Every finding on record at Autumn Lake Healthcare at Ruxton

Based on review of complaints 3135540 and 3032214, interviews, observations, and documentation review, it was determined that the facility failed to have an effective pest control program related to issues with mice. This was evident on all nursing units, in resident rooms, resident care areas, staff areas, and throughout the facility.The findings include: On 8/20/26 at 8:01 AM a review of complaints 3135540 and 3032214 was conducted and it was alleged that the facility was infested with mice. The complaint alleged that mice were climbing up the privacy curtains, on top of the resident's food trays, on the beds, and all over the facility. On 8/20/26 at 8:03 AM an interview was conducted with Resident #11 who stated that he/she was moved to the current room because they were doing construction in the old room. Resident #11 stated there were mice in the old room.On 8/20/26 at 8:05 AM Geriatric Nursing Assistant (GNA) #4 stated, There are mice running all over the place. It has gotten a little better with the construction because they are filling the holes in.On 8/20/26 at 8:06 AM GNA #5 stated, There are a whole bunch of field mice. There are no bed bugs and no insects, but the mice are all over the place.On 8/20/26 at 8:07 AM Resident #7 stated, There are mice. I have seen them now for the past couple of months. They were crawling up the end of my privacy curtain.On 8/20/26 at 8:08 AM Resident #8 stated, There are mice. About a week ago I saw them every day for a couple of days running on my floor.On 8/20/26 at 8:09 AM Resident #9 stated, The last time I saw a mouse was last night out in the hall and it came across my room on the floor and then it went out and did it again.On 8/20/26 at 8:10 AM Resident #10 stated, I see mice every day.On 8/20/26 at 8:11 AM Resident #3 stated, I see mice all the time ever since I have been here and that has been since June 2024. The last time I saw a mouse was yesterday in my room. There were 3 mice.On 8/20/26 at 10:42 AM the Director of Maintenance was interviewed and stated, I have been here 2 years and the problem is ongoing. Pest control is here every week. They are baiting and telling me if they find holes that I should seal everything up. They put bait everywhere. Outside there are new bait boxes. In the utility rooms, drop ceilings, and we have been sealing all entry points. It has been going on for a while now, at least 4 or 5 months.On 8/20/26 at 10:46 AM the Director of Nursing (DON) was interviewed and stated, I know we have complaints about the mice in the past. Me personally, I have not seen any mice, but we have had complaints in the past about mice. We have an exterminator that comes in. We have received complaints from the residents about the mice.On 8/20/26 at 1:30 PM Licensed Practical Nurse (LPN) #14 stated that he saw mice running from room to room.On 8/20/26 at 1:34 PM Resident #14 stated, The exterminator put a trap in my room. I last saw a mouse a couple of days ago. We need a lot of traps in here.On 8/20/26 at 1:35 PM Resident #15 stated, There have been mice in my room, and it bothers me.On 8/20/26 at 1:43 PM Resident #16 stated, There have been mice in my room on different occasions. It bothers me because it is dirty.On 8/20/26 at 1:44 PM Resident #17 stated, I have caught 18 mice in here on traps in my room. My son brought me 10 traps. They come out around 5 in the morning.On 8/20/26 at 1:47 PM Housekeeper #15 stated, I see mice in the basement.On 8/20/26 at 1:48 PM Resident #18 stated, I just saw a mouse in here a few minutes ago. It was going down the hall and turned and came in here, went to the corner and then scurried under the bathroom door. It is very disturbing, nasty and dirty. This place is unsanitary.On 8/20/26 at 1:21 PM observation was made of both doors on the ground level that led to the outside by the kitchen and maintenance room. The doors were propped open with a chunk of wood. There were no staff members in the area. A gap was observed under the doors that led to the outside where sunlight was shining through. A tour of the kitchen revealed metal box mouse traps around the perimeter of the kitchen.On 8/20/26 at 2:10 PM the Nursing Home Administrator (NHA) was asked by the surveyor, what can you tell me about your mice problem. The NHA stated, what mice problem. I have pest control coming in every week and they treat. I have not really seen any mice.On 8/21/26 at 8:10 AM observation was made of a mouse dropping in the bathroom of the conference room where the surveyors were located.On 8/21/26 at 8:20 PM a review of the pest control company service reports from 4/7/26 to 8/13/26 was conducted. The pest control company documented they have been coming to the facility weekly regarding the mice. It was documented that rooms on all nursing units have been treated including the air conditioner units, openings around pipes, and ceiling tiles. There was documentation that the lobby, kitchen, service hallway, entry areas and each nursing station in the facility was treated for mice activity. There was exterior treatment including courtyards.On 6/4/26 the pest control report documented, Treated for mice in the intake classroom on the service level floor. Inspected and treated the intake room and main dining room for mouse activity. Evidence of activity was observed in the classroom closet. A large void was noted in the drop ceiling and is recommended to be repaired or replaced. Missing ceiling tiles were also observed and should be replaced to help eliminate potential rodent entry points.On 6/25/26 the pest control company documented that room [ROOM NUMBER] was treated for mice activity. Previous inspection reports dated 4/15/26 and 4/22/26 documented the room was treated for mice activity and that all voids in the room should be sealed. The 6/25/26 report documented, treated room [ROOM NUMBER] for mice activity. Recommend sealing void in room [ROOM NUMBER].On 7/9/26 the pest control company documented they went to room [ROOM NUMBER] for mice activity and that they observed a void in the bathroom and recommended sealing. It was noted on the 4/7/26 pest control report that it recommended maintenance to seal all voids in all rooms.On 7/22/26 the pest control company treated for mice activity. They found and removed a dead mouse in tin can near emergency exit doors and recommended reinforcing door to eliminate gap under the door for mice to enter the facility. They observed voids in the air conditioner unit in room [ROOM NUMBER]. Again, they recommended all holes to be sealed off. They observed missing cove base behind the beds in room [ROOM NUMBER] and recommended better cleaning procedures to remove attractions for rodents.On 7/30/26 the pest control company documented receiving several reports of mice sightings throughout the building. They recommended voids to be sealed up with chalk and or steel wool to prevent travel for rodents and to follow up in resident rooms.On 8/6/26 the pest control company documented receiving verbal reports about mice throughout the building. They recommended that the exterior doors outside of the kitchen area remain closed when not in use.On 8/10/26 the pest control company documented, a structural opening was identified in the Arcadia (dementia unit) hallway that may provide a potential pest entry or harborage point. Recommend sealing the opening found in the Arcadia hallway to help prevent pest entry and eliminate potential harborage.On 8/13/26 the pest control company documented, verbal reports of mice activity in lounge on first floor, kitchen area, Arcadia unit on second floor, and in room [ROOM NUMBER]. Verbal report of roach activity in social services office. Verbal report of rodent activity in the past in dining hall on first floor. Recommend keeping the emergency exit doors closed leading to kitchen area when not in use.On 8/21/26 at 1:46 PM the surveyor observed the hallway by the kitchen and the emergency exit doors. There was a pallet filled with an item that had been brought in to the hallway. When the surveyor entered the hallway there were 2 employees picking up the pallet with a machine and taking it down the other hallway while the doors to the outside remained wide open.On 8/24/26 at 8:39 AM observation was made in the basement classroom of a ceiling tile missing approximately one fourth of the ceiling tile which created a large opening. In the classroom a ceiling tile had a gap because it did not fit in the grid and in the room was a square hole in a ceiling tile.On 8/24/26 at 10:49 AM observation was made in the basement by the kitchen of the emergency exit doors propped open with a chunk of wood and the kitchen door was not shut all the way. There were no staff members in the area.On 8/24/26 at 11:02 AM observation was made on the Acadia unit (dementia) as you walk through the entrance doors. The wall on the right side had an approximate 2-to-3-foot, inch wide gash in the wall that was open to the wood studding. There were mice droppings on the floor next to the gap in the wall. This was noted on the pest control report dated 8/10/26. The area had not been fixed per the recommendation.On 8/24/26 at 11:36 AM the Maintenance Director was asked about the recommendation for the Acadia Unit, and he stated that it had been taken care of. At that time the surveyor showed him the picture of the wall in the unit with the mice droppings on the floor next to the opening.On 8/24/26 at 11:44 AM the surveyor showed the NHA the pictures of the doors open to the exterior by the kitchen, the holes in the walls and ceilings, and expressed concern that the items had not been fixed as recommended by the pest control company. The NHA stated, I don't know how much more we can do. The problem is the technician will come and look at the pest control books and there is nothing written in there. I had a resident council meeting and told the residents they have to tell the staff.

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure parameters for administering blood pressure medications to a resident. This was evident for 1 (Resident #6) of 3 residents reviewed for unnecessary medications during a complaint survey.The findings include: Review of Complaint 3065123 was conducted on 8/20/26 regarding care provided to Resident #6. Review of Resident #6's medical record on 8/20/26 revealed the Resident was admitted to the facility in March 2026 with a diagnosis to include hypertension (high blood pressure). Review of Resident #6's May, June, July and August 2026 Medication Administration Record revealed the Resident was administered the following blood pressure medications when the Resident's blood pressure did not meet the physician ordered blood pressure parameters for administration: 1)Amlodipine 5 mg one time a day for hypertension, hold for systolic blood pressure less than 110. a)5/28/26 at 9:00 AM for blood pressure 109/63 b)7/10/26 at 9:00 AM for blood pressure 103/67 c)8/17/26 at 9:00 AM for blood pressure 106/60 2)Atenolol 100 mg one time a day for hypertension, hold for systolic blood pressure less than 110. a)5/28/26 at 9:00 AM for blood pressure 109/63 b)7/10/26 at 9:00 AM for blood pressure 103/67 c)8/17/26 at 9:00 AM for blood pressure 106/60 The Surveyor reviewed Resident #6's Medication Administration Records with the Director of Nursing on 8/24/26 at 7:30 AM. Interview with the Director of Nursing on 8/24/26 at 9:20 AM confirmed Resident #6 was administered blood pressure medications on 5/28, 7/10 and 8/17/26 when his/her blood pressure did not meet the physician ordered blood pressure parameters.

Based on observations and interviews it was determined that the facility staff failed to ensure the clean linen was in a clean area without dust. This was evident in 1 of 1 laundry areas observed during the complaint survey.The findings include:On 05/11/26 at 9:49 am the surveyor observed the air conditioning vent was not covering the vent opening. Further inspection of the clean linen room revealed dust particles on the wall above the table where the clean linen was folded. There were blankets, top sheets, and fitted sheets on the table. Also, the was dark-colored dust particles in the corner near an old vent that was not being used.On 05/11/26 at 9:58 am during an interview with Environmental Services Director #6 the surveyor asked how often the clean linen area was cleaned. EVS Director #6 verbalized the EVS staff are supposed to clean the area daily. They were uncertain when the area was last dusted. They try to make sure the area was cleaned, dusted, and walls wiped regularly.

Based on observations and interviews it was determined that the facility staff failed to dispose of furniture and refuse in a sealed container. This was evident in 1 of 1 refuse disposal areas observed during the complaint survey.The findings include:On 05/07/26 at 8:33 am the surveyor observed an orange dumpster with the lid and sliding side door opened with a large white garbage bag hanging over the side. The surveyor also observed other items on the ground near the dumpsters:-six plus wooden pallets-a blue mattress-large white garbage bag of waste on the grass-three boxes in front of a brown shed-eight tall wooden cabinetsOn 05/07/26 at 9:07 am the surveyor and Administrator #1 viewed the area around the dumpster. Administrator #1 reported new dumpsters were delivered the previous day and the staff were going to discard the items into the rolling dumpster.On 05/07/26 at 9:10 am during an interview with Maintenance Director #7 the surveyor asked who is responsible for ensuring the dumpsters are being used properly. Maintenance Director #7 verbalized housekeeping, culinary, and central supply staff all use the dumpsters. Maintenance is responsible for keeping the area clean. Sometimes the staff doesn't keep the area clean as they have been instructed to do so. The dumpsters are emptied on Monday, Thursday, and Saturday. They planned to discard the wardrobes in the rolling dumpster.On 05/08/26 at 8:53 am the surveyor observed an orange dumpster was almost full and the top lid was opened and the sliding side door was partially opened. The other items previously mentioned were not removed.

Based on review of an investigation and interview it was determined that the facility staff failed to complete a through investigation of an allegation of abuse. This deficient practice was evidenced in 1 (#1) of 1 resident allegation investigation reviewed during the complaint survey.The findings include:On 05/07/26 at 9:10 am a review of the facility's investigation of the allegation of abuse concerning Resident #1 revealed on 02/26/26 the resident called the police due to an allegation of abuse. Around 1:20 pm the local authorities came to the facility, and the staff became aware of the allegation. On 05/07/26 at 12:44 pm during an interview with Director of Nursing (DON) #2 the surveyor asked who interviewed the staff during the investigation. DON #2 verbalized they and the Assistant Director of Nursing obtained statements from the staff during the investigation. Resident #1 reported a male who had weapons abused them, therefore they interviewed male residents and staff that worked on the unit. They interviewed staff during the time of the alleged incident to find out if they were aware of anything. Director of Nursing #2 confirmed the surveyor was provided the entire investigation. The surveyor requested a copy of the staffing sheet of the unit when the allegation was made. On 05/08/26 at 9:39 am a review of the staffing sheet for the Unit Somerset dated 02/26/26 for shift 7:00 am - 3:00 pm revealed Geriatric Nursing Assistant (GNA) #10 and GNA #11 worked on the unit during the time of the alleged incident; there were no statements to verify they were interviewed. At 9:53 am during an interview with DON #2 the surveyor asked why there were no interviews from GNA #10 and GNA #11 included in the investigation. DON #2 was unable to inform the surveyor why there were no statements from the two GNA's.

Based on observations and interviews it was determined that the facility staff failed to ensure the laundry area maintenance was completed, this was evident in 1 of 1 laundry areas observed during the complaint survey. The findings include:On 05/08/26 at 11:39 am while in the laundry room the surveyor observed water dripping from a hose behind the first washing machine near the entry door. The surveyor asked Laundry Supervisor #8 did the maintenance department know of the leak behind the washing machine. Laundry Supervisor #8 verbalized a repair man was scheduled to make repairs.On 05/11/26 at 9:15 am during an interview with Maintenance Director #7 the surveyor asked to explain their preventative maintenance schedule. Maintenance Director #7 verbalized preventative maintenance is done once a month which entailed changing the filters, checking the power cords, ensuring the doors are latching, ensuring call bells are working, and checking the electrical outlets. They check the connections on the washers and clean the dryers. The surveyor asked how the staff communicates maintenance concerns to the maintenance department. The staff communicates to the maintenance department through word of mouth. They keep track of work orders in TELS, and the staff can use TELS to put maintenance concerns in TELS.On 05/11/26 at 9:23 am while in the laundry room with Maintenance Director # 7 the surveyor observed water dripping on the floor behind the first washing machine. Maintenance Director #7 verbalized the fitting needed to be tightened. Minor Repairs are completed in-house. If there is a maintenance issue the staff will make them aware. The surveyor asked were they made aware of the water dripping behind the washing machine. Maintenance Director #7 responded no. The surveyor walked to the folding room with Maintenance Director #7 where the clean laundry was on the table. The surveyor asked were they aware the vent was not covered. Maintenance Director #7 verbalized they knew the vent was not covered and a new vent covered was ordered. They were waiting for the new vent cover to be delivered. The surveyor asked for documentation to verify the vent cover was ordered. Maintenance Director #7 was unable to verify whether a vent cover was ordered. The surveyor observed a hole in the wall in the folding room. The surveyor asked Maintenance Director #7 were they aware the wall needed to be repaired. Maintenance Director #7 verbalized they were going to make the repair.

Based on observation and interview it was determined the facility failed to ensure food maintained appropriate temperature in accordance with professional standards for food service safety. This was evident during the surveyor's review of the kitchen task during the facility's recertification survey. The findings include:On 2/18/2026 at 2:36PM the surveyor conducted an interview of Resident #17 who reported to this surveyor that at breakfast time, their milk was cold, however it was sour and spoiled. On 2/24/2026 at 12:19PM the facility's Certified Dietary Manager (CDM) #12 provided a test tray for palatability testing to be performed by the survey team at which time the milk temperature was taken and observed to be 47.3F. On 2/24/26 at 12:30PM the surveyor conducted an observation of the facility's milk supply within the kitchen and asked CDM #12 to pull a milk carton from the facility's walk in refrigerator at which time the milk was immediately tested and found to be at 42F. At this time, the surveyor shared the concerns and conducted an interview of CDM #12 who stated to the surveyor that the temperature expectation for milk is to be between 39F and 41F. On 2/24/26 at 12:37PM the surveyor observed an open refrigerated well adjacent to the facility's steam table in which milk and other food items requiring refrigeration were being held. At this time the surveyor inquired to CDM #12 as to where the temperature monitoring was for the refrigerated well. CDM #12 observed and confirmed with the surveyor that there was no thermometer present for the monitoring of the well and after surveyor intervention, Regional Food Service Director (RFSD) #27 was observed directing CDM #12 to obtain and place a thermometer into the well. No temperature log was observed to be present for temperature monitoring of the well. The surveyor noted also that the facility's reach in refrigerator was not in working order and out of service.Reference to CMS 2567, F908.

Based on observation and interview it was determined the facility failed to: 1) Ensure professional standards for food service safety were followed. 2) Maintain a sanitary kitchen environment: Ensure thorough cleaning of kitchen, equipment, and areas where food is served and stored. Ensure surfaces used for food preparation, storage and serving were clean and in good repair. 3) Ensure the kitchen environment was pest free. 4) Ensure furniture for dining was clean and in good repair. This was evident during the surveyor's kitchen and dining tour during the facility's recertification survey.The findings include:The surveyor conducted an initial tour of the facility's kitchen on 2/18/26 beginning at 7:40AM.During the surveyor's initial tour of the facility's kitchen on 2/18/26 at 7:47AM the surveyor observed a food prep table with an unclean surface with a brown and white substance present on it with Food Services Director (FSD) #12. One metal cutting board holder rack was observed sitting on the food prep table with the unclean surface and the holder itself was observed with white and brown crusty debris present on it's surface which was holding several cutting boards. FSD #12 acknowledged the surveyor's concerns and directed a kitchen staff member to assist with cleaning of the concerns.On 2/18/26 at 7:49AM the surveyor observed the flooring surface below the two compartment sink across from a food prep table. The flooring area below the two compartment sink was observed to have an unclean appearance with darker areas of soiling and food crumbs present. FSD #12 observed the concern at this time with the surveyor and acknowledged the concern.On 2/18/26 at 7:49AM the surveyor observed the two tier food preparation table located across from the two compartment sink which was observed to have prepped pork meat on the top tier surface, and on the lower tier's surface numerous dark rod shaped pellets approximately the size of a grain of rice, scattered on the lower tier surface in addition to food debris and areas of yellow sticky liquid matter next to a bag of corn starch and next to containers which held flour, sugar, white rice, and thickener powder were observed. On 2/18/26 at 7:52AM the surveyor conducted an interview and dual observation of the concerns with FSD #12 and inquired as to if the facility kitchen had pest concerns at present. FSD #12 stated to the surveyor during the interview: We have had a problem in the building with mice in the last six months, the health department has been out several times investigating mice, we've changed exterminators in response to that but there are still some mice, we have been cleaning extra, but they haven't cleaned since the snow storm. During the dual observation with FSD #12, four out of four exterior surfaces of the containers which held food items on the lower tier were observed to be unclean with staining, food crumbs and cloudy appearing areas, and the inside of the container holding sugar was observed with a mounted scooper in which the handle and scooper was observed to have brown specks of matter present on it, and the inside of the container holding flour was observed with a mounted scooper in which the handle was observed to have a dark piece of debris present on it. On 2/18/26 at 8:00AM the flooring material leading to the walk in refrigerator was felt to be movable upon walking upon it, and upon closer observation by the surveyor, was observed to be movable.On 2/18/26 at 8:04AM the surveyor inquired as to where the designated staff area was for personal beverages etc, at which time FSD #12 stated: Unfortunately, we don't have one and showed the surveyor to the facility's reach in refrigerator which had exterior signage present on it dated December 2025 and Out of service. The interior thermometer of the reach in refrigerator was observed to be at 78F and a sign was observed for the lower shelf which was designated for staff food. During the interview FSD #12 informed the surveyor that the reach in refrigerator was also used to hold food items needed to carry out the tray line and that the current Administrator was aware that the facility bills were still being sent to the previous facility Administrator and that companies aren't coming to fix things until the bills are paid.On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. On 2/20/26 at 12:48PM the surveyor again reviewed concerns with the facility's Administrator. On 2/24/26 at 10:45AM the surveyor observed the second floor lounge area where the Resident food refrigerator was located. One wall was observed to have several areas of white spackling present with a layer of white powder observed to be present on the floor beneath the spackled areas, which was adjacent to dining tables. On 2/24/26 at 10:46AM the surveyor conducted an interview of Geriatric Nursing Assistant #28 who confirmed with the surveyor that facility Residents use the lounge and sometimes eat in the lounge. On 2/24/2026 at 10:54AM the surveyor conducted a dual observation with Unit Manager (UM) #29 at which time six out of seven dining chairs in the second floor lounge were observed with a layer of dark soiling present on the arm rests. At this time, the surveyor conducted an interview and shared concerns with UM #29, and after surveyor intervention, UM #29 stated: I'm gonna let maintenance know to come remove them, and housekeeping to clean once they are removed. During the observation, facility staff was observed assisting a Resident into the lounge area at which time UM #29 offered a different space to use.On 2/24/26 at 12:34PM the surveyor observed two out of two fan covers located within the facility's walk in refrigerator which had a dark gritty debris present on the surfaces. Similar dark gritty debris was observed present on the ceiling and along the piping in the walk in refrigerator with one area observed to have a steady dripping of clear liquid. During the observation FSD #12 observed and acknowledged the concerns.On 2/24/26 at 12:40PM the surveyor observed the tray line at which time the exterior surface of the equipment was observed to have a side panel which was grate like in appearance which was observed to be unclean with fuzzy grey colored matter present within it. At this time the surveyor shared the concern and conducted a dual observation of the concern with FSD #12 who acknowledged the concern. On 2/24/26 at 12:48PM the surveyor observed several rust colored areas present on the lower tier of the food serving steam table equipment located in the main dining area of the facility. Upon further surveyor observation of the food serving steam table equipment located in the main dining area of the facility on 2/24/26 at 12:52PM it was revealed that the food prep/tray line surface had black taping present between the metal surface of the steam table and the prep surface with food crumbs/debris present in between. At this time the surveyor conducted a dual observation of the concern with FSD #12 who after surveyor intervention, was observed removing the black taping which was observed to be holding food crumbs/matter within the surface. On 2/24/26 at 12:52PM the surveyor observed a long rectangular table present next to the food serving steam table equipment which was observed to have rough worn edges with exposed uncovered particle board type material. FSD #12 indicated to the surveyor that the table was used with regard to food service. At this time, the surveyor shared the concern with FSD #12 who acknowledged the concern. At the conclusion of the observation FSD #12 reported to the surveyor that they were going to notify maintenance staff of the walk in refrigerator fans which required cleaning.After surveyor intervention, on 2/25/26 at 8:50AM the surveyor observed that the food serving steam table equipment was clean in appearance and the table had been replaced with a table in which had a cleanable surface and the damaged table was marked with signage that read: do not use.Concerns were reviewed by the survey team at the facility's exit conference with Regional Director of Operations #18 and the facility's Director of Nursing on 2/25/26. Reference to CMS 2567, F804, F908.

Based on observation and interview it was determined the facility failed to ensure the garbage area was maintained in sanitary condition. This was evident during the surveyor's initial tour of the facility for 1 out of 1 trash area observed during the facility's recertification survey.The findings include: On 2/18/26 at 8:13AM the surveyor conducted a dual observation of the facility's trash area with Food Service Director (FSD) #12 which was located exteriorly adjacent to an entrance to the facility's kitchen at which time the following observations were made:1.) One uncovered rolling trash container was observed parked in the dumpster area with copious food trash items and food debris present which were no longer contained within trash bags which included but was not limited to food cups, open food containers, food matter, open milk containers, rice, carrots, soda bottles, juice containers, protein shake cartons etc.2.) Trash items and pieces of food were observed scattered on the ground near to the container3.) Two broken overbed tables4.) Two sitting chairs5.) Numerous wooden pallets6.) numerous trash cans with broken equipment present7.) Bed mattresses8.) Several trash cans situated on their side9.) Broken mop bucket10.) Various pieces of wet cardboard11.) Various pieces of plastic and paper trash and bags of ice melt stacked up against vents leading into the facility's electrical room.At this time the surveyor shared their concerns with FSD #12 who acknowledged and confirmed understanding of the concerns and reported to the surveyor that, at times, raccoons are present in the garbage area and discussed their concerning behavior with this surveyor. This surveyor additionally noted signs indicative of a pest issue were observed to be present within the facility's kitchen during the initial tour of the facility's kitchen prior to the trash area observation. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing (DON) who acknowledged the surveyor's concerns with each stating: Okay, thank you. On 2/19/26 at 2:57PM the surveyor again shared concerns with the facility's Administrator, DON, Corporate Nurse #6, and Regional Nurse #5. On 2/20/26 at 2:29PM the surveyor conducted an interview of the facility's Director of Maintenance #13 who confirmed that the facility at present continued to have a pest issue with mice and after surveyor intervention, reported that the facility had brought in a flat bed because they didn't have enough trash can space to dispose of everything that needed disposed of. During the interview, Director of Maintenance #13 stated that facility staff were: not breaking down trash like they are supposed to, not breaking boxes down, causing trash cans to not have enough space. At this time, the surveyor shared the concerns with them at which time they acknowledged the surveyor's concerns. After the conclusion of the interview on 2/20/26, a receipt for a 20 yard container to remove the garbage dated 2/20/26 was provided to the surveyor. On 2/25/26 all concerns were reviewed by the survey team during the facility's exit conference with Regional Director of Operations #18 and the Director of Nursing.

Based on observation and interview it was determined the facility failed to adhere to infection control practices and guidelines. This was found to be evident during observations made throughout the facility's annual Medicare/Medicaid survey. The findings include:1.) On 2/18/26 at 9:26AM the surveyor observed Resident #99 approach the floor two nutrition room door utilizing their rolling walker, and removed their hand from the walker's handle, opened the door and used their hand to scoop ice and fill a bath basin situated on their walker seat with ice. The surveyor observed their arm touching the inside surface of the ice cooler while scooping the ice, and no hand sanitization or other method of cleaning hands was observed to be performed prior to accessing the cooler. The surveyor observed Resident #99 leave the ice scoop and handle directly in the ice within the cooler. Several trash items were observed to be present on the floor surrounding the ice cooler. On 2/18/26 at 9:26AM the surveyor conducted an interview of Resident #99 who informed the surveyor: I use the ice for drinking and to keep my juice. On 2/18/26 at 9:39AM the surveyor conducted and interview and shared the concern with Licensed Practical Nurse #33 who stated: I can remove the scoop, and I'll let the ADON (Assistant Director of Nursing) know. 1b.On 2/18/26 at 9:51AM the surveyor observed Resident #97 approach the floor two nutrition room door utilizing their walker, removed their hands from their walker handles, opened the nutrition room door and was observed obtaining ice from the cooler using the scooper located within the ice and no hand sanitization or other method of cleaning hands was observed to be performed prior to accessing the cooler. The surveyor observed Resident #97 leave the ice scoop and handle directly in the ice within the cooler. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. 2) On 2/18/26 at 2:04PM the surveyor observed a mesh bag of laundry outside of Resident #10's room door, on the floor in the Resident hallway sitting up against a personal protective equipment (ppe) cart containing ppe and observed a contact precautions sign on Resident #10's room door. A floor caution sign was observed sitting on top of the mesh bag of laundry and against the ppe cart. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. 2b.) On 02/25/2026 at 7:06 AM the surveyor observed bagged laundry outside of room [ROOM NUMBER] on the floor in the Resident hallway. 2c.) On 02/25/2026 at 7:07 AM the surveyor observed bagged laundry outside of room [ROOM NUMBER] on the floor in the Resident hallway. On 2/25/26 concerns were reviewed during the facility's exit conference with the facility's Regional Director of Operations #18 and Director of Nursing. 2d.) On 02/18/2026 at 2:20PM the surveyor observed brown matter on the bed mattress of Resident #4 at which time the surveyor requested and performed a dual observation of the concern with Licensed Practical Nurse #33 who observed and acknowledged the surveyor's concern. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. On 2/25/26 concerns were reviewed during the facility's exit conference with the facility's Regional Director of Operations #18 and Director of Nursing. 3) On 2/19/26 at 10:35AM the surveyor observed a clean linen cart situated in the Resident hallway outside of room [ROOM NUMBER]. The cart was observed with a green cover in severely worn condition with areas which no longer green with exposed white thread material. A hair comb was observed sitting on top of the linen cart with strands of hair in it. Within the linen cart, two regular sized Resident personal bottles of body wash approximately 3/4 of the way full, were observed with the linen and incontinence care products. One bottle of the personal body wash was observed resting on top of linens and up against the incontinence care products. On 2/19/26 at 10:37AM the surveyor shared the concern and conducted an interview with Geriatric Nursing Assistant #8 who confirmed the personal bottles of body wash belonged to room [ROOM NUMBER] and room [ROOM NUMBER] Residents and were used for their showers. On 2/19/26 at 10:44AM the surveyor shared the concerns with Assistant Director of Nursing #3 who confirmed understanding of the concerns. On 2/19/26 at 2:57PM the surveyor shared concerns with the facility's Administrator, Director of Nursing, Regional Nurse #5 and Corporate Nurse #6. 3b.) On 02/25/2026 at 6:49AM Geriatric Nursing Assistant (GNA) #32 was observed by the surveyor wearing a yellow personal protective equipment (ppe) gown with gloves on their hands in the Resident hallway obtaining linens from the linen cart. Two bags filled with trash were observed sitting in the Resident hallway on the floor next to the linen cart. GNA #32 was observed by the surveyor holding linens in one hand against their ppe gown and picking up two bags filled with trash off of the Resident hallway floor with their other hand. At this time, the surveyor conducted an interview of GNA #32 who stated I'm going into this room and confirmed it was Resident #85's room which was observed to have both contact and droplet precautions signage present. GNA #32 stated to the surveyor regarding the two bags of trash in the Resident hallway: This trash is from another room. 3c.) On 02/25/2026 at 7:09 AM the surveyor observed a trail of wet clear liquid drops on the flooring extending from room [ROOM NUMBER] into the Resident hallway. On 02/25/2026 at 7:11AM the surveyor conducted another interview of GNA #32 who reported to the surveyor: I came out to take some linen out. GNA #32 confirmed with the surveyor that they had came out of the Resident room which had both contact and droplet precautions signage present on the door. When the surveyor inquired as to why they were wearing ppe out of a room with precautions, GNA #32 stated: You're right, I didn't expect it, (the surveyor to be present) that's why I came out to take it (the linen). When the surveyor inquired to GNA #32 as to what their understanding was of why ppe was to be worn in a room with droplet and contact precautions, they stated: It's so the droplet will not get on me, the Resident I learned yesterday, has an infection, s/he is the last one (Resident) I did, I saw s/he was wet so I came to pick up linen. At this time the surveyor shared the concern with GNA #32 who acknowledged and confirmed understanding of the concern and stated to the surveyor: Okay thank you. On 02/25/2026 at 6:54AM the surveyor shared the concern with Unit Manager (UM) #29 who acknowledged and confirmed understanding of the concern. When the surveyor inquired as to if employees receive infection control training, UM #29 stated: Absolutely. UM #29 reported to the surveyor that they would be speaking with GNA #32 and would be addressing the issue. On 02/25/2026 all concerns were reviewed during the facility's exit conference with Regional Director of Operations #18 and the facility's Director of Nursing. 4.) On 2/24/2026 at 9:15AM, during medication administration observation on the Medbridge Unit, the Surveyor observed Registered Nurse (RN) #24 retrieve vital signs for Resident #126 using a blood pressure cuff and pulse oximeter connected to a portable vital signs monitor. RN #24 administered medication to Resident #126 and exited the room with the portable vital signs monitor with connections. The Surveyor did not observe disinfectant wipes on the portable vital sign monitor. RN #24 failed to disinfect the portable vital signs monitor including blood pressure cuff and pulse oximeter after use. 4b.) On 2/24/2026 at 9:36AM, during continued medication administration, the Surveyor observed RN #24 retrieve vital signs for Resident #184 using the same portable vital sign monitor with blood pressure cuff and pulse oximeter connections used for Resident #126. RN #24 administered medication to Resident #184 and exited the room with the portable vital signs monitor with connections. RN #24 failed to disinfect the portable vital signs monitor including blood pressure cuff and pulse oximeter after use. 4c.) On 2/24/2026 at 9:51AM, during continued medication administration, the Surveyor observed RN #24 retrieve vital signs for Resident #175 using the same portable vital sign monitor with blood pressure cuff and pulse oximeter connections used for Resident #126 and Resident #184. RN #24 administered medication to Resident #175 and exited the room with the portable vital signs monitor with connections. RN #24 failed to disinfect the portable vital signs monitor including blood pressure cuff and pulse oximeter after use. During an interview conducted with RN #24 on 2/24/2026 at 10:25AM, the Surveyor expressed the concern that they failed to ensure infection control by disinfecting the portable vital signs monitor including blood pressure cuff and pulse oximeter after use. The Surveyor asked if the medication cart contained disinfecting wipes to clean equipment after use. The Surveyor confirmed disinfectant wipes in the bottom drawer of the medication cart. RN #24 acknowledged the Surveyor concerns and stated that morning medication administration can be a long process and resident's may require assistance that may extend their time with them and lead to late medication administration; however, the expectation is to disinfect equipment used in between residents. During an interview conducted with the Assistant Director Of Nursing/ Infection Preventionist (ADON/IP) on 2/24/2026 at 2:47PM, the Surveyor expressed the concern that RN #24 failed to disinfect the portable vital signs monitor including blood pressure cuff and pulse oximeter after use. ADON/IP stated that the expectation is that any shared equipment used for residents should be disinfected after use for that resident and before entering the next room. Sanitizing wipes should be located on each medication cart and portable vital sign monitor that has a basket to place them in. 4d.) On 2/25/2026 at 8:27AM, during medication administration observation on the Somerset Unit, the Surveyor observed Licensed Practical Nurse (LPN) #15 retrieve a blood sugar reading for Resident #81 using a portable glucometer wearing gloves. LPN #15 removed and discarded their gloves in the trash, exited the resident's room, and placed the glucometer back in the medication cart. LPN #15 failed to disinfect the glucometer after use. 4e.) On 2/25/2026 at 8:35AM, during continued medication administration, the Surveyor observed LPN #15 retrieved Resident #78's vital signs using a black portable wrist cuff. After obtaining the resident's vitals, LPN #15 exited the resident's room and placed the black portable wrist cuff on the medication cart. The Surveyor did not observe disinfectant wipes on the medication cart. LPN #15 failed to disinfect the black portable wrist cuff after use. An interview with LPN #15 on 2/25/2026 at 8:55AM, revealed that there were no wipes inside the medication cart. The LPN acknowledged they failed to disinfect the glucometer and the black portable wrist cuff after use. During an interview with ADON/IP on 2/26/2026 at 2:00PM, the Surveyor expressed the concern that LPN #15 failed to disinfect the glucometer and black portable wrist cuff after use. ADON/IP stated that education will be provided to nursing staff on cleaning and disinfecting shared resident equipment after use. 4f.) On 2/25/2026 at 8:20AM, during medication administration observation on the Somerset Unit, the Surveyor observed Licensed Practical Nurse (LPN) #15 administer insulin to Resident #81 while wearing gloves. LPN #15 removed their gloves, discarded them in the trash, and exited the resident's room. LPN #15 gathered supplies to retrieve a blood sugar reading for Resident #78 using a portable glucometer. The LPN put on gloves, reentered the room, and obtained a blood sugar reading for resident #78. LPN #15 failed to wash or sanitize their hands in between resident's care. During an interview with LPN #15, the Surveyor expressed the concern that they did not wash or sanitize their hands in between medication administration for Resident #81 and retrieving the blood sugar for Resident #78. LPN #15 stated that they didn't realize they didn't wash or sanitize their hands between residents. During an interview with ADON/IP on 2/26/2026 at 2:00PM, the Surveyor expressed the concern that LPN #15 failed to wash or sanitize their hands. ADON/IP stated all staff receive hand hygiene education and will ensure LPN #15 is reeducated on the expectation of proper hand hygiene when providing resident care and medication administration.

Based on observation and interview it was determined the facility failed to ensure essential kitchen equipment needed to manage functions of food service was maintained in safe operating condition. This was evident for: 1 out of 2 steamer compartments, 1 out of 1 single door reach in refrigerator, 1 out of 2 convection oven compartments, and 1 out of 6 steam table wells observed during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility's kitchen, on 2/18/26 at 8:04AM the surveyor inquired as to where the designated staff area was for personal beverages etc, at which time FSD #12 stated: Unfortunately, we don't have one and showed the surveyor to the facility's reach in refrigerator which had exterior signage present on it dated December 2025 and Out of service. The interior thermometer of the reach in refrigerator was observed to be at 78F and a sign was observed for the lower shelf which was designated for staff food. During the interview FSD #12 informed the surveyor that the reach in refrigerator was also used to hold food items needed to carry out the tray line and that the current Administrator was aware that the facility bills were still being sent to the previous facility Administrator and that companies aren't coming to fix things until the bills are paid.On 2/18/26 at 8:06AM the surveyor observed one of two electric convection steamer compartments to be operational, at which time FSD #12 reported that one of two steamers (compartments) was broken, and the kitchen was responsible for boiling food for up to over two hundred residents and that it was hard to keep up and discussed their concern for burn hazard regarding employees having to boil large quantities of food needed to support the facility's census. On 2/18/26 at 8:07AM the surveyor observed the food tray line at which time one out of six steam wells on the steam table was observed to be operational. The temperature knob below the fourth steam well was observed by the surveyor to have a copious amount of clear tape over it. When the surveyor inquired to FSD #12 as to why the tape was present, they confirmed the steam well was not in working order and stated: You can't turn it on because it will electrocute you. During the interview, FSD #12 confirmed with the surveyor that the bottom convection oven was unable to hold appropriate temperature and that they considered the broken pieces of kitchen equipment to be essential equipment needed to carry out the function of food service to the facility Residents. During the interview, it was confirmed by FSD #12 that the broken essential kitchen equipment had been placed in the facility's TELS maintenance system for approximately three months and they had repeatedly informed facility staff regarding the need for the equipment to be in working order. On 2/18/26 at 8:21AM the surveyor approached the door to the kitchen at which time a piece of metal was felt to be sharp and the door handle was observed to be missing revealing an open hole surrounded with sharp metal edges. At this time, the surveyor shared their concern with FSD #12 who observed and acknowledged the concern and stated: It broke yesterday. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you.

Based on observation, interview and record review it was determined the facility failed to ensure onsite emergency water supply. This was evident during the surveyor's tour of the emergency water storage area during the facility's recertification survey.The findings include: On 2/18/26 at approximately 7:53AM the surveyor was provided with facility census documentation which documented that 168 Residents resided in the facility. On 2/18/26 at 8:17AM during the surveyor's initial tour of the facility's kitchen the surveyor conducted an interview of Food Service Manager (FSM) #12 and inquired as to where the emergency water was located in the building. FSM #12 reported to the surveyor regarding the emergency water supply, that it was not in the building and confirmed that is was not stored anywhere in the building. On 2/18/26 at 1:14PM the surveyor conducted an interview of the Administrator and asked them to show this surveyor where the emergency water supply was located within the building at which time the surveyor was taken to the floor where the kitchen was located and this surveyor observed the Administrator ask FSM #12 for the keys to the emergency water supply room at which time FSM #12 was observed retrieving a key. The Administrator reported to the surveyor during the interview that they did not think emergency water was needed onsite. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. On 2/18/26 at 1:16PM the surveyor conducted a dual observation of the facility's emergency water supply with FSM #12 and the Administrator at which time the following was revealed:1.) cardboard cases of gallon jugs of water in which appeared crushed inward2.) gallon jugs of water which were sitting opened and uncapped3.) several gallon jugs of water which were capped, but empty4.) cases of gallon jugs of water which were observed with a layer of white powder present5.) best by dates from year 2024 and 2025 were present on part of the supply of water6.) the supply amount of emergency water was observed to be inadequate for the amount of facility residents for three days in the event of an emergency.Roughly 250-300 gallons was observed to be present which was confirmed by the facility's Administrator and FSM #12 stated to the surveyor: It's not in condition to serve to Residents. Additionally FSM #12 explained that due to temperature changes in the emergency water supply room, gallons of water had exploded and reported that maintenance work was recently done in the room. The facility Administrator acknowledged during the observation that the supply was not enough to meet the emergency needs of the facility.On 2/24/26 at 12:08PM the surveyor was provided with the facility's emergency water supply policy dated as last revised on 1/3/26 which documented the following information under the section labeled policy explanation and compliance guidelines: The Dietary Manager maintains a three day supply of bottled water for drinking and cooking but no less than as specified by state regulations (3 gallons per resident, per day); This water is stored on the service level across the kitchen.Review of the facility's disaster and emergency response plan by the surveyor on 2/24/26 at 12:08PM revealed the following documentation under the section labeled emergency procedures: Food and Water: The facility has an emergency supply of water located in storage on the lower level of the facility.

Based on observation, interview and record review it was determined the facility failed to ensure effective management of pest control. This was evident for all floors of the facility during surveyor review of environment during the facility's recertification survey.The findings include: On this surveyor's initial tour of the facility's kitchen the surveyor's observations on 2/18/26 at 7:49AM included the lower tier of a two tier food preparation table located across from the two compartment sink which was observed to have numerous dark rod shaped pellets approximately the size of a grain of rice, scattered on it's surface in addition to food debris and areas of yellow sticky liquid matter next to a bag of corn starch and next to containers which held flour, sugar, white rice, and thickener powder were observed. On 2/18/26 at 7:52AM the surveyor conducted an interview and dual observation of the concerns with FSD #12 and inquired as to if the facility kitchen had pest concerns at present. FSD #12 stated to the surveyor during the interview: We have had a problem in the building with mice in the last six months, the health department has been out several times investigating mice, we've changed exterminators in response to that but there are still some mice, we have been cleaning extra, but they haven't cleaned since the snow storm. During the dual observation with FSD #12, four out of four exterior surfaces of the containers which held food items on the lower tier were observed to be unclean with staining, food crumbs and cloudy appearing areas in addition to other observations made by the surveyor.On 2/18/26 at 8:13AM the surveyor conducted a dual observation of the facility's trash area with Food Service Director (FSD) #12 which was located exteriorly adjacent to an entrance to the facility's kitchen at which time the following observations were made: 1.) One uncovered rolling trash container was observed parked in the dumpster area with copious food trash items and food debris present which were no longer contained within trash bags which included but was not limited to food cups, open food containers, food matter, open milk containers, rice, carrots, soda bottles, juice containers, protein shake cartons etc. 2.) Trash items and pieces of food were observed scattered on the ground near to the container, 3.) Two broken overbed tables, 4.) Two sitting chairs, 5.) Numerous wooden pallets, 6.) numerous trash cans with broken equipment present, 7.) Bed mattresses, 8.) Several trash cans situated on their side, 9.) Broken mop bucket, 10.) Various pieces of wet cardboard, and 11.) Various pieces of plastic and paper trash and bags of ice melt stacked up against vents leading into the facility's electrical room. At this time the surveyor shared their concerns with FSD #12 who acknowledged and confirmed understanding of the concerns and reported to the surveyor that, at times, raccoons are present in the garbage area and discussed their concerning behavior with this surveyor. On 2/18/26 the following Residents reported observations of mice within the facility to the survey team member(s): Resident #11, #15, #18, #135 and additionally one family member of a Resident who wished to remain anonymous.On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. On 2/20/26 at 2:29PM the surveyor conducted an interview of the facility's Director of Maintenance #13 who confirmed that the facility at present continued to have a pest issue with mice and after surveyor intervention, reported that the facility had brought in a flat bed because they didn't have enough trash can space to dispose of everything that needed disposed of. During the interview, Director of Maintenance #13 stated that facility staff were: not breaking down trash like they are supposed to, not breaking boxes down, causing trash cans to not have enough space. Director of Maintenance #13 reported to the surveyor during the interview that at first, there was a strong issue with mice for a good three months and the pest control problem was not handled correctly and the pest control company the facility utilized was changed to a different company. Director of Maintenance #13 reported that the pest control company handles the bait and traps while maintenance staff are responsible for handling pest entry points and that they last visited the facility the day prior. At this time, the surveyor shared the concerns with them at which time they acknowledged the surveyor's concerns. After the conclusion of the interview, a receipt for a 20 yard container to remove the garbage dated 2/20/26 was provided to the surveyor on 2/20/26. On 2/20/26 at 2:51PM the surveyor conducted a review of pest control log documentation which revealed pest control concerns logged which included current active concerns. Documentation in the pest control logs included the following dates in which pest control concerns were documented: 6/9/25, 6/12/25, 6/15/25, 7/3/25, 7/29/25, 7/30/25, 10/16/25,10/25/25,10/28/25, 11/19/25,12/17/25, 12/19/25, 12/23/25, 12/24/25, 12/28/25, 1/3/26, 1/29/26, 1/31/26, 2/1/26, 2/2/26, and 2/20/26.On 2/20/26 2:53PM the surveyor observed the trash area adjacent to the facility's kitchen with several dumpsters in which were overfilled with trash visible above level of the top of dumpsters. On 2/20/26 at 2:10PM the surveyor observed the facility's activity room at which time numerous dark rod shaped pellets approximately the size of a grain of rice were observed scattered on areas of the flooring.On 2/24/26 at 8:54AM the surveyor conducted a review of the pest control company documentation which revealed documentation which included the following information: 1.) Logbooks were recommended by the pest control company to be utilized on the 10/23/25 service inspection report and also on the 12/11/25 and 12/28/25 service inspection reports, 2.) The 12/31/25 service inspection report documented Observed poor sanitation and several large voids, and recommended deep cleaning of a room and maintenance to seal voids as soon as possible, 3.) The 1/8/26 service inspection report documented Observed minor dead mice activity in tin cats next to the loading dock exit doors in the basement next to the kitchen, 4.) The 1/22/26 service inspection report documented reports of mice within the facility's kitchen and recommended Behind cooking machines and underneath tables against baseboards would benefit from improved sanitation, Checked in with (facility Administrator), 5.) The 1/29/26 service inspection report documented Treated along the exit doors and loading dock area to prevent further activity, 6.) The 2/4/26 service inspection report documented confirmed pest activity within the facility's kitchen and documented having spoken with the facility Administrator, and 7.) The 2/19/26 service inspection report documented confirmed pest activity behind the facility's ice machine.On 2/25/26 concerns were reviewed by the survey team during the facility's exit conference with Regional Director of Operations #18 and the Director of Nursing.

Based on observation, interview and record review it was determined the facility failed to ensure a Resident (#97) had the capability of safe self administration of a medication and failed to ensure the interdisciplinary team was aware of the Resident's self administration of the medication. This was evident for 1 (#97) out of 2 Residents reviewed for quality of care during the facility's recertification survey. The findings include: On 2/19/26 at 10:05AM the surveyor conducted an interview with Resident #97 and observed them retrieve a bottle of magnesium citrate from the drawer which had a prescription label on it. Resident #97 showed the bottle to this surveyor and informed this surveyor that they needed more of the medication and that they had asked Licensed Practical Nurse Supervisor (LPNS) #9 for more of it three to four weeks ago and were told that they would get it but had not yet been given it. Resident #97 explained to this surveyor that they keep the medication for emergencies for a problem with constipation. On 2/19/26 at 10:09AM the surveyor conducted an interview with LPNS #9 who reported to this surveyor that (Resident #97) likes to keep his/her stuff, it's prn (as needed) for him/her so when s/he is constipated we give him/her the bottle to use it when s/he needs it. At this time, the surveyor shared the concern with LPNS #9 and after surveyor intervention, LPNS #9 was observed removing the medication bottle from the Resident's room.On 2/19/26 at 10:15AM the surveyor shared the concern and conducted an interview of Medical Director Physician (MDP) #7 who reported to this surveyor that Resident #97 was confused about it and stated that the medication was always available in the medication cart when s/he needs it. At this time, the surveyor shared the concern with MDP #7 who was unaware that Resident #97 had the medication in their possession and and that staff leave the medication with him/her. The surveyor confirmed during the interview that Resident #97 had not been safely assessed for self administration of their medication. On 2/19/26 this surveyor shared the concern with the facility's Assistant Director of Nursing (ADON) who acknowledged understanding of the surveyor's concern. This surveyor also shared the concern with the facility's [NAME] President of Operations Registered Nurse.On 2/20/2026 at 1:09PM the surveyor conducted an interview with ADON #3 who confirmed that medication should not have been left with Resident #97 and stated to the surveyor that the bottle of medication was removed from Resident #97 and Resident #97 was told that when they need medication, to request it from the nurse and they will follow up with them. When the surveyor inquired as to if the facility had taken any measures at the current time to address medication being left with a Resident who was not assessed for safe self administration, ADON #3 stated: It would be education with the nurse, and all staff education, I'll go check.On 2/20/2026 at 1:34PM the surveyor conducted an interview with the facility's Director of Nursing who stated during the interview to the survey team: I have to check, I don't know if s/he had a self administration of medication assessment. On 2/20/26 at 1:49PM the surveyor conducted a review of the medical record of Resident #97 and noted that no medical order or documentation of an assessment for self administration of medications for the Resident could be found. On 2/24/26 at 9:32AM the surveyor conducted an interview of the facility's Director of Nursing (DON) who stated to the survey team regarding Resident #97: S/he is going to be assessed for capability of self medication administration, if s/he is safe to have it in the room. Additionally after surveyor intervention, the surveyor was provided with documentation of in service education provided to facility staff in response to the surveyor's concern which was dated 2/18/26 and documented review of the following: Medication Administration; no medication should be left in Resident's room at any time. Additionally, the surveyor was provided with a disciplinary action form for LPNS #9 dated 2/18/26 with signatures present for LPNS #9 and ADON #3 which stated the following information regarding the details of occurrence: When administering medications nurses should assure medication is taken by patients, and No medications should be left in patient's rooms. The surveyor noted that both the education documentation and the disciplinary action forms were all dated as having been performed on 2/18/26, however, the date of the concern observed by the surveyor was not until 2/19/26.All concerns were reviewed during the facility's exit conference on 2/25/26 with the facility's Regional Director of Operations #18 and the Director of Nursing.

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident received showers according to personal preference. This was evident for 1 (Resident #104) out of 1 resident reviewed for preference in shower schedule.The findings include: During observation of Resident #104's wound dressing change on 2/20/26 at 2:50 PM the resident stated that he/she was supposed to get two showers twice a week in the evening but doesn't always get one. Staff #15 who was doing the dressing change offered that the resident was supposed to get showers on the 3-11 shifts. Resident said he/she wanted showers on the 7-3 shift and has told nursing staff that he/she wants showers on day shift because he/she wants the showers before wound dressings are changed not after. The resident said even if the old dressing got wet it would have to come off anyway so getting wet would not matter. The resident then stated that they did not get a shower on Tuesday, 2/17/26.This surveyor interviewed the Director of Nursing (DON) on 2/24/26 at 3:05 PM. This surveyor explained the resident's concerns and preference for shower times. The DON said she understood and would talk with the nurses on the unit to make necessary changes.A review of the facility's Documentation Survey Report on 2/24/26 revealed that the resident did not receive scheduled showers on 12/2/25, 12/5/25, 12/19/25, 12/22/25, 12/26/25, 12/30/25, 1/9/26, 1/13/26, 1/16/26, 1/20/26, 1/23/26, 1/27/26, 2/6/26, 2/13/26, 2/20/26. The resident was marked as having received a shower on 2/17/26 but the resident denied receiving one. The resident's sister was interviewed on 2/25/26 at 11:43 AM. She was asked about the resident's showers. She said that he/she has complained to the nursing staff about not getting showered and nursing staff tell him/her that he/she has to get showered at night even though he/she has told them he/she prefers to get showers during the day.

Based on resident interview and staff interview, it was determined that the facility staff failed to provide a resident with a quarterly statement for a personal funds account. This was evident for 1 (#104) out of 2 residents reviewed for a personal funds account.The findings include:During the initial tour of the facility on 2/18/26 this surveyor interviewed Resident #104 at 2:51 PM. Resident #104 informed the surveyor that they do not get a quarterly statement telling them how much is in their personal funds account. Staff #18 was interviewed on 2/25/26 at 2:59 PM. This surveyor requested a copy of the quarterly statements provided to Resident #104 and signed by the resident indicating that the resident received the statements.The quarterly statements with signatures were not provided to the survey team at the exit conference. This surveyor's business card was provided to Staff #18 at the exit conference so that the facility staff could email copies to this surveyor. Copies were provided via email on 3/2/26 at 10:38 AM but they were not signed.

Based on observations and interviews with resident's and facility staff, it was determined the facility failed to ensure Resident's room furniture and the resident's environment was clean and well maintained for residents residing in the facility . This was evident during the surveyor's initial tour of the facility for two Resident rooms (#208, and #210) located on the second floor, observations of Resident # 19 Room and for Room # 309 during the facility's recertification survey.The findings include:1.On 2/18/26 at 9:02AM the surveyor observed Resident room [ROOM NUMBER] at which time the nightstand furniture was found to be in disrepair with wood located at the base of one of the nightstand observed to be broken in half with areas present in which the wood stain was worn off. A white substance was observed smeared across the front of one of the nightstand drawers. Further observation of the furniture in Resident room [ROOM NUMBER] revealed a wooden dresser with multiple worn and chipped areas in which the wood stain was worn off. A metal heat unit was observed within the room with grey scrapes across the surface with rust colored areas also present. One wall located near to the heat unit was observed to have an area of square patching affixed to the surface of the wall with a broken area present which revealed an opening which was present between the wall and the cove molding. A broken area of corner wall molding was also observed to be present. A wall within the room adjacent to the bathroom was observed to have several holes and scrapes present with a bubbled appearance. The surveyor noted that the heat unit and bedside nightstand was observable from the facility hallway. 2.On 2/18/26 at 9:07AM the surveyor observed the flooring within room [ROOM NUMBER] from within the Resident hallway at which time numerous areas of scraping and white colored staining was observed to be present. During the observation, Resident #97 requested to speak with this surveyor. On 2/18/26 at 9:07AM the surveyor conducted an interview of Resident #97 who expressed to the surveyor that their walker was scraping the floor area within their room and they had reported their concern to staff who attempted to clean the areas, however cleaning did not work and their concern was not resolved yet by the facility. Resident #97 reported having asked facility staff to address the walker with equipment to mitigate the scratching however, had not been provided with a solution to that concern. On 2/18/26 at 4:19PM the surveyor shared concerns with the facility's Administrator and Director of Nursing who acknowledged the surveyor's concerns with each stating: Okay, thank you. 3.During a meeting with resident # 19 on 2/18/26 at 2:20 PM an observation was made of the resident room and there were crumbs and trash noted on the resident floor. There was also a strong urine odor present in the room. At this time, the resident stated that s/he was planning to get back into bed, but the bed was wet and not changed. The nurse who was present in the room, removed the linen from the resident bed and placed clean linen on the bed. The DON was made aware of the concern that the resident room was not clean, and the bed was not changed at the time the resident wanted to get into bed in the afternoon. 4.This surveyor observed on 2/25/26 at 1:15 PM that room [ROOM NUMBER] had a hole in the drywall on the righthand side wall as one entered the room. The hole was behind door at ankle height and just above the molding. There was also a scratched area on the wall at waist height that was also behind the door. There was also an area on the left side wall near the entrance at ankle height below the duct that was scraped and chipped. The Unit Manager (Staff #21) was shown the areas and interviewed on 2/25/26 at 1:18 PM. He confirmed the findings and took pictures of the areas. He then said it was a problem and he would address it immediately with maintenance and ask that they fix it. All concerns were discussed with the Administration team at the exit conference on 2/25/26.

Based on record review and interviews with staff and a resident representative, it was determined that the facility failed to follow the grievance process for a resident and resident representative. This was evident for 1 (Resident #180) of 2 residents reviewed for grievances during the annual recertification and complaint survey.The findings include:A grievance is a formal or informal, written or oral complaint by a resident or resident representative regarding care, treatment, staff behavior, or quality of life. Facility staff are responsible for making prompt efforts to resolve (facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance) a grievance and to keep the resident/resident representative informed of the progress towards a resolution.On 2/24/2026 at 3:45PM, a review of Resident #180's Complaint/Grievance Forms filed by the resident representative included:1/17/2025-Failure to ensure nurses and aides have appropriate competencies: Requested water from aide working the night shift, request ignored. Pt had large amounts of antibiotics prescribed and was hot and sweaty with increased need for hydration with limited upper body mobility and range of motion in hands.2/3/2025-Failure to provide safe and appropriate pain management; pt requested to be turned and repositioned during the 3rd shift on two occasions. Ignored both occasions, slept in painful position.2/3/2025-Failure to promote and facilitate resident self determination through support of resident choice; Multiple requests made to staff and management to place resident in chair to participate in activities. 4 separate requests since 2/2/2025.2/3/2025-Failure to provide appropriate treatment and care according to orders, resident preferences and goal; Pain in both feet, infection on the right foot discovered in 2nd toe, antibiotics were prescribed but the pt still in pain with no follow up or care plan. No record of podiatry consult/appointment.2/4/2025-Failure to post nursing staff information each day; [Representative] requested staff information regarding who left the resident laying on [his/her] side throughout the night. [Representative was advised by [staff] that the information was confidential. [Representative was only able to get the information once they retrieved POA (Power of Attorney) information from the admission department.2/9/2025- Failure to provide appropriate pain management; pt informed [Physician] spasms were increasing in frequency and intensity. Requesting an immediate pain management review.2/9/2025-Failure to assist in gaining access to vision and hearing services; complaints of ear pain for the last couple of weeks (pain on right side of head). This complaint was expressed to the physician on duty. (No resolution as of 2/12/2025)2/10/2025-Failure to reasonably accommodate the needs and preferences of the patient; Pt was advised the [NAME] chair was not available to get [him/her] out of bed. When [representative] visited on 2/8 and 2/10 the chair was right outside the door in the hall.2/12/2025-Failure to ensure there is a pest program; complaints of rodents in patient room; Initially discussed last week.2/12/2025- Failure to provide and implement infection prevention and control program; within one month patient has acquired bedsores, UTI, foot infection (right foot), and possible finger infection on left hand, along with what appears to be an infection of both ears.2/12/2025-Failure to develop and implement a complete care plan that meets all the resident's needs with timetables and measurable action. [Representative] requesting a meeting with the complete care team responsible for [resident] care.Further review of all the Complaint/Grievance Forms completed and submitted by the resident representative revealed that once forms have been submitted, a facility representative will review and contact the complainant regarding their statement within 72 hours. The bottom portion of the form was labeled Facility Representative to complete the following. The facility staff completed the Findings and the How was this issue resolved section and the forms were all signed by the Grievance Officer (signature unknown by facility staff) and NHA (Nursing Home Administrator) #1 on 2/6/2025. The facility staff failed to document the Referred to, Date Form Received, and the Date shared with the person filing the complaint/grievance portion of the form.On 2/25/2026 at 10:13AM, during an interview with the Resident #180's resident representative, the Surveyor was informed that they filed grievances in January and February 2025 via the Complaint/Grievance Form provided by the facility. The facility failed to acknowledge receipt of the complaint/grievance and the resident representative was not made aware of the progress of the facility's investigation or informed of the findings or resolutions to the complaint /grievance they submitted to the facility.On 2/25/2026 at 11:46AM, during an interview conducted with the Director of Nursing (DON), the Surveyor was informed that if the resident or resident representative has a complaint/grievance, any staff member can receive the grievance and record specific information on the grievance form, they can assist the complainant to complete the form, or the complainant can fill the form out themselves. The grievance form would then be sent to the Grievance Officer and distributed to the specific department manager to follow up with the complaint. Once the department completes its investigation or determines a resolution, the form should be returned to NHA #1. NHA #1 is the Grievance Officer and oversees the grievance process. The Surveyor requested NHA #1's date of hire.On 2/25/2026 at 2:27PM, an interview with Unit Manager #29 revealed that Resident #180's resident representative and UM #29 had numerous conversations regarding the care provided for the resident. UM #29 stated that any concerns the resident representative brought to their attention, were addressed with the resident representative as soon as possible. UM #29 does not recall receiving any complaint/grievance forms with concerns regarding Resident #180.On 2/25/2026 at 3:00PM, during an interview with the DON, the Surveyor confirmed that NHA #1 was hired on 2/24/2025. The Surveyor expressed the concern that Resident #180's resident representative submitted Complaint/Grievance Forms on 1/17/2025, 2/3/2025, 2/4/2025, 2/9/2025, 2/10/2025, and 2/12/2025 and all forms were signed as completed by a Grievance Officer (unknown signature) and NHA #1 on 2/6/2025. 2/6/2025 was prior to NHA #1's hire and after grievances filed on 1/17/2025, 2/3/2025, and 2/4/2025.Further review of the Complaint/Grievance form, in the section, Facility Representative to complete the following, the facility failed to document who the concern was referred to, the date the form was received, and the date shared with the person filing the complaint/grievance.The Surveyor questioned the DON about the documentation on the Complaint/Grievance Forms and was unable to give an explanation. The Surveyor also expressed the concerns that the facility failed to acknowledge receipt of the Complaint/Grievance Forms and inform Resident #180's resident representative of the findings and any resolutions to their concerns outlined on the forms. A review of the Resident and Family Grievances policy revealed that the Grievance Officer will issue a written decision on the grievance to the resident or resident representative and that documentation was not provided to the resident representative.

Based on interview and record review it was determined the facility failed to ensure Resident #4's personal funds was appropriately managed. This was evident for 1 out of 2 Residents reviewed for personal funds during the facility's recertification survey.The findings include:On 02/18/2026 at 2:15PM the surveyor conducted an interview of Resident #4 who expressed to the surveyor that they had sought Social Security for themself and learned that they had been approved for disability benefit, and in approximately October or November of 2025 they had received a check that came in their mail which was in their own name and made payable to only them. Resident #4 stated to the surveyor: The Administrator took my check, it was for $19,780.00 and then s/he supposedly put $2000.00 in an account for me, I don't get a statement or anything. During the interview Resident #4 continued to express to the surveyor that they did not understand why the check was taken from them when it was payable to their name, and was not made payable to the facility. Resident #4 stated they had wished to use the money from the check to facilitate them moving out of the facility and back into the community. Resident #4 reported during the interview that facility staff had informed them that the money was taken to pay for their care at the facility.On 02/25/2026 at 1:38PM the surveyor conducted an interview of the facility's Regional Director of Operations (RDO) #18 regarding Resident #4. RDO #18 stated during the interview to surveyors that Resident #4 received payment for disability which was back pay and they had been on Medicaid and were not approved right away for disability. RDO #18 stated to surveyors: The income was owed to us. RDO #18 reported to surveyors that the personal needs allowance was subtracted from the amount of money the Resident received and that approximately $2000.00 was placed in a Resident fund management service (RFMS) account for them. At this time, the surveyor requested to RDO #18 for them to provide billing statements for the Resident's care, RFMS account statements and documentation of it having been issued to the Resident, and the copy of the front and back of the check that the Resident had received for their back payment.On 02/25/2026 at approximately 2:13PM the surveyor was provided with Resident #4's Social Security Administration Retirement, Survivors, and Disability Insurance notice of award letter which documented information which included: You will receive $19,780.00 around October 8, 2025.On 02/25/2026 at approximately 2:13PM the surveyor was provided with a RFMS account statement which documented the date of opening of the account was 1/8/24 however, the statement documentation history provided began on the date of 11/19/25. At this time RDO #18 indicated that there was no other account statement history.Another interview was conducted by the survey team on 02/25/2026 at 2:21PM with RDO #18 who stated that the Resident was receiving an RFMS statement and reported that Medicaid had approved the Resident and the Resident did not have any income at that time and disability was not approved at that time, and that Medicaid was paying for the Resident's care based on zero income. The survey team again requested for RDO #18 to provide the billing statements for the Resident's care.On 02/25/2026 at 2:59PM the survey team conducted an interview of RDO #18 who reported to surveyors that Medicaid had paid in full, and when they do a sweep, they let Medicaid know they got it. RDO #18 confirmed the facility had Resident #4's money and reported to surveyors that Medicaid hadn't retrieved it back yet. RDO #18 stated: We let Medicaid know the money came. At this time, the surveyor requested for RDO #18 to again provide the outstanding requests for documentation and additionally to provide documentation regarding the facility's notification to Medicaid.On 02/25/26 all concerns were reviewed with the facility's RDO #18 and Director of Nursing during the facility's exit conference and the survey team noted that at the time of exit, no further outstanding documentation which was previously requested multiple times by the survey team had been provided by the facility.

Based on record reviews and interviews, the facility failed to provide written information regarding transfers to the hospital and discharge to; the resident and/or the resident's responsible party (RP), and the local Ombudsman. This was evident for 6 (# 94, # 181, # 179, # 12, #140, # 7) of 6 residents reviewed for transfer / discharge.The findings include: 1.On 2/18/26 at 2:45 PM a medical record review was conducted and upon review it was revealed Resident # 94 was transferred to the hospital on [DATE]. The resident has cognitive impairment and is not their own RP. At this time the survey team requested documentation of the written notification of the hospital transfer documentation and bed hold policy that was provided to the resident responsible party. The facility provided 2 documents to the survey team for Resident # 94. Review of the first page titled, Notice of Acute Emergent Discharge or Transfer Form had a listed reason for resident # 94 hospital transfer. There was no area on the form for resident and/or RP signature, and it was not signed by the RP. Review of the second page titled, Bed Hold, did not have the resident name listed, no payment amount, and in the space titled Patient signature, or RP signature, it was blank. At the bottom of the form there were two staff signatures with a date, however, no signatures were present by the RP that the document was offered. An interview was conducted with the Director of Nursing (DON) on 2/20/26 at 12:55 PM and she explained that the nurse is responsible for ensuring that the form is completed. The nurse then gets another person to sign the document. The DON confirmed that the facility was unable to provide documentation that the resident and/or the RP received a written copy of the document, and she also confirmed that the Ombudsman did not receive written notice of the transfer. All concerns were discussed with the Administration team at the exit conference on 2/25/26. 2.On 2/20/2026 at 11:00AM, a review of Resident #181's electronic medical record revealed that the resident was transferred to the hospital on 1/10/2026. On 2/20/2026 at 11:30AM, a review of Resident #179's electronic medical record revealed that the resident was discharged from the facility on 12/17/2025. On 2/20/2026 at 11:40AM, the Surveyor requested, from the Director of Nursing (DON), documentation of the notification of discharges and transfers sent to the local Ombudsman for December 2025 and January 2026. On 2/20/2026 at 1:06PM, the DON was unable to provide documentation to verify the local Ombudsman was notified of Resident #181's transfer to the hospital on 1/10/2026 and Resident #179's discharge from the facility on 12/17/2025. During an interview conducted with the DON, the Surveyor asked if the Social Work Department informs the Ombudsman, at least monthly, of the transfers and discharges from the facility. The DON stated that the Social Work Department does not send resident transfer/discharge notification to the local Ombudsman and was unable to verify any other department sent it. The Surveyor expressed the concern that the local Ombudsman does not receive information regarding the transfers and discharges from the facility. 3. On 2/20/2026 at 11:33AM, during a review of Resident #12's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] and transferred to the hospital on 2/12/2026. On 2/20/2026 at 1:00PM, during an interview conducted with the DON, the Surveyor was informed that when a resident is transferred to the hospital, the following documents, but not limited to, should be sent with the resident: Change of Condition (if done) Face Sheet MOLST Physician Orders Labs Provider Note Bed hold Policy On 2/25/2026 at 12:20PM, a review of the Change in Condition/Concurrent Review evaluation, Section O Documents Sent to Provider, the following items must be sent with resident for receiving provider: Comprehensive Care Plans Face Sheet Current Medication List or Current MAR Change in Condition progress note (if completed) Advanced Directives Advance Care Orders (MOLST) Printed Vaccination Record Most recent History and Physical Recent Hospital Discharge Summary Relevant Lab Results (from last 1-3 months Relevant X-rays and other Diagnostic Test Results Recent MD/NP/PA Progress Notes Transfer Form A further review of Resident #12's Change in Condition/Concurrent Review evaluation, Section O Documents Sent to Provider, failed to reveal comprehensive care plans, a current medication list or Current MAR (medication administration record), a printed vaccination record, most recent history and physical, and recent hospital discharge summary was sent with the resident. 4.Resident #140 was transferred to the hospital on 4/30/25. Review of the medical record did not reveal that the resident was provided with a written copy of the discharge or transfer documentation. The facility provided a copy of a discharge/transfer from which indicated that two personnel verified that a copy of the bed hold policy was offered to the resident. Review of the medical record revealed that Resident #140 is cognitively intact (BIMS score of 15). During an interview on 2/20/26, the resident stated that s/he never received and /or offered any form during the hospital transfer. 5.Resident #7 was transferred to the hospital on 1/14/26. Review of the medical record did not reveal that the resident's responsible party was provided with a written copy of the discharge or transfer documentation. The facility provided a copy of a discharge/transfer form, which indicated that two personnel verified that a copy of the bed hold policy was offered to the resident. Review of the medical record revealed that Resident #7 is not cognitively intact (BIMS score of 3, indicating severe cognitive impairment). During an interview on 2/20/26 at 3:00 PM, the Director of Nursing stated that the facility provides the discharge/transfer form to residents but was unable to explain why Resident #140 and Resident #7's responsible party were not provided with the form at the time of their hospital transfers.

Based on review of complaint MD 949, facility report MD 050, police reports, administrative and medical record review and staff interviews it was determined facility staff failed to ensure Resident #6 was free from abuse as evidenced by GNA #2's failure to cease care when Resident #6 actively resisted and yelled for GNA #2 to stop resulting in psychosocial harm and potential physical harm to the resident. This was evident for 1 of 9 residents reviewed for abuse during this complaint survey. GNA- Geriatric Nursing Assistant The findings include: Medical record review on 1/31/20 and 2/3/20 revealed Resident #6 was a long-term care resident with a history of Dementia, Anxiety Disorder, Urinary Incontinence, and Hearing Loss, Bilateral. The medical record contained a care plan initiated on 8/17/12 that addressed the resident's resistance and noncompliance with treatment/care as evidenced by the refusal to be washed, showered, and cleaned when soiled related to his/her cognitive impairment and confusion. Interventions included the need to allow for flexibility in the resident's ADL routine to accommodate mood, preferences, and customary routine. Other interventions instructed staff that if the resident resists care, leave (if safe to do so) and return later and inform the resident of ADL care that is required ahead of time and give two options of times to be done. ADLs (Activities of Daily Living) refer to daily self-care activities such as bathing, grooming and dressing. A Care plan initiated on 3/3/17 addressed the resident's difficulty communicating related to a hearing impairment. A care plan initiated on 8/9/12 addressed cognitive loss related to [MEDICAL CONDITION]/Dementia. Interventions instruct staff to explain each activity/ care procedure prior to beginning it. 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. Surveyor review of complaint (#MD 949) and facility reported incident (#MD 050) revealed an allegation that, on 7/19/19, GNA #2 grabbed Resident #6's forearm and bicep while providing incontinence care and continued providing care even when the resident complained that GNA #2 was hurting her/him. The Baltimore County Crime Lab responded to the nursing home complaint and took photographs of the bruising on the resident's left pinky knuckle, left forearm and bicep. The self-report related to this incident noted Resident #6 reported to a nursing assistant on the 7:00 AM- 3:00 PM shift that a GNA working the 11:00 PM- 7:00 AM shift held her/his arm down while providing care. Review of the written interview with the resident dated 7/19/19, as documented by RN #1, the resident stated a man came into his/her room after midnight and held her/him down with one hand and used the other hand to wipe him/her. RN #1 documented in a Skin Note dated 7/19/19 at 1:24 PM that a head to toe skin assessment was completed and two bruises were observed on the resident's left arm. It was further noted that the first bruise measured 2.6 cm (centimeters) x 1.5 cm and the second bruise measured 2.0 cm x1.0 cm. A physician's orders [REDACTED]. Review of the facility's investigation revealed a Suspension of Employment Notice dated 7/19/19 and an Employee Warning Notice dated 7/25/19, issued to GNA #2 that noted the employee failed to stop care immediately upon the resident's refusal of care and inform the nurse that care could not be performed. The employee was terminated. Review of a written statement from GNA #3 revealed s/he worked with resident #6 on 7/17/19 and did not notice any bruising on the resident's arms or other parts of her/his body. GNA #3 also noted that when the resident refuses care s/he leaves the resident alone and reports the refusal to the nurse. Review of a written statement form GNA #4 revealed s/he worked with Resident #6 on 7/16/19 and 7/18/19 and did not notice any bruising on the resident arms or other parts of her/his body. Review of a documented interview with GNA #2 dated 7/19/19 revealed GNA #2 reported the resident verbalized s/he did not want to receive care and GNA #2 responded that s/he did not want to leave the resident wet. GNA #2 stated that when s/he completed care the resident was cursing. When asked by the interviewer if s/he held the resident down GNA #2 reported the resident was putting her/his finger in his/her face and the GNA told the resident to calm down. GNA #2 told the interviewers s/he put his/her hand on the resident's left hand and moved it to the resident's chest. GNA #2 was asked by the interviewers if s/he reported this to the nurse and GNA #2 responded that s/he did not because the nurse could hear the noise in the room. RN #1 documented a statement from Resident #6 dated 7/19/19 wherein the resident reported a man/woman entered her/his room and held her/him down while trying to change her/him. Resident #6 reported s/he yelled for GNA #2 to stop but s/he did not. RN #1 asked if Resident #6 was in pain and s/he replied no, just scared. Review of the Forensic Services Laboratory Report dated 7/19/19 revealed Officer #2 arrived at the facility on 7/19/19 at 6:00 PM and met with Officer #1 and Resident #6. Officer #2 noted the resident had 2 bruises to the left arm, possible bruise to the top of the left hand, forearm and left bicep. The injuries were photographed. Review of the annual MDS assessment dated [DATE] revealed the facility entered a BIMS score of 12 out of 15 in Section C Cognitive Patterns. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive status. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. Review of Section G Functional Status G0110 Activities of Daily Living revealed the Resident #6 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. During an interview with the surveyor on, 2/3/20 at 9:45 AM, RN #1 stated Resident #6 came to her/him on 7/19/19 and said s/he had an issue with an aide overnight. RN #1 stated s/he did an assessment and found 2 bruises on the resident's left arm and made the Director of Nursing, Responsible Party and Nurse Practitioner aware. The surveyor asked if the resident has reported similar or same issues in the past and RN #1 replied no. The surveyor interviewed Officer #1 on 2/13/20 at 9:06 AM regarding his/her response to the facility's call on 7/19/19 to investigate the allegation of abuse. The Officer stated the Administrator related that Resident #6 reported at 11:30 AM that s/he was abused by a nurse. Officer #1 spoke to Resident #6 who stated the nursing assistant (GNA #2) entered her/his room to change her/his diaper. Resident #6 stated the GNA (GNA #2) grabbed her/his left wrist while attempting to change her/his diaper and wouldn't let go. Resident #6 reported s/he told GNA #2 to stop doing that, you're hurting my arm, multiple times and GNA #2 did not stop. Officer #1 stated s/he noted bruising on the resident's left wrist, forearm and bicep. The crime lab was called to the facility and took pictures of the bruises. Officer #1 stated the nursing assistant was not available for interview as the Administrator reported the nursing assistant had been suspended. Staff failed acknowledge Resident #6's right to refuse care and failed to follow the individualized care plan that addressed resistance to care resulting in psychosocial harm to Resident #6.

Based on review of complaint MD 530, medical record review, the facility's investigation and staff interview it was determined the facility failed to ensure beverages were served at a safe temperature and failed to provide adequate supervision for a visually, cognitively and functionally impaired resident (Resident #1) during his/her consumption of a hot beverage. This resulted in harm to the resident who sustained a burn to the right thigh after s/he spilled hot coffee on himself/herself while attempting to consume the coffee, unsupervised. This was evident for 1 of 9 residents reviewed for resident's rights during this complaint survey. The findings include: Medical record review on 1/30/20 revealed Resident #1 was a long-term care resident with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] Section G Functional Status G0110 ADL (Activities of Daily Living) Assistance: H-Eating as a 3/2 ( required the extensive assistance of 1 staff). Facility staff coded Resident #1 in Section B1000 Vision as impaired. ADLs (Activities of Daily Living) refer to daily self-care activities such as bathing, grooming and dressing. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A Nutrition Note dated 8/2/19 at 4:53 PM reported Resident #1 was ADL dependent with a variable PO (food) intake. A Nutrition Note, labeled Late Entry, dated 9/28/19 at 4:43 PM noted Resident #1 required assistance of one staff person at meals related to a cognitive deficit. A care plan for Resident #1 initiated on 1/24/20 addressed ADL self-care deficit as evidenced by the need for total assistance related to physical limitations and visual impairment. An intervention initiated on 1/24/20 directed staff to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of the GNA task documentation for January 2020 revealed Resident #1 was coded as independent for eating on 1/27/20, limited assistance on 1/28/20 at 2:23 PM, extensive assistance on 1/24/20, 1/26/20, and 1/28/20. The staff documented the resident was totally dependent for meal assistance on 1/25/20, 1/29/20, 1/30/20, 1/26/20 at 22:17, and 1/28/20 at 10:17 PM. A Social Services note dated 1/28/20 reported the Social Services staff met with Resident #1 and attempted to complete the BIMS. Resident #1scored a 99 and was not able to answer questions appropriately. It was also noted Resident #1 was experiencing impaired vision. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. Surveyor review of complaint #MD 530 on 1/30/20 revealed a concern that Resident #1 spilled hot coffee on himself/herself and sustained a burn. The medical record contained a Skin Note for Resident #1 dated 1/28/20 at 3:24 PM, written by RN #4, that noted a complaint of redness to the right anterior thigh with a superficial partial thickness area (10x4) of redness to the right anterior thigh with 4 blisters. It was noted Resident #1 was started on [MEDICATION NAME]. [MEDICATION NAME] is a topical antibiotic used in partial thickness and full [MEDICAL CONDITION] prevent infection. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was administered on January 29th and 30th 2020. During an interview with the surveyor, on 1/31/20 at 9:15 AM, the Food Service Manager stated that when the coffee is poured in the morning the temperature is checked on the tray line to ensure it is not above 150 degrees. The Food Service Manager stated that on 1/28/20 GNA #1 came to the kitchen door and the cook gave her/him a cup of coffee directly from the coffee machine, without checking the temperature . The temperature requirement is below 155 degrees. The Food Service Manager stated s/he began in-services for kitchen staff regarding checking the temperature of the coffee on the line and if someone comes to the kitchen to get the coffee. Instructions included the need to check the temperature and if necessary, place an ice cube in the drink to cool it off. In interview with the surveyor on 1/31/20 at 10:01 AM GNA #1, who was assigned to Resident #1's care on 1/28/20, stated the resident asked for coffee several times. S/he stated that when s/he was unable to reach the kitchen by phone, s/he went to the kitchen to get the coffee. The Kitchen Supervisor handed her/him the cup of coffee and s/he returned to the unit and gave it to the resident. The GNA reported that the resident stated the coffee was okay and s/he had no idea that it was too hot. GNA #1 stated s/he left Resident #1 sitting at a table with another resident and resumed other duties. During an interview with the surveyor on 1/31/20 at 10:30 AM the Kitchen Supervisor stated GNA #1 came to the kitchen around 2:30 PM on 1/28/20 and asked for a cup of coffee. The surveyor asked if s/he was aware that s/he needed to check the temperature of the coffee. The Kitchen Supervisor responded that s/he was trying to accommodate the resident. The Kitchen supervisor noted s/he received in-service regarding dispensing/serving coffee to residents after the incident. During an interview with the surveyor on 1/31/20 at 2:34 PM LPN #1 stated s/he was at the nurses' station on 1/28/20, and heard someone say, did you spill coffee. S/he went to the Resident #1 and saw coffee on the resident's pants. S/he reported that s/he took Resident #1 to his/her room for examination and observed a reddened area on Resident #1's right thigh and notified RN #1. LPN #1 further stated the resident was apologetic for spilling the coffee. A physician's note dated 2/1/20 reported the resident had [DIAGNOSES REDACTED]tous (exhibiting abnormal redness of the skin) changes and signs of burned skin resulting in four blisters. The physician noted Resident #1 spilled coffee on himself/herself which resulted in a second-degree burn. The Food Service Manager stated during an interview with the surveyor on 2/6/20 at 12:43 PM that as soon as the incident occurred the Administrator asked him/her to check the temperature of the coffee machine. The Food Service Manger noted it was between 170-175 degrees. S/he further stated the temperature is set at about 170 degrees and comes out about 160 degrees. RN #1 stated in an interview with the surveyor on 2/7/20 at 10:41 AM that s/he assessed the area and noted it was reddened with 4 intact blisters. RN #1 said s/he discussed [MEDICATION NAME] as a possible treatment. Medical record review and staff interview revealed a failure to ensure beverages were served at a safe temperature and that residents received the appropriate level of supervision and assistance when consuming beverages resulting in Resident #1 sustaining a burn due to spilling hot coffee on himself/herself.

Based on medical record review and staff interview it was determined that the facility staff disregarded a resident's decision-making powers and 1). Failed to honor the resident's right to refuse medication and 2). Concealed the administration of an antipsychotic to a resident without properly informing the resident of the concealed medication administration. This failure resulted in Immediate Jeopardy being identified on 1/26/2018 at 4:36 PM. The Nursing Home Administrator and the Director of Nursing were informed of the need to prepare and implement an action plan to remove the condition of Immediate Jeopardy. On 1/26/ 2018 at 8:36 PM the Immediate Jeopardy was abated, as the facility put in place a plan to remove immediacy.After removal of the immediacy the deficient practice continued at a scope and severity of D with potential for minimal harm for the remaining residents. The findings included: On 1/24/2018 Resident #2's medical record was reviewed. Resident # 2 was initially admitted to the facility on [DATE] following hip surgery with a [DIAGNOSES REDACTED]. MD #1's Admission History and Physical notes that the resident's judgement and insight were within normal limits, and that he/she was alert and oriented to person, place and time. Resident #2's affect was noted to be appropriate, with no depression or anxiety noted. Resident #2 was his/her own responsible party and decision maker. His/her most recent Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 10/15/2017 reflected that the resident had a BIMS (Brief Interview of Mental Status) score of 15 which indicated that he/she was cognitively intact. The BIMS is a test utilized to assess an individual's cognition. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. On 7/24/2017 a Behavioral Symptoms Assessment was completed by Nursing staff. Resident # 2 was identified as exhibiting depression and anxiety, with no abnormal behaviors noted. On 7/25/2017 an order for [REDACTED]. On 9/20/2017 a Behavioral Systems Assessment was completed by Nursing staff and coded to note that Resident # 2 was exhibiting anxiety and depression. A Psychiatric (Psych) consult was ordered on [DATE] and completed on 9/21/2017. The Psychiatric progress note reads: Per staff, patient has been refusing care and argumentative with staff. Resident #2 was diagnosed with [REDACTED]. On 9/24/2017 a Behavioral Symptoms Assessment was completed by RN # 1. Resident # 2 was noted to be exhibiting depression, anxiety, verbal aggression, agitation, irritability or [MEDICAL CONDITION], and was verbally abusive to staff. The resident was seen by Psych services on 9/25/2017. Resident # 2 was restarted on [MEDICATION NAME] 10 mg once a day for Depression and [MEDICATION NAME] 0.25 mg once a day for Anxiety, as both medications had been discontinued when the resident left the facility for a hospitalization that spanned 9/13/2017-9/17/2017. [MEDICATION NAME] is a medication used to treat anxiety. The addition of [MEDICATION NAME] 2 mg once a day was recommended. [MEDICATION NAME] is an antipsychotic medication used to treat Depression and other mental disorders. [MEDICATION NAME] was started on 9/27/2017. On 10/11/2017 a Behavioral Symptoms Assessment was completed by Nursing staff and reads: Patient noted talking and responding to him/herself. On 10/11/2017 a Facility Incident Report documented that at 11:50 PM Resident # 2 was noted to have been waving a pair of scissors and threatening staff. Per facility documentation the scissors were removed from Resident #2's room while he/she was sleeping. On 10/12/2017 AT 9:45 AM an order was written by MD # 1 to transfer Resident # 2 to the emergency room due to confusion. The resident returned to the facility that evening. Medical records from the hospital do not report that the resident presented a danger to self or others and did not include any new [DIAGNOSES REDACTED]. On 10/13/2017 A Psychiatric Progress Note reads: Patient denies talking to his/herself. Affect is neutral congruent with mood. Patient does not appear to be attending to internal stimuli. The note was updated to add: This writer saw the patient in his/her room this morning per facility request for medication review, hallucinations, and talking to his/herself. Patient seems stable during assessment. Order given over the phone to patient's nurse to transfer pt to ER (emergency room ) if patient becomes threat to self or others or if there is any change in patient's mental status. On 10/13/2017 a Behavioral Symptoms Assessment completed by Nursing staff indicated that the resident was exhibiting verbal aggression, agitation, irritability or [MEDICAL CONDITION], resistance to ADL's (activities of daily living), distressing delusional behaviors, socially disruptive behaviors, depression, unrealistic demands, unsafe impulsive behaviors and sleep problems. The note reads: Patient has been aggressive and agitated, during wound change today. (Resident #2) told the nurse that he/she would kick her if he/she could move her leg, stating the pair of scissors that the nurse had were his/hers and demanded that the nurse give them back to him/her. On 10/13/2017 a Physician's Progress Note entered in the record by MD # 1 reads: (Resident # 2) was mad at me because of transferring (him/her) to the ER the night before and stated that he/she has no mental issues and I am accusing him/her of mental problems. (Resident # 2) wanted to speak with his/her brother. I called his/her brother. He was worried about the patient and was asking me about him/her. I told him the things I witnessed on my last visit and the wound nurse's comments. He agreed about transferring him/her to the ER .(Resident # 2) was resistant. I told (Resident #2) that if he/she doesn't go I have to EP ((Emergency Petition)) him/her and the police comes and he/she has to go. (Resident #2) agreed to go at that point. When I was at the nurse's station two policewomen and two paramedics came to the station and told me they cannot EP the patient and from their point of view the patient is not a danger to him/herself or others. An Emergency Petition is a legal petition that calls for the emergency evaluation and potential involuntary hospitalization of an individual who presents as a danger to the life of self or others. Review of the medical record reveals that Resident # 2 declined to voluntarily transfer to the emergency room for evaluation at that time. MD # 1's 10/13/17 Physician's Progress Note continues: I completed an EP form in the DON's (Director of Nursing) office after, as he/she and the evening Nurse Supervisor were following the events. I called patient's brother and told him that I am EP'ing the patient. He agreed and was appreciative because he was concerned for (Resident # 2) and wanted to be made aware of the things happening to him/her. Review of the Resident's medical record reveals that Resident # 2 was Emergency Petitioned to theER on the evening of 10/13/2017. A Late Entry Nursing Progress note dated 10/14/2017 reads: This nurse received a call from the doctor at the ER department at about 2:45 AM requesting for the reasons why we have been trying to send patient to ER for the last 3 days because he/she is not seeing any acute distress in the patient. Nurse gave him the most current change in mental status in the patient as I received with response that he/she was going to keep patient in their psychiatrist ward for observation. Resident remains out for this 11-7 shift. Resident # 2 returned to the facility on [DATE] at 12:30 PM. Medical records from the hospital do not report that the resident presented a danger to self or others and did not include any new [DIAGNOSES REDACTED]. On 10/15/2017 a Behavioral Symptoms Assessment was completed for the resident. The progress note reads: Patient refused [MEDICATION NAME] and [MEDICATION NAME] scheduled for this AM stating that he/she does not want any psych medication. (Resident # 2) also stated that he/she does not want to see anyone from Psych. On 10/18/2017 Resident #2 was seen by MD # 2. MD # 2's Psychiatric Progress Note signed at 10:28 AM reads Patient admits that he/she was sent to ER, said he/she didn't threaten, but was reported to threaten with scissors. (Resident #2) denies and was returned from psych eval (evaluation) as not being dangerous to others. (Resident #2) admits now that he/she doesn't like the way people treat him/her. Is not taking [MEDICATION NAME] but is taking his/her [MEDICATION NAME] and [MEDICATION NAME]. Staff reports no threatening behavior since Friday, before he/she was sent to ER. The note identifies a Medication Intervention outlined as Discontinue [MEDICATION NAME], start [MEDICATION NAME] 1 mg PO (by mouth) BID (twice a day) discontinue [MEDICATION NAME]. [MEDICATION NAME] is an antipsychotic medication used to treat a variety of mental illnesses. Under the section labeled Diagnosis, Assessment and Plan, MD # 2 writes Steroid-induced [MEDICAL CONDITION], with delusions. Use [MEDICATION NAME] and increase [MEDICATION NAME], discontinue [MEDICATION NAME]. Refer to gero-psych unit, patient is not competent and brother can sign him/her into treatment there. There is no documentation in the chart to indicate that Resident # 2 was declared incapacitated by two physicians or ceded his/her decision-making powers to his/her brother at this or any other point in time. On 10/18/2017 at 18:20 PM A Care Plan Progress Note was entered into the medical record and reads: IDT (Interdisciplinary team) met in this resident's room per his/her request This resident remains his/her own RP (responsible party). He/she is A&Ox4 (alert and oriented to person, place, time and situation). (Resident #2) can effectively communicate his/her needs and express wishes. Last BIMS administered on 10/18/2017, resident scored 15/15, indicating cognitively intact. MOLST reviewed w/resident where he/she continues to exhibit full understanding and express wishes for FULL CODE .This resident's mood appears stable at this time. SS (Social Services) will continue to provide support. In interview on 1/24/2017 at 11:00 AM the Administrator stated that Resident # 2's has always been his/her own responsible party. It was never taken away and when there was an issue with Resident #2's [MEDICAL CONDITION] the brother was very involved, we kept him aware of everything. Medical record review revealed a Nursing Progress note entered into the medical record on 10/19/2017 at 3:55 PM which read: MD #2 is made aware of patient's refusal to take [MEDICATION NAME] 1 mg BID (twice a day) as ordered, new order to start liquid [MEDICATION NAME] 1 mg to be added to patient's drink per order BID, if ok with R/P (responsible party). Patient's brother made aware of new order and is ok with the order. MD made aware. Will continue to monitor. On 1/25/2018 at 2:50 PM MD #2 was interviewed and stated, Resident #2 had Lupus Induced [MEDICAL CONDITION]. He/She was unable to make decisions based on his/her best interest. I think someone said they didn't want Resident # 2 hospitalized . I felt if I could treat him/her her by getting the brother to substitute consent Resident # 2 could have the antipsychotic in his/her drink until the [MEDICAL CONDITION] was resolved. Once his/her [MEDICAL CONDITION] had cleared up he/she would be competent again. In that short term I thought, no need to get two certs (certifications of incapacity). We did not need to get certs because it was a temporary issue. I am the one who decides these things. In the hospital setting it just takes one opinion. Record review confirms that on October 19, 2017 an order for [REDACTED]. Said order was discontinued on October 19, 2017. A new order was initiated which stated that 1 mg of [MEDICATION NAME] Concentrate was to be administered by mouth two times a day for [MEDICAL CONDITION]. On October 27, 2017 a Physician's Progress Note entered into the medical record by MD # 1 reads: Per current nurse [MEDICATION NAME] is being mixed with water and Resident #2 is not aware of getting it. On January 24, 2018, at 1:24 PM MD #1 was interviewed and affirmed that he/she was aware that [MEDICATION NAME] was being concealed in the resident's water and felt that that action was appropriate. MD #1 stated: the brother said that Resident #2 was not the same, was abnormal and he was asking us to do something Resident #2 was interviewed on January 24, 2018 at 11:30 AM and stated: They kept changing medications. I had to tell them every day that I didn't want any psychedelic drugs. I had to check daily or they would try to add things in. MD #2 would add medications all the time that I would have to tell them I didn't want. When asked if the resident would feel comfortable with his/her brother making decisions on his/her behalf Resident #2 stated, My brother is willing to do whatever doctors tell him. I would not want him to make decisions about my medications. To do that I would have to make him my healthcare power of attorney and I haven't done that yet. On 1/24/2018 at 3:00 PM RN #1 was interviewed and stated, Resident #2 had behaviors, was angry and refusing his/her meds. The doctor made it into a liquid and said put it in his/her drink. The doctor got consent from the brother first. We didn't tell Resident # 2 after that, s/he would not have taken the medicine otherwise. LPN # 1 was interviewed on 1/24/2018 at 3:50 PM and affirmed that Resident #2 would routinely refuse [MEDICATION NAME]. When asked if the resident would take the medication if it was not concealed in the water, LPN # 1 responded No. Review of Resident # 2's MAR (Medication Administration Record) reveals that the resident was administered [MEDICATION NAME] 1 mg BID daily from 10/19/2017-12/16/2017 save for 11 instances of documented refusals. On 12/16/2017 MD # 3 discontinued the order for [MEDICATION NAME]. When interviewed on 1/26/2018 at 3:00 PM MD # 3 stated that he/she had no concerns regarding Resident # 2's decision making abilities. Per MD # 3 Resident # 2 requested the medication be discontinued and said that he/she did not need it and did not want to take it. There were no behavior problems so I discontinued it. The findings were shared with the Administrator and the Director of Nursing on 1/25/ 2018 at 4:15 PM.

Based on medical record review, interviews with the administrator, director of nursing and social worker, it was determined the facility staff failed to: 1. Ensure the end of life wishes was honored for Resident # 277 when the Primary care physician changed the MOLST form from the hospital from DNR to full code without evidence that CPR (cardiopulmonary resuscitation) were the wishes of the resident and 2. The facility staff failed to update and complete a new MOLST when the resident was assessed and the facility determined that CPR would be medically ineffective on [DATE] because of this action the resident has the high likelihood of suffering injury if CPR is initiated. This was evident for 1 of 30 residents selected for review in the stage 2 survey sample. The findings include: 1 A. The facility staff failed to ensure the end of life wishes were honored for a resident when the Primary care physician changed the MOLST form from the hospital from DNR to full code without evidence that CPR (cardiopulmonary resuscitation) were the wishes of the resident. Full code means that CPR should be attempted as a resuscitative measure if a person went into cardiopulmonary arrest. Medical record review revealed on [DATE] Resident # 277 was transferred to the facility from a hospital. The resident arrived with a MOLST form completed by the resident with collaboration of the physician while the resident was in the hospital on [DATE]. The MOLST form indicated Resident # 277 wanted to be a DNR/DNI with Supportive/Palliative Care. On [DATE] the resident was assessed in the facility by the primary care physician. The physician documented Patient is forgetful and confused. Does not have capacity to make decisions. I (the physician) wanted to discuss and review the MOLST form. Patient was confused regarding what she/he wants. Tried to contact the number on face sheet. Did not get an answer. Informed social work. Will mark full code for now and try to contact family. Interview with the social worker on [DATE] at 2:30 PM revealed the physician had already voided the MOLST form from the hospital prior to the social worker's completion of his/her initial admission assessment of the resident. The social worker revealed he/she was not sure why the physician voided the MOLST form from the hospital. The social worker also stated he/she spoke with the physician on [DATE] and the physician stated that he/she (the physician) was not sure that the previous MOLST form completed by the resident on [DATE] was valid because the resident was not able to verbalize their end of life wishes on [DATE]. It was also revealed that the physician attempted to contact the resident's family, but was not able to reach them to further reinforce the resident's end of life wishes. The social worker also revealed he/she spoke with the resident's family (surrogate) and the surrogate was going to come into the facility to review the end of life wishes of the resident, but at the same time the surrogate had other emergencies that kept her from the facility. Lastly, the social worker stated: It fell off the radar. A surrogate decision maker are advocates for incompetent patients. If a patient is unable to make decisions or decide for themselves about personal health care, someone else must provide direction in decision-making, as the surrogate decision-maker. Record review revealed on [DATE] the physician voided the MOLST from the hospital and completed a new MOLST making the resident a full code. (Capacity is the ability to make decisions with the consideration of: understanding the information provided; retaining the information long enough to consider the information provided; being able to weigh the information long enough to consider factors and the ability to communicate a decision). The (Medical Orders for Life-Sustaining Treatment) MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). DNR order, is a medical order written by a doctor in collaboration with the resident or Health Care Agent and it instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. The orders on a MOLST form are based on a patient's wishes about medical treatments. Further record review revealed on [DATE] the primary care physician completed a new MOLST that indicated the resident was to be a full code; however, there is no evidence the physician or facility staff thoroughly determined the end of life wishes for Resident # 277 prior to discontinuing the MOLST completed by the resident themselves on [DATE]. It was further noted the attending physician documented on Resident # 277's medical record on: [DATE], [DATE], [DATE], [DATE]; however, the physician failed to complete a new MOLST form for Resident # 277 to reflect the resident's last known end of life wishes. Furthermore, there was no documentation in the medical record regarding the rationale for why the facility's staff made the resident full code when the resident's last known end of life wishes, as evidenced by the resident's MOLST form which was completed just 4 days prior to admission, indicated that the resident desired to not undergo CPR. 1 B. The facility staff failed to update and complete a MOLST when Resident # 277 was assessed and the facility staff determined that CPR would be medically ineffective on [DATE]. Further record review for Resident # 277 revealed the resident was ordered to be a full code starting on [DATE] when the primary care physician voided the previous MOLST form completed by the resident on [DATE] indicating a DNR status. On [DATE] and [DATE], 2 physicians certified treatment would be medically ineffective including: CPR, Intubation, [MEDICAL TREATMENT] and Tube Feeding. However, the facility staff failed to ensure a new MOLST was completed to reflect the medical ineffective certifications. Medically ineffective treatment is defined by Maryland law as treatment that, to a reasonable degree of medical certainty (a probability of greater than 95%) will neither prevent nor reduce the deterioration of the health of an individual or prevent the impending death (according to the Attorney General's office impending death should encompass the timeframe of hours, a few days, or within the present hospital admission). It was further noted the attending physician documented on Resident # 277's medical record on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; however, the physician failed to reconcile or update the resident's MOLST form with the [DATE] and [DATE] Physician Certifications that certain treatments including CPR, would be medically ineffective. Interview with the Social Worker on [DATE] at 2:30 PM revealed that once the Physicians' Certification of Medical Ineffectiveness was completed, he/she flagged the chart to bring to the attention of the physician the need for a new MOLST form to be completed; however, he/she stated that once the chart was flagged, the physician failed to complete a new MOLST form. The social worker also stated, the physician failed to complete the new MOLST form in a timely manner and it just got missed. The social worker also revealed that the resident's family (surrogate) was notified via phone shortly after the medical effectiveness certifications were completed of the medical ineffectiveness that had been completed on [DATE]. During that phone conversation with the social worker, the surrogate also informed the social worker that the resident would not have wanted CPR. The family member (surrogate) was not able to come into the facility to complete the MOLST form and again, the social worker stated: it got missed. Interview with the Nursing Home Administrator on [DATE] at 2:30 PM revealed at the front desk of the facility is a folder for each physician. In that folder is communication between the facility staff and the physician. It was also revealed every day, each physician is to stop at the desk and review that folder for communication needs; however, the physician failed to address that communication folder to determine the need for the new MOLST form. As a result of the medical record review and interview it was determined the facility staff failed to honor the end of life wishes of Resident # 277 with: the physician arbitrarily changing the completed MOLST by the resident from DNR to full code and failure of the facility staff to complete a new MOLST when 2 physicians deemed that CPR would be medical ineffective for Resident # 277. As a result of the above interviews and medical record review for Resident # 277 an Immediate Jeopardy was called at 3:00 PM AM on [DATE]. The Plan of Correction submitted by the facilty to remove the immediacy of the Immediate Jeopardy included some of the interventions: A. The surrogate for Resident # 277 was contacted and confirmed the resident's desire to be a DNR/DNI. MOLST form corrected at that time and new MOLST reflecting the DNR/DNI placed on the medical record. B. A house wide audit by the social worker of all residents to access accuracy of MOLST forms with Certifications of Incapacity and Certifications of Medical Ineffectiveness. C. Binders placed on each unit for the physicians to facilitate communication and necessary interventions related to MOLST forms, Certifications of Incapacity and Certification of Medical Ineffectiveness. The Immediate Jeopardy was abated on [DATE] at 7:00 PM.

Based on medical record and facility investigation review, surveyor interview of facility staff and residents, as well as, resident observation it was evident that the facility failed to provide adequate supervision and assistance during bed mobility for a resident. This resulted in the resident falling from bed, landing face down on the floor between his/her bedside table and bed, sustaining physical and emotional trauma. This was evident for 1 (Resident #2) of 3 residents selected for review. The findings included the following: On 5/7/15 the surveyor reviewed Resident #2 ' s medical record and the facility investigation regarding her/his fall. By way of history, from 5/6/13-5/9/13 the resident had been in the hospital. Prior to that she/he had resided in an assisted living facility. While in there she /he had slipped and fallen resulting in a fractured left ankle which became displaced requiring surgical repair at the hospital. Her/his other [DIAGNOSES REDACTED]. The resident was discharged to the facility for rehabilitation. On 5/10/13 the resident was admitted to the facility from the hospital. On 2/17/15 the quarterly minimum data set (MDS) section G noted that the resident required extensive assistance and 2 persons for bed mobility (how the resident moved to and from a lying position, turned from side to side, and positioned his/her body while in bed). The correlating care plan and Geriatric Nursing Assistant (GNA) task sheets, also, noted that 2 persons were to assist with bed mobility, turning, positioning and incontinent care. These were the assessments, plan of care and tasks to be carried out by the facility staff at the time of the fall. On 4/14/15 at 11:24 PM, per the progress notes, the resident fell from bed landing face down while being turned by GNA #1 as she provided care by herself. Resident #2 was assessed to have a very large hematoma (collection of blood outside of the vessels, larger than 10 centimeters) in the center of his/her forehead. He/she complained of left ankle pain at a rate of 7/10 (on a scale of 1-10) and the physician ordered that the resident be transferred to the emergency room (ER). On 4/15/15 at 12:39 AM, the resident was assessed at the hospital for head trauma. Her/his injury was described as a concussion (a traumatic injury to the brain, usually caused by a blow to the head) and contusion (an injury from a blow to the head that doesn't break the skin but causes discoloration with signs and symptoms of a lump/bump with pain and swelling). At 1:30 AM, per the physician order [REDACTED]. Her/his head was to be elevated in bed; a follow up visit was to be scheduled with his/her physician; neurological assessments were to be done; ice was to be applied to his/her forehead; and complaints of pain were to be treated with medications, as needed. At 4 PM, per the POS, new orders included: ice packs to both eyes for 10-20 minutes for 48 hours from 8 AM-12 PM as the areas around both eyes had become discolored. X-rays of the right hip and left ankle because of pain. At 9:40 PM, the X-rays of the left ankle and hip were negative for a fracture. The radiologist noted to consider an X-ray of the pelvis as there was a possibility of a fracture on the right hip. On 4/15/15 the Administrator (ADM) documented a summary of interviews with the resident, her/his son and the resident's roommate. According to the interviews the resident felt as though the GNA that was with him/her at the time of the fall, GNA #1, had pushed him/her out of bed and was being nasty. On 4/16/15 there was an order for [REDACTED]. The physician described a large frontal hematoma on the forehead, tenderness of the right hip and some edema of the left leg. At 3:42 PM there was an order for [REDACTED]. At 5:59 PM the pelvis x-ray results were negative for a fracture. At an undocumented time GNA #1 was interviewed by the Director of Nursing (DON) and Human Resources Director (HRD). GNA #1 was the only person with the resident at the time of the fall. Her statement noted that she asked for help from other staff members before providing care to Resident #2 but that nobody was available so she provided care alone - the resident fell from the bed landing face down on the floor. On 4/17/15 at 1:20 PM the Certified Registered Nurse Practitioner (CRNP) assessed Resident #2 noting some facial grimacing and changed the pain management regime. The Tylenol was increased from 500 milligrams to 1000 mg every 8 hours and Tramadol 25 mg (a narcotic-like medication) was added at 10 AM and 4 PM for 14 days to help with the facial pain. At an undocumented time, GNA #10 was interviewed by the nursing supervisor. The documented statement noted that GNA #10 described Resident #2 stating that he/she was afraid of turning on his/her side as a result of the fall. At an undocumented time there was a statement from Nurse #4. She had responded to Resident #2's fall on 4/14/15 and described hearing GNA #1 screaming from the resident's doorway. She described the resident to be face down between the bed and the bedside table. During her assessment she described feeling a goose egg on Resident #2's forehead - a lump. Nurse #4 was quoted to state that the resident had that panic look in his/her face like somebody is going to get in trouble. On 4/21/15 the HRD gave GNA #1 an employee warning notice which GNA #1 refused to sign. The documentation which made the final warning/ termination necessary included the following: on the evening of 4/14/15 while providing activities of daily living (ADL) care GNA #1 did not follow the plan of care. As a result the resident fell from bed which caused significant physical and mental injury. In addition, GNA #1 was not honest in her statements when she described asking for help of other GNA's - which was unconfirmed during the investigation and statements of other staff. On 4/22/15, the initial psychiatric evaluation was done because the resident felt he/she was pushed out of bed and that GNA #1 should have had someone else with her. She/he was described to have significant facial bruising and follow up emotional support was recommended. On 5/1/15 the CRNP noted that the resident still complained of aching all over including his/her face/head. The Tramadol was increased from 25 mgs to 50 mg at 8 AM and 25 mg at 4 PM. On 5/5/15 psychotherapy consulted again noting that the resident was healing from the recent fall with supportive therapy. On 5/7/15 at 9:34 AM the surveyor interviewed the Administrator (ADM) and Director of Nursing (DON). The ADM stated that the facility investigation revealed that the resident had been in bed while GNA #1 provided care. That GNA rolled Resident #2 on her/his side while she/he was holding on to the night stand and rolled out of the bed when the table rolled. The ADM added that prior to the fall the resident had been evaluated to require 2 persons for bed mobility - the GNA had been alone with the resident. She added that the GNA was terminated because, she felt, and that if there had been 2 persons in the room the resident would not have had to hold on to the bedside stand which slid away resulting in the resident's fall and injury. At 10:24 AM the surveyor observed, as well as, interviewed Resident #2. The resident observation took place more than 3 weeks after the fall. There was a raised area about the size of a nickel in the center of his/her forehead, above his/her eyes. The area protruded about 1 centimeter, about the depth of a fingertip and was varying degrees of yellow, brown, blue, green, and purple. The resident was touching the area. Both sides of her/his face were discolored. The left side was discolored from right above and into the eyebrow with a patch about 1.5 cm, the length of a fingertip and was varying degrees of brown, yellow, green, blue and purple. The areas on both cheeks were varying degrees of blue, green, yellow and purple and ran from beneath both eyes to both sides of the chin down onto the neck below the jaw. The surveyor observed the resident's room. It was a large double occupancy room, her/his bed was located in the area next to the window. The area between the bed and window was about 4 feet. The bedside table was between the bed and window at a slanted angle. The surveyor interviewed Resident #2 who remembered the events of the fall. She/he recalled that the aide (GNA #1) told him/her to roll over. When he/she told GNA #1 that he/she needed some help GNA #1 pushed him/her. The resident went on to describe falling face down on the floor and hearing a wham - smacking his/her hands together and stating, like that. She/he described lying on the floor until help came - feeling pain in his/her face, ankle and hip. She/he added that he/she was afraid of GNA #1. She/he recalled going in an ambulance and coming back to the facility late that night. The facility failed to provide adequate supervision and assistance during bed mobility for the resident. This resulted in the resident falling from bed, landing face down on the floor between his/her bedside table and bed, sustaining physical and emotional trauma.