was terminated by the facility on 09/04/2020. A review of LPN5's witness statement revealed that staff were wheeling residents to their rooms for the dinner meal. LPN5 witnessed GNA2 speak to Resident #901 and told her/him that S/he had already eaten his/her meal and to go back to his/her room. Resident #901 moved forward towards GNA2. That is when GNA2 became verbally aggressive and stated, I told you to move you already ate. Resident #901 then told GNA2 to leave her/him alone. GNA2 was then holding Resident #901's wheelchair handles trying to move Resident #901 backwards and kicked Resident #901 and attempted to move Resident #901. Resident #901 screamed out you kicked me, get away from me now and leave me alone. Resident #901 wheeled him/herself down the hall. LPN5 indicated S/he followed Resident #901 and when S/he approached LPN5 witnessed Resident #901 crying and observed the skin tear to the right lower leg. LPN5 indicated that S/he informed the supervisor of the incident. GNA2 was asked to leave the facility and later terminated. During an interview that took place with the Director of Nurses (DON) on 01/24/25 at 4:35 PM, the DON stated that all staff received abuse education, other residents were interviewed, and that this abuse incident was reviewed during the October 2020 QAPI meeting.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents were free of physical restraints for one of 22 sampled residents (Resident (R) 44). R44 was observed in a geriatric chair and a wheelchair with an added lap tray which prevented R44 from standing up for staff convenience. This failure placed R44 at risk for increased anxiety, agitation, and a diminished quality of life. Findings include: Review of the facility's policy titled, Restraint Policy, revised May 2023 revealed Residents have the right to be free from a restraint of any kind and the right to function at their highest level in the least restrictive environment possible. Restraints will not be used unless the facility's interdisciplinary team has completed an assessment and evaluation to identify causative medical or environmental factors and has considered less restrictive alternatives, except in the case of an emergency . the use of restraints is a measure of last resort to protect the safety of the resident or others and must not extend beyond the immediate episode. Physical restraints will never to be used as a disciplinary action or for staff convenience. Medical symptoms that warrant the use of restraints will be documented in the resident's medical record, ongoing assessments, and care plan. The physician's order for restraints should reflect the presence of a qualifying medical symptom. The facility will engage in a systematic and gradual process toward reduction of restraint use. Restraints must be reviewed at least monthly to evaluate necessity and appropriateness. Falls do not constitute self-injurious behavior or a medical condition that warrants the use of physical restraint. ln the past, some types of restraints were used to prevent falls. However, the risks for serious injury related to restraints and the lack of supporting evidence for restraint efficacy in fall prevention, have led to the eradication of that practice. 'Convenience: Any action taken by the facility to control residents' behavior or maintain patients/residents with a lesser amount of effort by the facility and not the resident's best interest.' 'Freedom of Movement': Any change in place or position for the body or any part of the body that the person is physically able to control.' .'Removes Easily': The manual method, device, material, or equipment can be removed intentionally by the resident in the same manner it was applied by the staff considering the resident's physical condition and ability to accomplish objective (i.e.) transfer to a chair, gets to the bathroom in time). Complete Restraint Assessment, if appropriate, then obtain order for: type of restraint, duration (time frame) to be utilized, medical diagnosis or symptom necessitating restraint use, parameters for use (including release schedule), frequency of checking, removal schedule .Documented therapy evaluation. The interdisciplinary team meets as soon as possible to review the assessment and to consider if alternatives and interventions have been selected and implemented for how each resident can attain the highest level of functioning with the least restrictive measures. Review each resident currently using a restraint device, at least monthly and for any change of condition. Attempt gradual reduction of restraint use by implementing interventions which may serve as enablers and reminders. Reduction attempts should be documented, including the resident response to the interventions. The plan of care should be updated at least quarterly and with any significant change, including the medical symptoms which continue to warrant the need for a restraint. Review of R44's undated Face Sheet, located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. Review R44's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/26/24 and located under the resident's EMR under the Resident Assessment Instrument (RAI) tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15which indicated the resident was cognitively intact. The MDS identified R44's utilized assistive devices of a wheelchair and a walker. The MDS also indicated the resident had a history of falls. R44 required partial or moderate assistance with upper/lower body dressing, maximum assistance with putting on/taking off footwear; sit to stand needs supervision or touching assistance, speech therapy/occupational therapy/physical therapy was administered 6 days week. Review of R44's Care Plan, revised 01/14/25 and located in the resident's EMR under the RAI tab revealed no problem, goal, or interventions for the use of the geriatric chair with a lap tray which prevented her from rising. and the lap tray over her wheelchair. Review of R44's EMR revealed no documented evidence the facility assessed R44 for the use of a geriatric chair or for the use of a lap tray. assessments for the use of the geriatric chair or a lap tray on her wheelchair. Observation on 01/20/25 at 10:12 AM revealed R44 was seated in a geriatric chair near the nurses' station. R44 attempted to get out of the geriatric chair and staff immediately told her to sit back down. Observation on 01/21/25 at 3:18 PM revealed R44 was assisted with two staff people walking her down the hallway, then she was returned to sit in the geriatric chair. The staff reclined the resident back and placed an over the bed table over her lap. Observation on 01/20/25 at 3:31 PM of R44 revealed she was seated in a geriatric chair by the nurse's station. She had an overbed table positioned over her lap and the geriatric chair was in a reclined position. She tried to get out of the geriatric chair by trying to sit up and swing her legs over the side of the chair, staff would place her legs back in the chair and gently have her sit back in the chair. Observation on 01/21/25 12:30 PM of R44 revealed she was seated in the geriatric chair with an overbed table over the top. The head of the chair was up, and she was eating her lunch. Observation on 01/21/25 at 3:00 PM revealed R44 was seated in a wheelchair with a black padded tray over the front of the wheelchair. She appeared agitated and was trying to move the tray off. Staff were intervening to keep the tray down, so she was unable to get out of the wheelchair. There were no wheelchair pedals on, and her feet were dangling. During an interview at the time of the observation, Licensed Practical Nurses (LPN) 1 and LPN2 stated they had not noticed she did not have pedals on the wheelchair. They agreed her feet were just dangling down. LPN2said if the chair was lower, she could put her feet on the floor. They agreed R44 was at risk for falls and that is why she is kept in the geriatric chair or the wheelchair with a lap tray. Interview on 01/23/25 at 11:55 AM with Registered (RN) 1 and RN2 revealed RN1 completed the MDS assessments for long-term care residents. RN1 had not completed an assessment or care plan for R44 as she had received skilled services. RN2 stated she completed the skilled services residents MDS assessments and care plans. They agreed the care plan had not been revised for R44 for the use of restrictive devices. They had not been aware she had been placed in a geriatric chair and wheelchair with a lap tray. Interview on 01/23/25 at 12:36 PM with the DON and Administrator revealed they had not considered the geriatric chair with overbed table or the wheelchair with the lap tray as restraints. They agreed there had been no assessment or care planning completed to ensure safety with the use of those devices. Observation and interview on 01/23/25 at 3:00 PM revealed R44 was seated in a wheelchair with a lap tray. Her feet did not touch the floor, and she did not have any foot pedals. She was eating a cookie and had a drink on the tray. When asked why she wanted to get out of the chair to walk, R44 stated she had things to do at her house. When asked how she felt about the lap tray, she told me she felt nervous and anxious when she was not able to stand up and walk where she wanted to go. She was able to lift the lap tray up after numerous requests. Interview on 01/23/25 at 3:30 PM with RN3 revealed most of the time R44 would not stay in bed at night so she would be brought out in the geriatric chair to the nurses' station. She would then sleep in the geriatric chair. RN3 stated when R44 was in the geriatric chair, she was leaned back in a full reclined position with an overbed table over the top. RN3 also stated R44 was unable to get out of the geriatric chair and she would try to swing her legs over the side at times trying to get out of the chair. Continued interview revealed there were times when staff did not even try to have R44 sleep in her bed, and she was just put into the geriatric chair and left by the nurses' station. RN3 agreed when the geriatric chair was in the reclined position, she was unable to sit up or get out of the geriatric chair.

Based on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to implement the facility's existing abuse policy and procedures when an allegation of sexual abuse was reported by 2 staff members. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey. The findings include: Review of anonymous complaint MD00194310 on 01/21/2025 at 1 PM, revealed an allegation that Resident #911 was observed sexually assaulting Resident #911's on or around July 12, 2023. The anonymous complaint also listed allegations that included: the facility administration requiring the licensed nurse to take back their nursing documentation about the incident and the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. In an interview with the facility Director of Social Work on 01/21/25 at 3:55 PM, the Director of Social Work was asked if there ever was an allegation of sexual abuse regarding Resident #913. The Director of Social Work stated yes. The Director of Social Work then stated that a GNA reported an allegation of sexual abuse regarding Resident's #913 and #911. The Director of Social Work reported that the GNA #1 stated that she/he observed Resident #913 with his hands inside Resident #911's brief touching Resident #911's genitals. The Social Work Director stated that she/he had not heard of this occurring in the past. The Director of Social Work stated she/he informed the facility Administrator and the Director of Nurses right away on the day the allegation was reported to him/her. The Director of Social Work stated that he/she and the other facility Social Worker initiated an investigation into the allegation of sexual abuse but could not recall the exact day of the allegation. In an interview with the facility Administrator on 01/21/25 at 4:35 PM, the nurse surveyor requested the facility investigative documents into the staff witnessed allegation of sexual abuse that allegedly occurred between Residents #911 and #913 on or around July 12, 2023. In an interview with the facility Administrator, DON, Director of Social Work, and the Corporate Nurse on 01/22/2025 at 10:45 AM, the facility Administrator stated a staff nurse documented in Resident #913's medical record an incident between Residents #913 and #911 which occurred on 06/30/23. The time of the note was 3:43 PM. The medical record indicated that the 06/30/23, 3:43 PM nursing progress note was changed to read Invalid. The facility Administrator stated that only the staff nurse that wrote the progress note can change the progress note to read as Invalid. The facility Administrator stated that there were no administrative documents or investigative records regarding the alleged resident sexual abuse between Resident's #911 and #913 from 06/30/23. The facility Administrator also stated that there were no staff or other resident witness statements. The local police and the State Survey Agency were not notified either. The facility Administrator and DON stated that the staff were aware that Resident #913's had a history of intrusive behaviors while residing in the facility. In an interview with LPN #3 on 01/22/25 at 2:52 PM, LPN #3 stated that S/he was the nurse who reported the allegation of resident-to-resident sexual abuse to the nursing supervisor (RN #4) on 06/30/23. LPN #3 stated that S/he documented the incident in Resident #913's, the alleged perpetrator's medical record. LPN #3 stated that S/he was not aware of how the 06/30/23, 3:43 PM progress note was labeled Invalid. LPN #3 stated that on 06/30/23 S/he was informed by GNA #1 that S/he witnessed sexual abuse between Residents #911 and #913 on 06/30/23. LPN #3 stated that GNA #1 was a new GNA and was observed in a frantic state and could hardly inform her/him of the S/he witnessed. LPN #3 stated that after being informed by GNA #1, LPN #3 went immediately to Resident #911's room and separated Resident #911 and #913. LPN #3 also stated that S/he was not asked to formally write a witness statement or was interviewed by any administrative staff regarding the 06/30/23 alleged resident to resident sexual abuse. A review of the facility abuse, neglect, exploitation, or mistreatment policy on 01/22/25 revealed that: 1) the facility's leadership ensures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, 2) the facility's leadership shall report immediately, but not later than 2 hours, after the allegation received of suspected abuse to the State Survey Agency, 3) the facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse and will implement immediate action to safeguard resident, and 4) the facility's leadership will provide notification to the proper authorities.

Based on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to report an allegation of resident to resident sexual abuse to the State Survey Agency. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey. The findings include: Review of anonymous complaint MD00194310 on 01/21/2025 at 1 PM, revealed an allegation that Resident #913 was observed sexually assaulting Resident #911's on or around July 12, 2023. The anonymous complaint also listed allegations that included: the facility administration requiring the licensed nurse to take back their nursing documentation about the incident and the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. In an interview with the facility Director of Social Work on 01/21/25 at 3:55 PM, the Director of Social Work was asked if there ever was an allegation of sexual abuse regarding Resident #913. The Director of Social Work stated yes. The Director of Social Work then stated that a GNA reported an allegation of sexual abuse regarding Resident's #913 and #911. The Director of Social Work reported that the GNA #1 stated that she/he observed Resident #913 with his/her hands inside Resident #911's brief touching Resident #911's genitals. The Social Work Director stated that she/he had not heard of this occurring in the past. The Director of Social Work stated she/he informed the facility Administrator and the Director of Nurses right away on the day the allegation was reported to him/her. The Director of Social Work stated that he/she and the other facility Social Worker initiated an investigation into the allegation of sexual abuse but could not recall the exact day of the allegation. In an interview with the facility Administrator on 01/21/25 at 4:35 PM, the nurse surveyor requested the facility investigative documents into the staff witnessed allegation of sexual abuse that allegedly occurred between Residents #911 and #913 on or around July 12, 2023. In an interview with the facility Administrator, DON, Director of Social Work, and the Corporate Nurse on 01/22/2025 at10:45 AM, the facility Administrator stated a staff nurse documented in Resident #913's medical record an incident between Residents #913 and #911 which occurred on 06/30/23. The time of the note was 3:43 PM. The nursing progress noted the 06/30/23 was Invalid. The facility Administrator stated that the nurse that wrote the progress note can indicate that the progress note is Invalid. The facility Administrator stated that there were no administrative documents or investigative records regarding the alleged resident to resident sexual abuse from 06/30/23. There were no staff or resident witness statements. The local police and the State Survey Agency were not notified either. The facility Administrator and DON stated that the staff were aware of Resident #913's intrusive behaviors through the facility. In an interview with LPN #3 on 01/22/25 at 2:52 PM, LPN #3 stated that s/he was the nurse who reported the allegation of resident-to-resident sexual abuse to the facility administrative staff on 06/30/23. LPN #3 stated that s/he documented the incident in Resident #913's, alleged perpetrator's, medical record. LPN #3 stated that s/he was not aware of how the 06/30/23, 3:43 PM progress note was labeled Invalid. LPN #3 stated s/he was informed by GNA #1 of the alleged sexual abuse between Residents #911 and #913 on 06/30/23. LPN #3 stated that GNA #1 was a new GNA and was observed in a frantic state and could hardly inform her/him of the witnessed incident. LPN #3 stated that after being informed by GNA #1, LPN #3 went immediately to Resident #911's room and separated Resident #911 and #913. LPN #3 also stated that s/he was not asked to formally write a witness statement or was interviewed by any administrative staff regarding the 06/30/23 alleged resident to resident sexual abuse. A review of the facility abuse, neglect, exploitation, or mistreatment policy on 01/22/25 revealed that: 1) the facility's leadership ensures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, 2) the facility's leadership shall report immediately, but not later than 2 hours, after the allegation received of suspected abuse to the State Survey Agency, 3) the facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse and will implement immediate action to safeguard resident, and 4) the facility's leadership will provide notification to the proper authorities.

Based on observation, interview, record review, and policy review, the facility failed to revise residents care plan to include the use of a geriatric chair and lap trays for one of 22 sampled residents (Resident (R) 44). This failure placed the resident at risk for unmet care needs, safety risks, and increased anxiety related to devices that were considered restraints. Findings include: Review of the facility's policy titled, Care Plan Process, Person Centered Care, dated 05/05/23 revealed The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home. The Interdisciplinary Team (IDT) will review effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. Review of R44's undated Face Sheet, located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. Review R44's admission Minimum Data Set (MDS,) with an assessment reference date (ARD) of 11/26/24 and located under the Resident Assessment Instrument (RAI) tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Review of R44's care plan located under the RAI tab last revised on 01/14/25 revealed no problem, goal, or interventions for the use of the geriatric chair which prevented her from rising and the lap tray over her wheelchair. The use of a geriatric chair nor the use of a lap tray was identified in any area of the resident's care plan. Observation on 01/20/25 at 3:31 PM of R44 revealed she was seated in a geriatric chair by the nurse's station. She had an overbed table positioned over her lap and the geriatric chair was in a reclined position. She tried to get out of the geriatric chair by trying to sit up and swing her legs over the side of the chair, staff would place her legs back in the chair and gently have her sit back in the chair. Observation on 01/21/25 at 3:00 PM revealed R44 was seated in a wheelchair with a black padded tray over the front of the wheelchair. She appeared agitated and was trying to move the tray off. Staff were intervening to keep the tray down, so she was unable to get out of the wheelchair. During an interview on 01/21/25 at 3:00 PM, Licensed Practical Nurse (LPN) 1 and LPN2 stated they had not noticed she did not have pedals. They agreed her feet were just dangling down. They agreed R44 was at risk for falls and that is why she is kept in the geriatric chair or the wheelchair with a lap tray. During an interview on 01/23/25 at 11:55 AM, Registered Nurse (RN) 1 and RN2 stated they were MDS nurses. RN1 stated she had not revised R44's care plan for the use of restrictive devices and neither were aware R44 had been placed in a geriatric chair and used a lap tray when in a wheelchair. Both RN1 and RN2 verified the use of a geriatric chair and/or the use of lap trays were not part of R44's plan of care. RN1 and RN2 confirmed the resident was placed in a geriatric chair on 11/23/24 after a fall. Interview on 01/23/25 at 12:36 PM with the DON and Administrator revealed they had not considered the geriatric chair with overbed table and a wheelchair with the lap tray as restraints. They agreed there had been no assessment or care planning completed to ensure safety with the use of those devices.

Based on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to investigate an allegation of resident to resident sexual abuse when it was reported by staff members. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey. The findings include: Review of anonymous complaint MD00194310 on 01/21/2025 at 1 PM, revealed an allegation that Resident #913 was observed sexually assaulting Resident #911's on or around July 12, 2023. The anonymous complaint also listed allegations that included: the facility administration requiring the licensed nurse to take back their nursing documentation about the incident and the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. In an interview with the facility Director of Social Work on 01/21/25 at 3:55 PM, the Director of Social Work was asked if there ever was an allegation of sexual abuse regarding Resident #913. The Director of Social Work stated yes. The Director of Social Work then stated that a GNA reported an allegation of sexual abuse regarding Resident's #913 and #911. The Director of Social Work reported that the GNA #1 stated that she/he observed Resident #913 with his/her hands inside Resident #911's brief touching Resident #911's Genitals. The Social Work Director stated that she/he had not heard of this occurring in the past. The Director of Social Work stated she/he informed the facility Administrator and the Director of Nurses right away on the day the allegation was reported to him/her. The Director of Social Work stated that he/she and the other facility Social Worker initiated an investigation into the allegation of sexual abuse but could not recall the exact day of the allegation. In an interview with the facility Administrator on 01/21/25 at 4:35 PM, the nurse surveyor requested the facility investigative documents into the staff witnessed allegation of sexual abuse that allegedly occurred between Residents #911 and #913 on or around July 12, 2023. In an interview with the facility Administrator, DON, Director of Social Work, and the Corporate Nurse on 01/22/2025 at10:45 AM, the facility Administrator stated a staff nurse documented in Resident #913's medical record an incident between Residents #913 and #911 which occurred on 06/30/23. The time of the note was 3:43 PM. The nursing progress noted the 06/30/23 was Invalid. The facility Administrator stated that the nurse that wrote the progress note can indicate that the progress note is Invalid. The facility Administrator stated that there are no administrative documents or investigative records regarding the alleged resident to resident sexual abuse from 06/30/23. There were no staff or resident witness statements. The local police and the State Survey Agency were not notified either. The facility Administrator and DON stated that the staff were aware of Resident #913's intrusive behaviors through the facility. In an interview with LPN #3 on 01/22/25 at 2:52 PM, LPN #3 stated that s/he was the nurse who reported the allegation of resident-to-resident sexual abuse to the facility administrative staff on 06/30/23. LPN #3 stated that s/he documented the incident in Resident #913's, alleged perpetrator's, medical record. LPN #3 stated that s/he is not aware of how the 06/30/23, 3:43 PM progress note was labeled Invalid. LPN #3 stated s/he was informed by GNA #1 of the alleged sexual abuse between Residents #911 and #913 on 06/30/23. LPN #3 stated that GNA #1 was a new GNA and was observed in a frantic state and could hardly inform her/him of the witnessed incident. LPN #3 stated that after being informed by GNA #1, LPN #3 went immediately to Resident #911's room and separated Resident #911 and #913. LPN #3 also stated that s/he was not asked to formally write a witness statement or was interviewed by any administrative staff regarding the 06/30/23 alleged resident to resident sexual abuse. A review of the facility abuse, neglect, exploitation, or mistreatment policy on 01/22/25 revealed that: 1) the facility's leadership ensures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, 2) the facility's leadership shall report immediately, but not later than 2 hours, after the allegation received of suspected abuse to the State Survey Agency, 3) the facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse and will implement immediate action to safeguard resident, and 4) the facility's leadership will provide notification to the proper authorities.

Based on observation and staff interview, it was determined that the facility staff failed to properly store medications. This was observed twice on the 2 south nursing unit during the infection control survey. The findings include: During an observation of 2 south nursing unit on 11/23/20 at 1 PM, the surveyor observed a medication cart that appeared to be unlocked an unattended. The surveyor asked the facility infection control practitioner (ICP) if the medication cart was unlocked. The facility ICP confirmed the medication cart was unlocked and then proceeded to lock it. Further observations on the 2 south nursing unit revealed an administrative room that housed vitamins and Tylenol on a book shelf. The administrative room was unlocked and the medications were not secure in a locked cabinet. The facility ICP closed and locked the door to the administrative room.

Based on review of a closed medical record and hospital record, as well as staff interview, it was determined the facility staff failed to take steps to treat a resident's change in condition in the presence of an elevated white count. This occurred for 1 of 7 residents reviewed during a complaint survey. The findings include: Resident #2 is an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 is cognitively impaired and required extensive assistance from the facility staff for all aspects of her care. Resident #2 was admitted to the facility with a Foley catheter in place. Review of resident #2's [MEDICAL CONDITION] care plan, on 10/25/2010, revealed nursing interventions to treat resident #2's inability to urinate which included obtaining a urology consult, monitoring resident #2 for an increase in lower abdominal discomfort, perform Foley catheter care every shift, and monitor resident #2's intake and output. Resident #2 was admitted to the facility rehabilitation unit upon admission to the facility. On 07/27/2010, resident #2 had a urology consult and the Foley catheter was discontinued. Resident #2 was also placed on the antibiotic, [MEDICATION NAME] 50 mg orally every evening, to help prevent a urinary tract infection. The nursing staff was instructed to monitor resident #2's urine output by straight catheterization every six hours. On 08/01/2010, a physician's orders [REDACTED]. On 08/08/2010 at 6:35 pm, the nursing staff assessed resident #2 and found her to be having lower abdominal pain and had voided 100 cc of dark, thick, foul smelling urine with sediment. The nursing staff notified resident #2's physician and then obtained urine for analysis and culture and sensitivity, by straight catheterization, at 9:30 pm. On 08/10/2010, resident #2 was placed on the antibiotic, [MEDICATION NAME] 500 mg orally every six hours times 7 days for the indication of a urinary tract infection. On 08/12/2010, resident #2 was discharged from rehabilitation and moved to the facility dementia unit. On 08/14/2010 and 08/15/2010 the nursing staff documented resident #2 was now voiding light brown to amber colored urine with a strong odor. Resident #2's physician was notified regarding the nursing observations on 08/14/2010. On 08/16/2010 at 11 am, the nursing staff observed that resident #2 was sitting in her wheelchair and non-mobile on the unit.Resident #2 was staring and not as responsive to questions, and was leaning to the right side of the wheelchair and dragging her foot. The nursing staff obtained a set of vital signs on resident #2 at this time and these were documented as BP 90/50, heart rate 136, respirations 18, and a temperature of 97.0 Fahrenheit. Resident #2's physician was notified about the change in condition and at that time the physician discontinued and changed resident #2's cardiac and antihypertensive medications, and also instructed the nursing staff to obtain a blood sample for a stat CBC (Complete Blood Count) and a BMP (Basic Metabolic Profile). At 10 pm on 08/16/2010, the nursing staff had received resident #2's stat lab results and documented that resident #2's physician was faxed the results, and was also notified by telephone of the results. Resident #2's CBC results indicated that resident #2 had a WBC count of 19.1 with a bandemia of 51 % (normal 5- 11). At 12:30 am on 08/17/2010, the nursing staff documented a set of vital signs as being BP 122/62, heart rate 78, respirations 20, and temperature 101.6 Fahrenheit. Resident #2 was administered 650 mg of Tylenol for the temperature. There was no documentation that resident #2's physician was made aware of this change in condition. The nursing staff documented that the night shift supervisor was made aware of resident #2's temperature of 101.6 Fahrenheit. At 7:00 am on 08/17/2010, the nursing staff documented a set of vital signs on resident #2 to be BP 100/60, pulse 120, respirations 20, and temperature 101.4. The nursing staff documented that resident #2 was moaning and showed facial grimacing when her abdomen was touched. The nursing staff administered 650 mg of Tylenol to resident #2 and called her physician. At 08:15 am on 08/17/2010, the nursing staff documented that resident #2's abdomen was distended. Resident #2's physician instructed the nursing staff to send resident #2 to the emergency room for evaluation. Review of resident #2's 08/17/2010 hospital record on 11/17/2010 revealed that resident #2 was admitted to the emergency room , and a Foley catheter was placed in resident #2's bladder. The hospital nursing staff documented a total of 1900 ml's of amber milky sediment output of urine. In an interview with resident #2's physician on 11/12/2010 at 2:07 pm, resident #2's physician stated that he did not recall the 08/16/2010 10 pm phone call from the nurse with the lab results nor did he see the faxed lab results for resident #2. Resident #2's physician stated that resident #2 should have been sent to the hospital with a 51% bandemia by itself. Resident #2's physician stated he agreed there was delay in treating resident #2. The facility staff failed to take steps and treat a resident's change in condition in the presence of an elevated white count which lead to resident #2 becoming septic, with an extraperitoneal rupture of the bladder.