Every finding on record at Bay Harbor Post Acute Healthcare Center

Based on medical record review and interviews, it was determined that the facility staff failed to enter medication orders into a resident's electronic health record (EHR). This deficient practice was evidenced in 1 (R #238) of 5 resident records reviewed for medication administration during the recertification survey. The deficient practice resulted in harm to R#238.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/13/2026. The findings include:On 04/15/26 at 4:05 p.m., a review of the facility's investigation concerning R #238 revealed the resident was discharged from a local hospital on [DATE] and was readmitted to the facility about 12:30 am on 03/07/26. Registered Nurse (RN) #28 was the receiving nurse at the facility and was responsible for completing the admission, which included ensuring the physical assessment was documented and entering the resident's medication orders.On 04/16/26 at 9:55 a.m., a review of R #238's discharge summary revealed the resident was ordered Acetaminophen (Tylenol) 650 mg every (q) 5 hours (hr) PRN (as needed), Eliquis 10 mg by mouth (PO) twice a day (BID) for three 3 days, and 10 other medications. The only medication the resident received was Acetaminophen. Eliquis was the medication prescribed to help prevent the resident's blood from clotting.On 04/16/26 at 11:36 am, during an interview with Director of Nursing #2, she verbalized R #238 came to them on a Friday night a little after midnight; RN #28 was the assigned nurse, and the resident was a readmission. Sunday before lunch, the resident's daughter reported they had leg pain and wanted the resident to go to the hospital. The resident's daughter asked RN #26 about the resident's medications, and it was discovered their admission medication orders were not entered. The resident's previous orders were on the chart, but the new admission orders were not entered. The resident returned to the facility with a new order for Eliquis; three doses of Eliquis were not given because the new medication orders were not entered into the EHR. The resident developed a clot and required a thrombectomy (a medical procedure used to remove a blood clot from a blood vessel).On 04/16/26 at 12:06 pm, during an interview with RN #26, she verbalized R #238 asked for pain medication and they told the medicine aide to give the resident Tylenol. The resident didn't complain of pain any longer. When the resident's daughter came to the facility to visit her parent, they asked if the resident received their pain medication; RN #26 verbalized yes. The daughter named the medication the resident was prescribed, but RN#26 didn't see the medications. There were only two medications on the medication administration record (MAR). When RN #26 read the discharge (DC) summary, they realized the medications were not entered. Nurse Supervisor #39 was made aware of the error and reviewed the medication regimen with the family. Nurse Supervisor #39 administered pain medication to the resident; the resident was reassessed after they received the pain medication. Resident #238 daughter requested her parent to be sent back to the hospital. The resident was sent back to the hospital.On 04/16/26 at 4:00 pm a review of R #238's operative note dated 03/08/26 revealed the resident was diagnosed with left lower extremity acute limb threatening ischemia with a recent history of left atrial thrombus (clot) with planned outpatient oral anticoagulation that was not continued after discharge from the hospital. R #238 underwent a left femoral tibial open embolectomy (surgical removal of a clot).On 04/16/26 at 7:07 pm during an interview with RN #28, who was assigned to admit Resident #238, she verbalized that the resident arrived early in the morning and they were unfamiliar with the readmission process. When a resident came back to the facility, they must start the whole process over; he/she thought everything carried over. The surveyor asked RN #28 if they reported to the oncoming nurse that the admission was not complete. RN #28 verbalized not being able to remember everything, but Nurse Supervisor #39 was made aware the admission was not complete. The surveyor asked RN #28 if the standard of practice was to give a report to the oncoming nurse or the supervisor. RN #28 verbalized they must have told the nurse.On 04/16/26 at 7:29 pm the surveyor completed a review of credible evidence to ensure the facility plan of correction was followed. An audit was completed of all new admissions within the past 30 days. The facility initiated a New Admission/readmission Checklist to be completed when every new admission/readmission comes to the facility. Also, the medications are reviewed to ensure the medications are entered into the electronic health record. All licensed nurses were reeducated on the admission process. All licensed nurses were re-educated on the process of completing a 24-hour chart check daily on the 11-7 shift to ensure all new orders for the day.Based on the above actions taken by the facility and verified by surveyors on site, it was determined that the facility's deficient practice was past-noncompliance with a compliance date of 3/13/26.

Based on observations, resident interview, and record review, and staff interview, it was determined that the facility failed to: 1.) supervise and identify residents needing assistance with smoking and 2.) ensure adequate supervision of residents in wheelchairs. This was evident for 4 (Resident #83, # 8, #47, #68) out of 32 residents reviewed during the recertification survey. 1. The survey team made several observations of residents sharing cigarettes in the designated smoking area from 4/12/26 – 4/15/26. The survey team requested the smoking policy on 4/12/26 at 1:00pm. Review of the smoking policy on 4/15/26 at 10:00am revealed residents are not permitted to share smoking items including cigarettes with another resident. The survey team interviewed smoking aide #14 on 4/16/26 at 12:30pm regarding smoking policy and his/her responsibilities as a smoking aide. Smoking aide #14 stated that he/she was responsible for monitoring residents in the designated smoking area. Smoking aide #14 admitted that he/she observed residents sharing cigarettes on many occasions. Smoking aide #14 also admitted that he/she failed to intervene when he/she observed residents sharing cigarettes in the designated smoking area. The survey team interviewed Activity Director #13 on 4/16/26 at 2:00pm regarding responsibilities and training of the smoking monitors. Activity Director #13 stated that the smoking monitors were trained to ensure that the facility smoking policy is adhered to by the residents. Smoking monitors are also responsible for informing nursing staff of policy violations by residents to ensure that smoking evaluations and any smoking privileges match the resident's status. The survey team interviewed the Director of Nursing (DON) regarding residents sharing cigarettes. The DON stated that he/she was aware that residents shared cigarettes. The survey team asked the DON if the facility placed the residents violating facility smoking policy on an improvement plan and the DON admitted that the facility failed to place the violation of smoking policy on an improvement plan. 2. The survey team made several observations of ambulatory residents pushing wheelchair bound residents without foot rests from 4/12/26 – 4/15/26. Several residents stated that facility staff will not push wheelchair bound residents without a foot rest. The survey team interviewed the Director of Nursing (DON) on 4/16/26 at 1:30pm regarding ambulatory residents pushing residents without foot rests. The DON confirmed that facility staff are trained to only push wheelchair residents with a foot rest. The survey team stated that they observed several ambulatory residents pushing wheelchair bound residents without foot rests. The DON stated that he/she was aware that ambulatory residents were pushing wheelchair bound residents without foot rests. The DON also stated that ambulatory residents are counseled about the safety concerns of pushing wheelchair bound residents without foot rests. The DON further stated that the ambulatory residents continue the action and .we can't tell residents what to do. 3. On 4/14/2026 at 9:45 AM, a review of Resident #83's record was conducted. The smoking evaluation from 4/19/2024 stated that Resident #83 did not smoke. The most recent smoking evaluation of 3/24/26 stated that Resident #83 does not smoke. According to the resident record, the resident's Brief Interview for Mental Status score is 15 and the resident was a quadriplegic. A BIMS (Brief Interview for Mental Status) score is a 0–15 rating used in long-term care to assess cognitive function, focusing on orientation, memory, and recall. It is mandatory for nursing home admissions to track cognitive health. Higher scores indicate better cognitive function, with scores of 13-15 representing normal memory and 0-7 indicating severe impairment. On 4/14/2026 at 10:52 AM, an interview with Resident #83 was conducted. Resident #83 stated that they go out to smoke during the daytime. Resident #83 stated that they ask other residents for cigarettes because they don't have any. When asked if the staff member outside that supervises them is okay with them asking other residents for cigarettes and smoking out there, Resident #83 stated, yes. When asked who was out supervising when they are smoking, the resident stated that usually Staff #14 or another activities staff member is out with them. On 4/14/2026 at 11:08 AM, an interview was conducted with the Director of Nursing (DON). When asked if nursing was aware that Resident #83 had recently started smoking, the DON stated that they were not aware. On 4/15/2026 at 9:58 AM, an interview with Staff #14 was conducted. When asked what is done when they notice anybody with new limitations, Staff #14 stated that they notify their boss. When asked if they have seen Resident #83 smoking outside, Staff #14 stated they have seen Resident #83 out there once or twice. When asked if it was common for residents to request cigarettes from other residents, Staff #14 stated, yes. On 4/15/2026 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Resident #83was evaluated yesterday (4/14/2026) after the survey team made them aware. The DON stated that the facility was not providing a list of current smokers to the activities staff prior to surveyor intervention. The DON stated that the activities staff were educated to make the nursing staff aware of anybody that is a new smoker or needs to be evaluated. 4. On 04/13/2026 at 10:22 AM, an interview with Resident #8 was conducted. They reported that they fell yesterday because another resident was pushing their wheelchair too fast. When asked why another resident was pushing them on the wheelchair, the resident stated that the facility staff had been told not to push residents on wheelchairs if a resident did not have footrests on. On 04/14/2026 at 4:20 AM, another surveyor observed Resident #47 pushing Resident #68 who was in a wheelchair without footrests. On 04/15/2026 at 9:14 AM, while conducting an observation of the facility's smoking designated area, the surveyor observed 3 other residents who were pushing residents in wheelchairs. On 04/15/2026 at 9:15 AM, an interview with Staff #21 was conducted. When asked if residents pushed other residents who were in wheelchairs, the staff stated that it occurred often because the facility staff had been trained not to push a resident on a wheelchair without footrests on. On 04/15/2026 at 1:23 PM, an interview with the Director of Nursing (DON) was conducted. She reported that the facility staff was trained and asked not to push residents if they had no footrest on the wheelchair. The DON also reported that there was no evidence that residents were educated on safe wheelchair use or instructed not to push other residents. The surveyor requested a copy of the education training that was provided to staff. On 04/16/2026 at 10:02 AM, the DON reported that she could not find the training education that was provided to the staff. At this time, the surveyor notified the DON of the supervision concerns.

Based on interviews and observations, it was determined that the facility failed to ensure that the smoking designated area was safe for residents who used wheelchairs. This was evident during a tour of the smoking designated area.The findings include:On 04/13/2026 at 10:22 AM, an interview with Resident #8 was conducted. They reported that residents who use wheelchairs to access the smoking area had a difficult time because the ramp is crooked and wheelchairs get stuck causing residents to fall. On 04/15/2026 at 9:04 AM, the surveyor toured the designated smoking area for residents. An inclined ramp was noted that leads to a gazebo and several uneven surface areas. On 04/15/2026 at 9:14 AM, an interview with Staff #21 was conducted. She reported that residents who are in wheelchairs had a hard time getting over the door seal to go over the ramp. She also reported that the door closes too fast which caused problems for residents and that she had witnessed several residents' wheelchairs [NAME] off the paved pathway and resulted to falls. At this time, Staff #21 pointed to an uneven surface area and stated, that's where the wheelchairs get stuck. When asked if she had reported these safety concerns to the administrator, she stated that she had reported them to her supervisor. On 04/15/2026 at 09:27 AM, an interview with Staff #35 was conducted. He reported that residents get stuck on the ramp often, he also reported that he had witnessed residents get hit by the door several times. He clarified that the doors to the smoking area opened slowly but closed too fast. On 04/15/2026 at 1:23 PM, an interview with the Director of Nursing (DON) was conducted. She reported that the facility has had a couple of fall incidents that happened in the smoking designated area, but no one had reported that residents were being hit by the door because it closed too fast. On 04/15/2026 at 1:46 PM, the DON was made aware of the safety concerns.

Based on record reviews and interviews it was determined that the facility failed to ensure complete and accurate dialysis orders were present for residents receiving dialysis services. This was evident for 1 (Resident #223) out of 1 residents reviewed for dialysis. The findings include: On 04/13/2026 at 9:47 AM, Resident #223's record review failed to reveal an active dialysis order. On 04/14/2026 at 6:28 AM, an interview with the Director of Nursing revealed that residents receiving dialysis are expected to have active dialysis orders in place. On 04/16/2026 at 10:57 AM, the concerns were brought up to the Director of Nursing and Nursing Home Administrator and they indicated that they understood.

Based on review of Geriatric Nursing Assistant personnel files and interviews it was determined that the facility failed to conduct yearly performance reviews at least every 12 months on 1 (Staff #24) out of 5 personnel files reviewed. The findings include: On 04/15/2026 at 3:00 PM, a review of Geriatric Nursing Assistant (Staff #24) personnel files revealed that there was no yearly evaluation in the personnel files. On 04/16/2026 at 10:35 AM, an interview with the Nursing Home Administrator revealed that she was unable to locate it. On 04/16/2026 at 10:57 AM, the concerns were addressed with the Nursing Home Administrator and Director of Nursing and they indicated that they understood.

Based on record reviews and interviews it was determined that the facility administered medication to a resident without clinical indication. This was evident for 1 (Resident #54) out of 9 residents reviewed for medication administration. The findings include: On 04/13/2026 at 12:04 PM, a complaint alleged that Resident #54 was administered Gabapentin (anticonvulsant) without clinical indication. On 04/13/2026 at 12:47 PM, record review revealed that Resident #54 did not have an active or discontinued order of Gabapentin. On 04/13/2026 at 12:50 PM, record review revealed that Resident #54 experienced side effects, including dizziness, following the administration. On 04/14/2026 at 9:27 AM, an interview with the Director of Nursing revealed that the medication error occurred and that the Gabapentin was intended for a different resident. On 04/16/2026 at 10:57 AM, the concerns were addressed with the Nursing Home Administrator and Director of Nursing and they indicated that they understood.

Based on interviews, observations and review of records, it was determined that the facility failed to provide routine dental services to residents. This was evident for 2 (Resident #56 and #9) out of 3 residents reviewed for dental services during the annual survey. The findings include:1.) On 04/13/2026 at 10:02 AM, an interview with Resident #56 was conducted. They reported that they had seen a dentist a while ago but was unsure when the follow-up was because the facility had not communicated. On 04/14/2026 at 10:58 AM, a review of Resident #56's medical records failed to reveal any dental notes or evaluations. The Director of Nursing (DON) was asked to provide dental assessments for the resident.On 04/14/2026 at 11:27 AM, an interview with the DON was conducted. She reported that she could not find any notes that indicated Resident #56 had been seen for routine dental evaluation. The only note available was an oral assessment completed when the resident was admitted into the facility. On 04/15/2026 at 10:10 AM, during a follow up interview, the DON confirmed that the resident had not been seen by dental services since 2024 and that the resident qualified to be seen by health drive for routine dental services. 2.) On 04/13/2026 at 10:34 AM, an interview with Resident #9 was conducted. They reported that they used to wear dentures and had not seen a dentist for about 2 years. The surveyor observed that the resident had a chipped tooth.On 04/14/2026 at 10:58 AM, a review of Resident #9's medical record was conducted. The review failed to reveal any dental evaluations or notes. On 04/14/2026 at 11:27 AM, an interview with the DON was conducted. She confirmed that the only oral evaluation completed was during the resident's nursing admission assessment. On 04/15/2026 at 10:17 AM a brief follow-up interview with the DON was conducted. She confirmed that Resident #9 had not received any routine dental services. She reported that she was unsure why because the resident qualified for routine dental services through health-drive.During this interview, the surveyor notified the DON of the dental concerns.

Based on observations, interviews and record reviews, it was determined that the facility failed to serve residents meals based on their menu tickets. This was evident for 2 residents (Resident #137 and #81) out of 4 residents observed during dining.The findings include: On 04/16/2026 at 1:03 PM, the surveyor observed the meal tray for Resident #137. Meal ticket indicated that the resident was to be served 8 oz of whole milk, however this resident's meal tray did not have milk. On 04/16/2026 at 1:04 PM, a brief interview was conducted with Resident #137. They reported that they did not like the facility's food, and that they looked forward to having milk, because it was the only thing they liked during mealtimes. Resident #137 added that they were not served milk today. Staff #5, Regional Food Service Director, was present during this interview, and confirmed that the resident was not served milk. On 04/16/2026 at 1:08 PM, surveyor and Staff #5, made another observation. Resident #81's meal ticket indicated that the resident should have been served pasta for lunch, however, the resident was served mashed potatoes. On 04/16/2026 at 1:22 PM, an interview with Staff #33, Facility's Food Service Director, was conducted. She reported that the employee at the end of the food line is responsible for ensuring the meal ticket matched what was served. She also acknowledged that residents should be served what is indicated on their meal tickets.On 04/16/2026 at 2:30 PM, the facility administrator was notified of the concern.

Based on medical record review and interview, facility nursing staff falsely documented medication administration to a resident (resident #244) when the medication was given to another resident (resident #237). This was evident in 1 of 8 residents reviewed; and failed to document when a resident who had wounds was repositioned to offload pressure. This was evidenced in 1 (#236) of 2 resident records reviewed with wounds during the recertification survey. Findings include: 1. Surveyor review of a complaint (2797325) on 4/13/26 at 9:00am alleging that a member of the facility's nursing staff erroneously administered medications to resident #237 that were prescribed for the resident's former roommate that had discharged earlier in the day. Review of resident # 237's medical records on 4/13/26 at 9:30am revealed a change in condition progress note dated 3/4/26 at 11:30pm stating that the resident was given his/her roommates night-time medication. Further review of the medical records revealed no adverse symptoms from the incorrect medication administration. Additional review of the resident's medication administration record revealed no record of the incorrect medication administration on 3/4/26 Interview with the Director of Nursing (DON) on 4/14/26 at 6:00am confirmed Resident #237's incorrect medication administration. The surveyor asked the DON if the facility investigated the root cause of the incorrect medication administration incident. The DON stated the facility investigated the incident and provided the investigation to the surveyor. Review of the incorrect medication administration incident investigation on 4/14/26 at 8:30am revealed CMA #44 failed to verify resident # 237's identity prior to administering medication that was prescribed for resident #244. CMA #44 stated in a statement that he/she administered the medication prescribed for resident #244 without verifying the resident's admission status. Review of resident #244's medical record on 4/14/26 at 9:00am revealed that the resident discharged from the facility on 3/4/24 at approximately 2:00pm. Further review of resident #244's medical record revealed medication administration documented administration of the following medications at 2200 (10PM): 750 mg Methocarbanol 40 mg Lipitor 0.25 ropiniol 81 mg asprin 60mg Cymbalta 25mg metoprolol 40mg protonix 500mg x2 bactrim 400mg x2 gabapentin 2. On 04/13/26 at 9:15 am a review of Resident #236 electronic health record (EHR) revealed during the resident's admission they had a wound on their right heel, (R) ischial, and sacrum. The surveyor checked the Task section to verify the resident was being turned to offload pressure; there was no documentation to verify the resident was being repositioned. On 04/13/26 at 10:34 am a review of Resident #236's MDS assessment review date (ARD) 12/12/25 Section GG0170 the resident required substantial maximum assistance with rolling to the left & right. The resident did not have the ability to roll from lying on back to the left and right side and return to lying on back in bed. On 04/13/26 at 10:48 am during an interview with LPN #27 the surveyor asked how often did the staff reposition a resident who was unable to turn independently and where was that documented? The nurse verbalized the typically go into the residents' room every two hours to reposition them; it's not documented anywhere for the nurses. On 04/13/26 at 10:49 am during an interview with GNA # 16 they verbalized when they need to turn a resident they would get a co-worker to assist or use the draw sheet to change the resident's position and they used to be able to document it in the Task Section in PointClickCare but now there is no place to document that it was done. On 04/13/26 at 10:50 am RN Unit Manager #6 reported if a resident had a wound they would have an air mattress. A wound Stage 3 or higher the resident would have an air mattress that rotates on a 20-minute cycle. The GNA's check them and offload pressure with pillows and documentation should be on the Kardex.

Based on observations, record review, and staff interview, it was determined that the facility failed to follow appropriate infection control practices while providing care. This was evident in 4 (Resident #14, #83, #240, and #196) out of 61 residents reviewed for infection control.Enhanced Barrier Precautions (EBP) are an infection control strategy for nursing homes, requiring gowns and gloves during high-contact resident care to prevent the spread of multidrug-resistant organisms. 1.) On 4/13/2026 at 6:47 AM, an observation of Resident #14 was made. The resident had a tracheostomy and an Enhanced Barrier precaution sign outside their door. On 4/13/2026 at 8:51 AM an observation of care provided to Resident #14 by Staff #37 was conducted. Staff #37 performed trach care with gloves but did not use an isolation gown. On 4/16/2026 at 4:19 PM, an interview was conducted with the Infection Preventionist (Staff #3). When asked if they were aware of the infection control concerns observed by the survey team, Staff #3 stated that she was made aware of all of the concerns and has educated all staff in the facility and complete teachable moments with specific staff members who displayed improper use of Enhanced Barrier Precautions. 2.) On 04/12/2026 at 11:53 AM, during the initial tour of the facility, Resident #196, who had a peripherally inserted central catheter (PICC line) and a wound vacuum device, had signage posted outside of the resident's room indicating Enhanced Barrier Precautions (EBP). During the observation, a Registered Nurse (Staff #37) entered the resident's room and did not don a gown while performing a blood glucose check. On 04/12/2026 at 12:01 PM, during an interview with the RN (Staff #37), She stated that she should have had a gown on when providing direct care with a resident on EBP, which included obtaining the blood glucose finger stick for that resident. 3.) On 4/12/2027 at 12:06 PM, during an interview with Resident #240, they stated that they were diagnosed with Clostridioides difficile (C-Diff) on 4/11/2026. The precaution signage posted outside the resident's room indicated Enhanced Barrier Precautions rather than Contact Precautions, which are required for residents with active C. diff infection per current infection control standards. During the observation, at the same time, a visitor was present in the room and was noted to be wearing gloves but not wearing a gown while in direct contact with the resident's environment. On 4/12/2026 at 12:31 PM, during an interview with Staff #3, the Infection Preventionist, she confirmed that Resident #240 was diagnosed with C-Diff on 4/11/2026. She confirmed that when a resident has C-Diff they require Contact precautions. She further stated that everyone that goes in and out of the room, including staff and visitors, were required to wear isolation gowns and gloves. She confirmed that the wrong signage was posted outside of the door and after surveyor intervention, the sign was changed. 4.) On 04/14/2026 at 4:24 AM, during unit observation, surveyor observed Staff #36, providing a bed bath to Resident #83. On the resident's door, there was a sign that indicated the resident was on Enhanced Barrier Precautions (EBP). On 04/14/2026 at 4:28 AM, a review of Resident #83's records was conducted. The review revealed an active EBP precautions order. On 04/14/2026 at 5:06 AM, an interview with Staff #36 was conducted. When asked why the staff was not wearing the indicated Personal Protective Equipment (PPE), a gown and gloves, Staff #36 replied, nobody uses the PPE. On 04/14/2026 at 5:10 AM, an interview with Resident #83 was conducted. They reported that the facility staff does not wear the appropriate PPE when providing direct care to them. On 04/14/2026 at 5:42 AM, the Director of Nursing was notified of the concern.

Based on observations and staff interview, it was determined that the facility failed to maintain a homelike environment. This was evident for 1 (Resident #83) out of 57 residents reviewed for environment. The findings include: On 4/14/2026 at 5:36 AM, an observation of Resident #83's room was conducted. Resident's nightstand drawer front was detached and placed inside of drawer. On 4/14/2026 at 9:14 AM, an interview was conducted with the Director of Nursing (DON). This surveyor showed the DON Resident #83's broken drawer. The DON stated they would take care of the drawer. On 4/14/2026 at 11:12 AM, an observation of Resident #83's room was conducted. The drawer was repaired after surveyor intervention.

Based on review of facility investigation, resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of verbal abuse. This was evident for 1 (Residents #57) of 6 residents reviewed for abuse.The findings include: On 04/16/2026 at 3:50 PM, a review of facility reported incident # 2726069 was conducted. The review alleged that on 1/15/2026, Staff #40 verbally abused Resident #57. On 04/16/2026 at 3:58 PM, a review of the facility's investigation records indicated that the facility had verified the abuse allegation. The review revealed a witness statement from Staff #21 who heard Staff #40 tell Resident #57, Just come inside, sit down, and shut up. A review of Staff #40 interview statement conducted by the Director of Nursing (DON) revealed that the staff had asked the resident to come inside from the smoking area. Resident #57 stated that they did not want to come, and the staff told the resident to shut up and come inside.On 04/16/2026 at 5:00 PM, an interview with Staff #13, Activities Director, was conducted. She recalled that on the day of the incident, she was notified by Staff #21 that Staff #40 was going back and forth with a resident and told the resident to shut up.On 04/16/2026 at 5:03 PM, an interview with the DON was conducted. She reported that during the facility's investigation, Staff #40 reported that he had words back and forth with Resident #57 and that the staff confirmed that he stated come inside and shut upOn 04/16/2026 at 5:08 PM, the DON was notified that this was a concern.

Based on record review and interviews, it was determined that the facility staff failed to ensure a resident's belongings were secured until the family was able to acquire them. This deficient practice was evidenced in 1 (#239) of 1 record reviewed for misappropriation of property during the recertification survey.The findings include: On 04/15/26 at 1:12 pm the surveyor reviewed the Self Report concerning Resident #239's missing cell phone. The resident transitioned on 03/17/26; when the family went to the facility to pick up the resident's belongings, his/her cell phone was missing. The resident's daughter reported to the Administrator on 03/20/26 at 1:08 pm that the resident's phone was missing. The laundry and the resident's room were searched, and the staff was unable to locate the phone. On 04/15/26 at 1:32 pm a review of a note dated 03/17/26 at 12:16 am indicated the resident passed and the family would come to the facility to collect the resident's belongings. A statement written on 03/19/26 at 7:32 pm by Nurse Supervisor #43 indicated the resident's family went to the facility to look for the resident's phone. When the phone could not be located at the police were notified. On 04/15/26 at 2:37 pm the surveyor read a statement written on 03/16/26 that indicated when Resident #239 passed, GNA #42 took money that was under the pillow to the nurse's station. The money was placed in the Unit Manager's office. On 03/23/26 GNA #30 wrote a statement indicating that on 03/18/26 during the 3 pm-11pm shift they saw the resident's cell phone and placed the phone in a green Bay Harbor bag. The bag was left in the room although the resident passed and was no longer able to use the phone. GNA #31 wrote a note on 03/24/26 indicating they saw the phone on Resident #239's bedside table on 03/17/26 during the 11 pm- 7 am shift. A note was written by RN Unit Manager #6 indicating the family went into the room and there was no phone or charger in the room. On 04/16/26 10:47 am, during a telephone interview with GNA #30 the surveyor asked when a resident passes what do they do with the resident's belongings. GNA #30 verbalized they pack up the belongings and put them behind the nurses' station with the resident's name on the bag. The belongings stay on the unit a day or two before housekeeping takes the belongings downstairs. There is not a place for them to secure the belongings until they are retrieved by the family. They put the residents name on a piece of paper inside the bag. GNA #30 terminated the call before the surveyor could ask further questions. On 04/16/26 at 2:30 pm during a telephone interview with GNA #31 the surveyor asked when Resident #239 passed what they did with the belongings. GNA #31 verbalized they didn't mess with anything because they were not told to do anything; usually the family picks up the belongings. The surveyor asked what the policy is. GNA #31 verbalized they were not sure about the policy, but the other aide should have packed it up. They worked 11pm -7 am; the resident was already gone. On 04/16/26 at 3:30 pm the surveyor reported to Administrator #1 that when Resident #239 transitioned, GNA #30 and GNA #31 saw the resident's cell phone and did not secure the phone. The cell phone was unable to be located, and the facility would be cited for misappropriation of property.

Based on record review and staff interview, it was determined that the facility failed to provide the resident or representative with the required discharge documentation. This was evident for 1 (Resident #230) out of 2 residents reviewed for hospitalizations.The findings include:On 4/16/2026 at 12:09 PM, a review of Resident #230's records was conducted. According to a nursing note on 3/15/2026 at 5:12 PM, the resident was sent to the hospital on 3/15/2026. The note stated that the resident's sibling was notified. Upon further investigation, the resident's profile stated that the resident was their own representative. On 4/16/2026 at 12:30 PM, an interview with the Director of Nursing (DON) was conducted. This surveyor requested evidence of written notification of discharge and bed hold notification that was provided to the resident or representative. The DON stated that the facility notifies the family and residents verbally of transfer. This surveyor referred the DON to the requirement of notifying the resident or their representative in writing of the reason for transfer. DON stated that they would look to see if the facility notified the resident or representative in writing and if the bed hold policy was provided. On 4/16/2026 at 1:01 PM, the DON confirmed that the resident or representative was not provided a written reason of transfer to hospital nor evidence that the bed hold policy was provided to the resident or representative.

Based on record review and staff interview, it was determined that the facility failed to complete Minimum Data Set Assessments accurately. This was evident for 2 (Resident #15 and #28) out of 8 residents reviewed in the Resident Assessment task. The findings include: The Minimum Data Set (MDS) is a federally mandated, standardized clinical assessment tool used in Medicare/Medicaid-certified nursing homes to measure the health status, functional capabilities, and care needs of residents. On 4/17/2026 at 8:52 AM, a review of Resident #15's record. The resident's MDS assessment conducted on 3/4/2026 indicated in Section N0415 that Resident #15 did not receive Antipsychotics. According to the resident's February and March Medication Administration Record in 2026, the resident received Olanzapine, an antipsychotic, every day in February and March. On 4/17/2026 at 8:58 AM, a review of Resident #28's record was conducted. The resident's admission MDS assessment from 3/3/2026 indicated in Section M0100 that the resident did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, and indicated in Section M0300 that the resident had a Stage 3 unhealed pressure ulcer. According to Resident #28's admission Screening Skin assessment, the resident had a stage 3 pressure ulcer on admission. On 4/17/2026 at 9:21 AM, an interview with the MDS Coordinator (Staff #41) was conducted. This surveyor reviewed Resident #15's MDS with Staff #41. Staff #41 stated that Resident #15's MDS section N was completed incorrectly. Staff #41 stated that the resident should have been marked yes to taking Antipsychotics in Section N0415. This surveyor reviewed Resident #28's MDS with Staff #41. Staff #41 stated that Resident #28's admission Section M0100 was checked No to Pressure wound on bony prominence in error. Staff #41 stated that they will amend the MDS assessments to ensure they are accurate.

Based on medical record review and interview, facility nursing staff failed 1.) to provide nursing services that did not meet professional standards by failing to correctly identify a resident (resident # 237) prior to medication administration leading to the resident being administered medication prescribed for another resident (resident #244), and 2.) to adhere to nursing care standards of practice as evidenced by a nurse failed to write a verbal order Glucagon after the medication was administered and 3.) failed to document a resident's ostomy care. This deficient practice was evidenced in 4 (# 237, #244, #234, & #236) of 13 medical records reviewed during the recertification survey. 1.) Surveyor review of a complaint (2797325) on 4/13/26 at 9:00am alleging that a member of the facility's nursing staff erroneously administered medications to resident #237 that were prescribed for the resident's former roommate that had discharged earlier in the day. Review of resident # 237's medical records on 4/13/26 at 9:30am revealed a change in condition progress note dated 3/4/26 at 11:30pm stating that the resident was given his/her roommates night-time medication. The resident had no abnormal signs or symptoms from the incorrect medication administration. The resident's provider was contacted and informed of the incident. The provider ordered the resident's vitals to be monitored every 4 hours for 12 hours. Further review of the medical records revealed no adverse symptoms from the incorrect medication administration. Interview with the Director of Nursing (DON) on 4/14/26 at 6:00am revealed resident #237's incorrect medication administration was considered an unusual medical event by the facility. The surveyor asked the DON if the facility reported the incorrect medication administration incident to OHCQ. The DON admitted that the facility failed to report the incident to OHCQ. The surveyor then asked the DON if the facility investigated the root cause of the incorrect medication administration incident. The DON stated the facility investigated the incident and provided the investigation to the surveyor. Review of the incorrect medication administration incident investigation on 4/14/26 at 8:30am revealed CMA #44 failed to verify resident # 237's identity prior to administering medication that was prescribed for resident #244. CMA #44 stated in a statement that he/she administered the medication prescribed for resident #244 without verifying the resident's admission status. Review of resident #244's medical record on 4/14/26 at 9:00am revealed that the resident discharged from the facility on 3/4/24 at approximately 2:00pm. Interview with RN #26 on 4/15/26 at 8:01am revealed that nursing staff that administer medication (RN, LPN, and CMT) are trained to verify resident unit census prior to medication administration pass. Also, each resident receiving medication requires the nursing staff member to verify identity prior to medication administration. The surveyor asked RN #26 about medication reconciliation after a resident discharge. RN #26 stated that nursing staff that are assigned to a medication cart are trained to reconcile resident medications prior their scheduled work shift and when a resident discharges during their scheduled work shift. When a resident discharges during the scheduled work shift, nursing staff assigned to the medication cart is trained to collect all medications not given to the resident and put the medications in the medication room for pharmacy pick-up. The medication should not be available for administration from the medication cart after the resident discharges from the facility. The surveyor informed the DON on 4/14/26 at 11:30am that the incorrect administration incident would be further reviewed by OHCQ for deficient practice. The surveyor informed the Administrator on 4/16/26 at 2:00pm that the incorrect administration incident would be further reviewed by OHCQ for deficient practice. 2.) On 04/13/26 at 10:08 am a review of Resident #236 electronic health record (EHR) revealed the resident was difficult to arouse on 01/02/26 at 11:32 pm and their fingerstick 50 mg/dl. Registered Nurse (RN) #26 gave the resident Glucagon in the resident's left thigh. The note indicated the on-call provider was made aware and a new order to recheck the glucose level in 10 min and give another dose of Glucagon and notify the provider of the results. On 04/13/26 at 3:02 pm the surveyor received a copy of the Health Status Note written by RN #26. The note indicated the on-call provider was made aware of the resident's hypoglycemic episode & Glucagon was given. An order was received to recheck the glucose level in 10 min and give another dose of Glucagon and notify the provider of the results. Further review of the EHR revealed an order was not written for Glucagon x 2 doses nor was a documented follow-up (F/U) fingerstick documented. On 04/14/26 at 7:39 am during an interview with RN#26, they verbalized the orders were received from Synergy's on call provider but was uncertain who they spoke with. During that time, they worked PRN (as needed) but currently she works full time. The resident received one dose of Glucagon and their F/U fingerstick was 88 mg/dl. She/he forgot to write the order. The next nurse was supposed to monitor Resident #236; she/he forgot to write the note that they spoke with the physician and the follow-up fingerstick. On 04/14/26 at 7:54 am during an interview with Director of Nursing (DON) #2, the y verbalized RN #26 should have written an F/U note and pass the information to the next shift. Their provider made a note. She/he should have put the order in and documented the F/U fingerstick. The Unit Managers, DON, and ADON review 24-hour notes, but that note was missed. They would have expected the incident to be entered as a change in condition. 3.) On 04/14/26 at 11:10 am during an interview with RN#37, the surveyor asked did they refuse to change Resident #234 ostomy appliance. RN#37 verbalized they had wound care training about 3 weeks and learned to perform ostomy care as a Certified Nursing Assistant (CNA). They changed Resident #234's ostomy appliance as needed. It was documented in the TAR. The resident had a fold that made the appliance difficult to sticking to the skin. The wound nurse assisted with helping the appliance to stick to the resident's skin. On 04/14/26 at 11:29 am a review of the Resident #234 treatment administration record (TAR) for February 2026 revealed there was no documentation to verify the staff was changing the residents' ostomy appliance or providing ostomy care. On 04/14/26 at 12:38 pm during an interview with RN #38 the surveyor asked if a resident has an ostomy, where is the care provided documented. RN #38 verbalized the care would be documented in the EHR; orders for ostomy care should be on the TAR. When the care was provided it should have been signed off on the TAR. On 04/15/26 at 1:07 pm during an interview with RN Wound Specialist #17 the surveyor reported there was no documentation in Resident #234 EHR to verify ostomy care was provided. At 1:26 pm RN Wound Specialist provided the surveyor with an order for the resident's colostomy appliance, but they were unable to find documentation the care was being provided.

Based on interviews and record reviews, it was determined that the facility failed to provide showers to dependent residents. This was evident for 2 (Resident #243 and #56) out of 10 residents reviewed for activities of daily living during the recertification survey.The findings include:1.) On 04/13/2026 at 9:29 AM, an interview with Resident #243 was conducted. They reported that they had not had a shower in a long time. They added that they wanted to shower at least once a week. On 04/14/2026 at 6:03 AM, a review of Resident #243's record indicated that they were scheduled to shower Monday and Thursdays 3pm to 11pm. The review of the care plan failed to reveal that the resident had refused showers but indicated that the resident was dependent on staff for showers. On 04/15/2026 at 11:26 AM, a review of the electronic records of shower refusal was compared to the shower sheets. Staff #34 had signed most of the shower sheets as resident refused including 4/6/2026. A review of Staff #34 work schedule was conducted. The was no evidence of a time punch and according to the schedule, Staff #34 was off on 4/6/26.2.) On 04/13/2026 at 9:58 AM, an interview with Resident #56 was conducted. They reported that they had not been offered a shower for several months. On 04/14/2026 at 5:51 AM, a review of Resident #56's medical record was conducted. The review of the shower task indicated that the resident was dependent on staff for showers. The resident was scheduled to shower on Tuesdays and Fridays.Review of the shower sheets for the month of March and April 2026 revealed that the resident refused showers and only had a shower once 3/24/26. However, the resident's care plan did not include a care plan for shower refusal. Upon further review of the shower sheets, the surveyor noted that Staff #34 had documented shower refusals on all the shifts. A review of Staff #34 schedule was conducted. The review indicated that the staff marked resident refused showers even though Resident #56 was not part of his assigned unit. The Director of Nursing (DON) was notified of the inconsistencies in shower documentation. On 04/15/2026 at 3:55 PM, an interview with Staff #34 was conducted. He confirmed that he was off on 4/6/2026. He also acknowledged that at the end of the shift he signed off the showers as refused without offering residents a shower opportunity. Staff confirmed that he had not offered showers to Resident #243 or Resident #56 in April. On 04/16/2026 at 9:32 AM, an interview with the DON was conducted. At this time the shower sheets and the electronic documentations were reviewed again. The DON confirmed that there are inconsistencies with documentation.Additionally, the DON reported that she had a conversation with Staff #34 who confirmed that he never offered residents a shower and instead marked off the task as refused.

Based on interview and record review, it was determined that the facility failed to administer medications to residents in accordance with minimum standards of care. This was evident for 3 Resident (Resident #237, #244, and #242) of 3 reviewed for insulin medication administration during the annual survey 1.) Surveyor review of a complaint (2797325) on 4/13/26 at 9:00am alleging that a member of the facility's nursing staff erroneously administered medications to resident #237 that were prescribed for the resident's former roommate that had discharged earlier in the day. Review of resident # 237's medical records on 4/13/26 at 9:30am revealed a change in condition progress note dated 3/4/26 at 11:30pm stating that the resident was given his/her roommates night-time medication. The resident had no abnormal signs or symptoms from the incorrect medication administration. The resident's provider was contacted and informed of the incident. The provider ordered the resident's vitals to be monitored every 4 hours for 12 hours. Further review of the medical records revealed no adverse symptoms from the incorrect medication administration. Interview with the Director of Nursing (DON) on 4/14/26 at 6:00am revealed resident #237's incorrect medication administration was considered an unusual medical event by the facility. The surveyor asked the DON if the facility reported the incorrect medication administration incident to OHCQ. The DON admitted that the facility failed to report the incident to OHCQ. The surveyor then asked the DON if the facility investigated the root cause of the incorrect medication administration incident. The DON stated the facility investigated the incident and provided the investigation to the surveyor. Review of the incorrect medication administration incident investigation on 4/14/26 at 8:30am revealed CMA #44 failed to verify resident # 237's identity prior to administering medication that was prescribed for resident #244. CMA #44 stated in a statement that he/she administered the medication prescribed for resident #244 without verifying the resident's admission status. Review of resident #244's medical record on 4/14/26 at 9:00am revealed that the resident discharged from the facility on 3/4/24 at approximately 2:00pm. The surveyor informed the DON on 4/14/26 at 11:30am that the incorrect administration incident would be further reviewed by OHCQ for deficient practice. The surveyor informed the Administrator on 4/16/26 at 2:00pm that the incorrect administration incident would be further reviewed by OHCQ for deficient practice. 2.) On 04/12/2026 at 1:20 PM, during an interview with Resident #242, the resident stated, I do get insulin, but it seems like I am always getting it late. On 04/15/2026 at 7:24 AM, record review revealed a physician order for HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Sliding Scale insulin. The order instructed administration subcutaneously before meals and at bedtime. The order specified administration times of 6:30 AM, 11:30 AM, 4:30 PM, and 10:00 PM. On 04/15/2026 at 7:28 AM, review of the medication administration record and audit report for Resident #242 for the period of 3/31/2026 through 4/14/2026 revealed ten (10) instances of late insulin administration as follows: On 4/3/2026, insulin due at 11:30 AM was administered at 12:44 PM. On 4/7/2026, insulin due at 11:30 AM was administered at 12:40 PM. On 4/8/2026, insulin due at 11:30 AM was administered at 1:07 PM. On 4/13/2026, insulin due at 11:30 AM was administered at 1:31 PM. On 3/31/2026, insulin due at 4:30 PM was administered at 7:11 PM. On 4/1/2026, insulin due at 4:30 PM was administered at 5:31 PM. On 4/3/2026, insulin due at 4:30 PM was administered at 6:03 PM. On 4/6/2026, insulin due at 4:30 PM was administered at 5:39 PM. On 4/8/2026, insulin due at 4:30 PM was administered at 6:08 PM. On 4/13/2026, insulin due at 4:30 PM was administered at 6:35 PM. On 04/15/2026 at 7:37 AM, review of Resident #242's blood glucose summary revealed blood glucose monitoring was performed and documented in concurrence with the times insulin was administered. On 04/15/2026 at 11:29 AM, during an interview with Registered Nurse (Staff #38), she stated insulin administration times for sliding scale insulin before meals are 6:30 AM, 11:30 AM, and 4:30 PM, with bedtime insulin scheduled for 10:00 PM. She also stated insulin may be administered within one hour before or one hour after the scheduled time, and administration beyond one hour after the scheduled time is considered late. On 04/17/2026 at 7:15 AM, during an interview with the Director of Nursing (DON), the DON stated insulin administration for sliding scale insulin is typically administered before meals and at bedtime. The DON stated fingerstick blood glucose checks are obtained and insulin is administered prior to meal tray delivery. The DON confirmed nurses are expected to administer insulin within one hour before or one hour after the scheduled time, and administration beyond this window is considered late. The DON was made aware of the concern at the time of interview.

Based on interviews and record reviews, it was determined that the facility failed to change a resident's foley catheter as ordered. This was evident for 1 (Resident #71) out of 3 residents reviewed for urinary tract infection during the recertification survey. The findings include:A Foley catheter is a thin, flexible, sterile tube inserted into the bladder to drain urine into a collection bag when a person cannot urinate on their own, or to keep the bladder empty On 04/13/2026 at 9:21 AM, an interview with Resident #71 was conducted. They reported that the facility does not change their foley catheter as often as they are supposed to. On 04/14/2026 at 9:53 AM, a review of Resident #71's medical records was conducted. The review revealed an active order to change the foley catheter every 28 days and as needed for blockage. Further review of the records indicated that the resident's foley catheter was changed on 4/6/2026 by Staff #39, wound care nurse. On 04/14/2026 at 10:15 AM, a follow up interview with Resident #71 was conducted. They reported that no one had changed their catheter in April. On 04/14/2026 at 10:39 AM, an interview with Staff #39 was conducted. When asked if she remembered changing Resident #71's foley catheter, staff stated that she had not changed any resident's foley catheter in April. She also confirmed that she marked the task as completed without changing the foley.On 04/14/2026 at 11:15 AM, the unit manager and Director of Nursing were made aware of the concern.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure four (Resident #41, Resident #11, Resident #22, and Resident #33) of 23 residents reviewed for abuse were reported/timely reported to the Administrator and State Survey Agency (SSA) and failed to ensure the results of investigations were submitted to the SSA/submitted within five working days of the incident for four (Resident #11, #2, 22, and 34 of 23 reviewed for abuse. Specifically, the failed to report/timely report the following: 1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to report the allegation to the SSA.2. Resident #11 reported that Housekeeper #28 pushed them. The facility failed to report the allegation to the SSA no later than two hours after the allegation was made and failed to report the results of the investigation to the SSA within five working days. 3. Resident #33 reported that Resident #22 attempted to touch Resident #33's genitals, and reported that after the resident reported the incident, Resident #22 and their significant other Resident #40, retaliated against the resident. Staff reported the allegations to the DON; however, the facility failed to report the allegations to the SSA.4. The facility failed to submit the results of an investigation regarding an allegation regarding Resident #2's injury of unknown origin.5. The facility failed to submit an abuse allegation regarding Resident #22 to the SSA no later than two hours after the allegation was made and failed to report the results of an abuse allegation within five working days.6. The facility failed to submit the results of an abuse allegation regarding Resident 34 within five working days of the incident. The failure to address residents' abuse allegations had the likelihood for further potential abuse and for physical and/or psychosocial harm to residents. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, F609, Reporting of Alleged Violations, at a scope and severity of K.The IJ began on 09/13/2025 when the facility failed to report an allegation of physical abuse.The survey team notified the DON and the Regional Director of Operations (RDO) of the IJ and provided the IJ template on 10/11/2025 at 6:26 PM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on 10/12/2025 at 1:57 AM. The IJ was removed on 10/12/2025, after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F609 remained at a lower scope and severity of E, a pattern, no actual harm with the potential for more than minimal harm. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 09/2022, revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. The policy also indicated, 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The policy for Follow-Up Report, also revealed, Within five (5) days of the incident, the administrator will provide a follow-up investigation report. 1. Resident #41's demographic sheet revealed the resident had a medical history that included diagnoses of muscle wasting and atrophy, atherosclerotic heart disease, essential hypertension, chronic obstructive pulmonary disease (COPD), generalized anxiety, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2025, revealed Resident #41's most recent admission to the facility was on 07/01/2025. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS also indicated the resident required supervision or touching assistance for bed-to-chair transfer. Resident #41's Care Plan Report, included a focus area, initiated 05/24/2025, that indicated the resident had sustained falls and continued to be at risk for falls related to deconditioning, weakness, and gait/balance problems. Interventions directed staff to provide hands-on assistance for moving from place to place (initiated 06/16/2025). During an interview on 10/10/2025 at 2:50 PM, Resident #41 stated that RN #20 had grabbed their head, squeezed their arm really hard, and hurt the resident. The resident stated it really made them mad. Resident #41 stated they told Unit Manager (UM) #18 that the nurse abused them. The resident stated they felt like UM #18 did not take the allegation seriously; subsequently, the resident told the UM to drop it and the UM said okay. The facility's self-reported incident list, for the timeframe from 02/03/2025 through 09/21/2025, indicated no report was made to the SSA regarding Resident #41's abuse allegation. During an interview on 10/08/2025 at 3:51 PM, Certified Medication Assistant (CMA) #11 stated Resident #41 reported that RN #20 grabbed them by the top of their head to get the resident off the floor after the resident fell out of their wheelchair on Saturday, 09/13/2025. Per CMA #11, the resident reported that RN #20 hurt them, and the resident was very irate about the situation. CMA #11 stated she notified Licensed Practical Nurse (LPN) #22 of the situation. During an interview on 10/09/2025 at 11:03 AM, Geriatric Nurse Aide (GNA) #21 stated that Resident #41 had fallen on the floor while the GNA was in another resident's room. She stated the door was closed but she could hear RN #20 yelling at the resident, telling the resident to Get up! Just get up! in a forceful manner. Per GNA #21, once the door was opened, Resident #41 stated that RN #20 pinned them down on the floor with his hand on top of the resident's head, roughed the resident up, and the resident could not get off the floor. GNA #21 stated that after the incident, Resident #41 told her that RN #20 brought the resident snacks, assisted the resident to and from the smoking area, and was trying to butter up the resident. GNA #21 stated she also reported the incident to LPN #22, the supervisor on duty the night of 09/13/2025. During an interview on 10/10/2025 at 11:39 AM, RN #20 stated the nurses asked him to assist with a resident who had fallen. RN #20 stated Resident #41 was sitting on the floor beside their bed in their room and the door was open while he was in the resident's room. He stated he performed a head-to-toe assessment of the resident, which included assessing the resident's head and palpating their arms to make sure there was no injury. RN #20 stated the resident had no concerns or complaints during the assessment and there were no injuries. According to RN #20, he did not recall documenting the assessment. RN #20 stated he did not remember who helped him assist the resident off the floor but stated it would have taken at least two people because the resident was not capable of getting up on their own. He stated the resident did not voice any complaints while moving them. Per RN #20, he interacted with Resident #41 after the fall and took the resident to smoke and to the snack machines and did not remember anything else about the event. RN #20 stated he wrote a witness statement and gave it to LPN #22. During an interview on 10/10/2025 at 2:30 PM, LPN #22, who worked as the weekend supervisor, stated that GNA #21 called to tell her that she heard RN #20 yelling at Resident #41. LPN #22 stated she spoke with Resident #41 and got the resident's written statement. She stated that when the resident fell, the resident was upset. LPN #22 stated she was not sure whether RN #20 made the resident upset; however, when she asked the resident what happened, whether the resident was hurt, and if the resident felt like RN #20 did something to them, the resident stated no. LPN #22 stated that she later saw RN #20 take the resident out to the smoking area and she asked the resident again if everything was okay, and the resident stated they were fine and did not think RN #20 meant to hurt them. She stated that when she spoke with LPN #38, the LPN stated that the resident was upset and the LPN told RN #20 to give the resident some space. LPN #22 stated she obtained witness statements from GNA #21, RN #20, and LPN #38. She stated she also notified the DON and the Administrator of the details of the fall/incident. Per LPN #22, the DON stated that she did not think that RN #20 was trying to hurt the resident based on the information she had provided. During an interview on 10/10/2025 at 4:04 PM, UM #18 stated that prior to that day, she had no knowledge of an incident with Resident #41 and RN #20. During an interview on 10/10/2025 at 3:43 PM, the DON stated that she expected staff to report abuse allegations to her or the Administrator. Per the DON, LPN #22 reported that Resident #41 had fallen and that the RN hurt them while getting them up off the floor. During a follow-up interview on 10/11/2025 at 2:09 PM, the DON stated that she was not aware that Resident #41 accused RN #20 of squeezing their head and twisting their arms until 10/09/2025. 2. An admission Record revealed the facility admitted Resident #11 on 12/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation, malignant neoplasm of the kidney and bladder neck, chronic obstructive pulmonary disease, congestive heart failure, generalized anxiety disorder, major depressive disorder, restlessness and agitation, and chronic pain syndrome. Resident #11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/22/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #11's Care Plan revealed a focus area, initiated 07/26/2025, that indicated the resident had a behavior problem, becoming aggressive and accusatory with staff when frustrated. A Facility Reported Incident Initial Report Form, dated 07/26/2025, revealed that Resident #11 alleged that Housekeeper #28 pushed them while in the resident's room at approximately 11:30 AM on 07/26/2025. According to the report, the Administrator submitted the report to the state agency (SA) on 07/26/2025 at 12:31 PM. A Facility Reported Incident Follow-Up Investigation Report Form, dated 07/28/2025, revealed the Director of Nursing (DON) sent the final report on 07/28/2025 at 3:00 PM. An email correspondence dated 10/10/2025 at 4:22 PM with the state agency revealed the initial report regarding Resident #11's allegation was received on 07/26/2025 at 2:36 PM, which was over two hours after the allegation was made. Furthermore, the email correspondence revealed no evidence that a five-day report was submitted to the SA. During an interview on 10/09/2025 at 5:07 PM, Regional Director of Operations (RDO) stated he had never been asked to show confirmation that they had submitted the incident reports to show that they submitted them timely. He said he thought they just took their word that the time that was documented on the reports was when the report was sent in and completed. He said now he understood that without that documentation they could have just put any date/time on the report, and it would not be accurate. He stated that he had no additional documents for any investigations to confirm when the State Agency was notified. Additionally, he expected staff to report any allegation to their supervisor immediately. During an interview on 10/16/2025 at 3:04 PM, Interim (Inter.) DON stated she expected the staff to report to the DON/Administrator immediately because any allegation of abuse had to be reported within two hours. 3. An admission Record revealed the facility admitted Resident #33 on 09/15/2020. According to the admission Record, Resident #33 had a medical history that included diagnoses of muscular dystrophy, unspecified heart failure, and generalized muscle weakness. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2024, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 07/03/2025, revealed Resident #33 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS revealed the resident was independent with a motorized wheelchair. Resident #33's Care Plan Report included a focus area initiated10/03/2024, that indicated Resident #33 was independent in fulfilling their leisure time and had a general willingness to participate in group programs. Interventions directed staff to check in with Resident #33 often to ensure their contentment items provided for self-directed independent leisure (initiated 10/03/2024), and indicated the resident enjoyed various group programs and socializing with other residents/staff (initiated 10/03/2024). An admission Record revealed the facility admitted Resident #22 on 10/17/2025. According to the admission Record, Resident #22 had a medical history that included diagnoses of demyelinating disease of the central nervous system, other intervertebral disc degeneration, fibromyalgia, ataxia, bipolar disorder, muscular dystrophy, unspecified heart failure, and generalized muscle weakness A quarterly MDS, with an ARD of 07/26/2025, revealed Resident #22 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS revealed the resident did not exhibit any behavioral symptoms during the assessment look-back period. The MDS revealed Resident #22 was also independent with a motorized wheelchair. Resident #22's Care Plan Report included a focus area dated 07/17/2025 that indicated the resident smoked and was able to smoke independently. A Social Service Assessment, dated 07/09/2025, revealed Resident #33 reported they had not any event that was unusually or especially frightening, horrible, or traumatic. Observation of and interview with Resident #33 on 10/08/2025 at 2:27 PM revealed they were in their room sitting upright in bed. Resident #33 was willing to discuss the details of the incident but was noted to have changes in voice quality during retelling. During an interview, Resident #33 stated that Resident #22 had been acting differently that day (08/24/2025) and Resident #33 believed that Resident #22 was intoxicated with an unknown substance. Resident #33 stated they were outside in the gazebo area and the resident was assisting Resident #22 with lighting their cigarette when Resident #22 started asking for some [vulgar slang term for a body part] Resident #33 stated they told Resident #22 to chill, and Resident #22 reached over and attempted to grab Resident #33's genital area. Resident #33 stated they blocked Resident #22's hands and then attempted to show them the ring worn on their left hand fourth finger. Per Resident #33, Resident #22 then grabbed Resident #33's left hand and attempted to open it and due to Resident #33's medical condition, they had to utilize their right hand to remove Resident #22's hands. At that time, Resident #33 left the gazebo and went back to their room. Resident #33 stated they limited their activity in the facility to prevent contact with Resident #22 and Resident #22's significant other, Resident #40. Resident #33 stated they felt like R#22's significant other had been watching them. The resident stated that on one occasion Resident #33 was waiting for a family member in the main lobby and Resident #22 and Resident #40 stared at the resident, making them feel uncomfortable and the resident elected to return to their room to wait for their family. Resident #33 stated this incident had triggered memories of childhood sexual molestation which had also led to their self-imposed isolation to their room. Resident #33 stated they had told everyone about the incident, but nothing had been done. During an interview on 10/08/2025 at 3:10 PM, Resident #22 stated that they had made a gesture of a male performing sexual self-gratification, and Resident #33 reported them for sexual harassment. Resident #22 denied having touched Resident #33 but reported they were unable to recall what was said during the incident on 08/24/2025. During an interview on 10/09/2025 at 11:53 AM, Resident #40 stated that they were present when the alleged incident occurred in the gazabo on 08/24/2025. Resident #40 stated that Resident #33 made a hand gesture of a male sexually self-pleasuring themself towards Resident #22 and Resident #40. Resident #40 stated that Resident #22 repeated the hand gesture, and that offended Resident #33. Resident #40 stated they believed the allegation was made due to Resident #33 being jealous of Resident #22 and Resident #40's relationship status. During an interview on 10/09/2025 at 10:02 AM, Geriatric Nurse Aide (GNA) #27 revealed she did not know exactly what happened, but that it had to be something pretty drastic for Resident #33 and Resident #22 to stop interacting. She reported that since that time, Resident #33 did not seem to want to get out of bed. During an interview on 10/09/2025 at 10:45 AM, GNA #24 stated that Resident #33 and Resident #22 were not friends anymore, and Resident #33 was no longer visiting the 200 and 300 Units. During an interview on 10/14/2025 at 2:16 PM, Licensed Practical Nurse (LPN) #15 stated that on Sunday, 08/31/2025 at approximately 10:00 PM, Resident #33 activated their call light and asked to speak with her specifically. She stated Resident #33 was crying and visibly upset. Per LPN #15, Resident #33 reported that Resident #22 had previously touched them and on that night, Resident #33 had gone to the lobby to await family and Resident #22 and Resident #40 cursed at the resident. LPN #15 stated she immediately reported the incident to her supervisor, LPN #22, who contacted the DON. LPN #15 stated the DON instructed her to move Resident #33 to another unit. She stated she moved the resident; however, she stated when she returned to work on Monday, Resident #33 was back in their old room. LPN #15 stated that Resident #33 had not been coming out of the resident's room since the incident because the resident was scared. She stated she had noticed the resident coming out more that week. During an interview on 10/16/2025 at 9:05 AM, LPN #22 stated that she had contacted the DON and the Administrator on Sunday (08/31/2025) with the allegation (unable to recall allegation details) and the decision was made to move Resident #33 to the 500 Unit. During an interview on 10/11/2025 at 3:18 PM, Unit Manager (UM) #10 stated Resident #33 told her about the incident several days after the occurrence (unable to recall the exact date). She stated that the resident reported that they were helping Resident #22 to smoke when something sexual was said, but she could not remember the details. UM #10 stated they also recalled something about Resident #33 showing their promise ring and talking about the importance of the item to them. Per UM #10, Resident #33 was worried that Resident #22 and Resident #40 would retaliate against them; however, she stated that she had not seen any retaliation against Resident #33. She stated that she was unable to recall any further details from the report. UM #10 stated she immediately reported the allegation to the DON, and the Mental Health Nurse Practitioner had seen the resident. According to UM #18, there had been no changes in Resident #33's behavior since the incident. During an interview on 10/09/2025 at 11:25 AM, the DON and the RDO revealed that Resident #33 had reported that Resident #22 made a comment about wanting [vulgar slang term for a body part], which made Resident #33 uncomfortable. The DON stated that she was also aware that Resident #33 felt like Resident #40 was watching them and that Resident #33 had elected to keep to themselves and not interact with the residents. Per the DON, they had treated this incident more from a perspective of the loss of friendship as the three residents had been friends prior to the incident. The DON stated they did not feel like it had reached the level of reporting or investigating. On 10/12/2025 at 1:59 AM, a Removal Plan was submitted by the facility and accepted by the State Agency, as follows: Corrective actions which will be accomplished for those residents found to have been affected. 1. Statements were obtained from involved residents #41, #22 and #33. Resident #11 is no longer in the facility on 10/11/25 by the Nurse manager. 2. Resident #41, Resident #22, and Resident #33 were assessed to ensure no injuries, physical or psychological, were present on 10/12/25 by the nurse manager. There were no new findings for residents# 41, #22 and #33. 3. RN #20 and Housekeeper #28 have been suspended on10/11/2025 by Regional Director of Operations. 4. The administrator and director of nursing have been suspended on 10/11/25 by Regional Director of Operations. 5. Statements were obtained from the accused employees #20 and #28 on 10/11/25 by Regional Nurse. 6. Social Services has met with involved residents #41, #22 and #33 to address any psychosocial concerns on 10/12/25. Resident #11 is no longer residing in the facility. 7. Residents #41 (allegation of physical abuse) and #33 (allegation of sexual abuse) responsible parties were made aware of the allegations by Nurse manager. Resident #11 is no longer in the facility. Education provided for timely abuse reporting based on CMS regulation. 8. Medical Directors were made aware of the allegations of physical and sexual abuse on 10/11/25. 9. Police were notified of the allegations of physical and sexual abuse on 10/09/25 and 10/10/25. Maryland Department of Health was notified of the allegations of physical and sexual abuse on 10/11/25. 10. Medical Directors were notified of the allegations of physical and sexual abuse for residents #41 and #33 on 10/11/25. 11. Ombudsman was notified of the allegations of physical and verbal abuse on 10/12/25. 12. Trauma informed evaluations completed for identified residents #41 and #33 on 10/11/25. Measures that will be put in place and systemic changes that will be made to ensure that the practices do not recur. Current employees will receive education regarding reporting abuse on 10/12/25 by Nurse Manager. Nurse managers and social workers will be educated on abuse reporting on 10/12/25 by Regional Nurse. Newly hired employees and vendors will receive education regarding reporting abuse prior to assuming any assignment by nurse manager. How the corrective actions will be monitored to ensure the practices will not re-occur. The results of the interviews will be reported during the monthly Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. The resident interviews will continue until the QAPI Committee has determined that there is substantial compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits. AD Hoc held on 10/11/25. The QAPI has been reviewed by the Medical Director on 10/12/25 Allegation of Compliance The facility alleges compliance with this plan on 10/12/2025. The immediacy of the IJ was removed on 10/12/25. Onsite Verification of Removal Plan: The IJ was removed on 10/13/2025 after the survey team completed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of E. Verification was completed as follows: 1. Witness statements from Residents #22, #33, and #41 were obtained by the DON. 2. Resident #22's weekly skin check assessment dated [DATE] no new skin impairments were identified, and the social services assessment dated [DATE] revealed the facility identified that the resident had a history of past sexual/physical abuse and was currently receiving psychiatric services. Resident #33's weekly skin assessment dated [DATE] revealed no new skin impairments were identified, and a social service assessment dated [DATE] revealed no emotional distress was identified. Resident #41's weekly skin check dated 10/09/2025 revealed no new skin impairments were identified, and a social service assessment dated [DATE] revealed the resident had no verbal indicators or emotional distress/anxiety. 3. Registered Nurse (RN) #20's timecard sheet revealed their last date worked was on 09/29/2025 and Housekeeper #28's last date worked was on 10/11/2025. 4. Record review revealed the RDO placed the Administrator and DON on administrative leave on 10/11/2025. 5. Record review revealed the facility obtained statements from RN #20 and Housekeeper #28 of their witness accounts of the allegations against them. 6. Record review revealed social services staff met with Resident #33 on 10/11/2025 and identified the resident as self-isolating and feeling guilty. Record review revealed social services staff met with Resident #41 on 10/11/2025 and identified no verbal indicators or emotional distress/anxiety during assessment. 7. Record review revealed Resident #33's representative was made aware of the abuse allegation on 10/11/2025 at 9:56 PM, and Resident #41's representative was made aware of the abuse allegations on 10/09/2025 at 3:15 PM. 8. Record review revealed the RDO notified the Medical Director of the allegation of physical abuse for Resident #41 and sexual abuse for Resident #33. 9. Record review revealed local Law Enforcement was notified of Resident #33's allegation of sexual abuse allegation and Resident #41's allegation of physical abuse allegation on 10/10/2025 and 10/09/2025, respectively. 10. Record review revealed the facility notified the SSA of Resident #41's physical abuse allegation on 10/09/2025 and Resident #33's allegation of sexual abuse on 10/09/2025. 11. Record review revealed Medical Directors were notified of the allegations of abuse on 10/11/2025. 12. Record review revealed the facility notified the Ombudsman of the allegations of abuse Resident #41 and Resident #33 on 10/12/2025. 13. Record review revealed Resident #33's trauma assessment completed on 10/11/2025 identified past sexual abuse and Resident #41's trauma assessment completed on 10/11/2025 identified no current trauma concerns. Measures that will be put in place and systemic changes that will be made to ensure that the practices do not recur. Interviews were conducted on 10/13/2025 with current staff onsite and via telephone for verification of abuse education received. Nurse managers and social workers were interviewed on 10/13/2025, onsite for verification of abuse education and training. Newly hired staff and vendors were to be provided abuse training prior to assignment. No newly hired staff or vendors began during the survey. How the corrective actions will be monitored to ensure the practices will not re-occur. The Medical Director on 10/13/2025 stated interviews would be reported during QAPI for the next three months. The Medical Director on 10/13/2025 stated the resident interviews would continue to be reported during QAPI until compliance was met. The Medical Director on 10/13/2025, stated he attended the Ad Hoc meeting on 10/11/2025. The Medical Director on 10/13/2025, stated he reviewed the QAPI. 4. An admission Record revealed the facility admitted Resident #2 on 06/06/2025. According to the admission Record, Resident #2 had a medical history that included muscle wasting and atrophy, type 2 diabetes mellitus with diabetic chronic kidney disease, compression fracture of the second lumbar vertebra, vascular dementia, and age-related physical debility. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognition. The MDS also revealed that the resident was dependent on staff for activities of daily living (ADL). Resident #2's Care Plan Report included a focus area, dated 06/09/2025, that indicated the resident had an ADL self-care performance deficit related to deconditioning and pain. Interventions directed staff to conduct a skin inspection daily during care, observing for redness, open areas, scratches, cuts, and bruises and to report abnormal findings (initiated 06/09/2025). A document titled, Maryland Department of Health Office of Health Care Quality Facility Reported Incident Initial Report Form, revealed that on 06/20/2025 at 5:00 PM, the facility was made aware of discoloration to Resident #2's left upper arm. The facility obtained witness statements and performed head-to-toe assessments of other residents. The conclusion for the discoloration was that Resident #2 had been administered insulin in the area of the noted discoloration. The Report indicated it was submitted to the SSA on 06/20/2025 at 6:50 PM. An email correspondence dated 10/10/2025 at 4:22 PM with the SSA revealed the initial report regarding Resident #2's allegation was received on 06/20/2025 at 6:52 PM and no final report was received. During an interview on 10/11/2025 at 6:24 PM, the DON stated she submitted the facility's five-day report but was unable to provide any type of confirmation. During an interview on 10/11/2025 at 6:24 PM, the RDO revealed they believed there were problems with the way the SSA had them submit final reports, because there was no way to get confirmation that the report was accepted. 5. An admission Record indicated the facility admitted Resident #22 on 10/17/2024. According to the admission Record, the resident had a medical history t

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure 4 (Residents #41, #11, #33, and #34) of 23 residents reviewed for abuse had thorough investigations completed. Specifically, the facility failed to conduct thorough investigations regarding the following:1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to conduct a thorough investigation and failed to suspend RN #20 placing Resident #41 and additional residents at risk for abuse.2. Resident #11 reported that Housekeeper #28 pushed them. The facility failed to conduct a skin audit or trauma assessment from Resident #11 and failed to obtain a witness statement from Resident #11 and additional residents.3. Resident #33 reported that Resident #22 attempted to touch Resident #33's genitals, and reported that after the resident reported the incident, Resident #22 and their significant other Resident #40, retaliated against the resident. Staff reported the allegations to the DON; however, the facility did not conduct an investigation. Resident #33 self-isolated in their room after the incident.4. The facility received an email correspondence that Resident #34 made an allegation that staff had verbally abused the resident. The facility failed to thoroughly investigate. The facility failed to obtain written interview statements from staff or residents related to the allegation. This failure to thoroughly investigate residents' allegations of abuse had the likelihood for further potential abuse and/or psychosocial harm to occur to residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, F610, Investigate/Prevent/Correct Alleged Violation, at a scope and severity of K. The IJ began on 09/13/2025 when the facility failed to report and investigate an allegation of physical abuse. The survey team notified the DON and the Regional Director of Operations (RDO) of the IJ and provided the IJ template on 10/11/2025 at 6:26 PM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on 10/12/2025 at 1:57 AM. The IJ was removed on 10/12/2025, after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F610 remained at a lower scope and severity of E, a pattern, no actual harm with the potential for more than minimal harm. Findings included:A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 09/2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy continued, 1. All allegations are thoroughly investigated. The administrator initiates investigations. The policy continued, 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. Findings included: 1. Resident #41's demographic sheet revealed the resident had a medical history that included diagnoses of muscle wasting and atrophy, atherosclerotic heart disease, essential hypertension, chronic obstructive pulmonary disease (COPD), generalized anxiety, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2025, revealed Resident #41's most recent admission to the facility was 07/01/2025. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident required supervision or touching assistance for bed-to-chair transfer. Resident #41's Care Plan Report included a focus area initiated 05/24/2025 that indicated the resident had sustained falls and continued to be at risk for falls related to deconditioning, weakness, and gait/balance problems. Interventions directed staff to provide hands-on assistance to move from place to place (initiated 06/16/2025). The facility's self-reported incident list, for the timeframe from 02/03/2025 through 09/21/2025, indicated no report was made to the SSA regarding Resident #41's abuse allegation. During an interview on 10/10/2025 at 2:50 PM, Resident #41 stated that RN #20 had grabbed their head, squeezed their arm really hard, and hurt the resident. The resident stated it really made them mad. Resident #41 stated they told Unit Manager (UM) #18 that the nurse abused them. The resident stated they felt like UM #18 did not take the allegation seriously; subsequently, the resident told the UM to drop it and the UM said okay. During an interview on 10/08/2025 at 3:51 PM, Certified Medication Assistant (CMA) #11 stated Resident #41 reported that RN #20 grabbed them on the top of their head to get the resident off the floor after the resident fell out of their wheelchair on Saturday, 09/13/2025. Per CMA #11, the resident reported that RN #20 hurt them, and the resident was very irate about the situation. CMA #11 stated she notified Licensed Practical Nurse (LPN) #22 of the situation. CMA #11 stated she was never questioned or interviewed about the event and said RN #20 worked the day after the alleged incident. During an interview on 10/09/2025 at 11:03 AM, Geriatric Nurse Aide (GNA) #21 stated that Resident #41 had fallen on the floor while the GNA was in another resident's room. She stated the door was closed but she could hear RN #20 yelling at the resident, telling the resident they needed to get up in a forceful manner. Per GNA #21, once the door was opened, Resident #41 stated that RN #20 pinned them down on the floor with his hand on top of the resident's head, roughed the resident up, and the resident could not get off the floor. GNA #21 stated that after the incident, Resident #41 told her that RN #20 brought the resident snacks, assisted the resident to and from the smoking area, and was trying to butter up the resident. GNA #21 stated she also reported the incident to LPN #22, the supervisor on duty the night of 09/13/2025. During an interview on 10/10/2025 at 2:30 PM, LPN #22, who worked as the weekend supervisor, stated that GNA #21 called to tell her that she [GNA #21] heard RN #20 yelling at Resident #41. LPN #22 stated she spoke with Resident #41 and got the resident's written statement. She stated that when the resident fell, the resident was upset. LPN #22 stated she was not sure whether RN #20 made the resident upset; however, when she asked the resident what happened, whether the resident was hurt, and if the resident felt like RN #20 did something to them, the resident stated no. LPN #22 stated that she later saw RN #20 take the resident out to the smoking area and she asked the resident again if everything was okay, and the resident stated they were fine and did not think RN #20 meant to hurt them. She stated that when she spoke with LPN #38, the LPN stated that the resident was upset and the LPN told RN #20 to give the resident some space. LPN #22 stated she obtained witness statements from GNA #21, RN #20, and LPN #38. She stated she also notified the DON and the Administrator of the details of the fall/incident. Per LPN #22, the DON stated that she did not think that RN #20 was trying to hurt the resident based on the information she had provided. LPN #22 stated no one reached out to her afterward regarding the information she had gathered. During an interview on 10/10/2025 at 11:39 AM, RN #20 stated the nurses asked him to assist with a resident who had fallen. RN #20 stated Resident #41 was sitting on the floor beside their bed in their room and the door was open while he was in the resident's room. He stated he performed a head-to-toe assessment of the resident, which included assessing the resident's head and palpating their arms to make sure there was no injury. RN #20 stated the resident had no concerns or complaints during the assessment and there were no injuries. According to RN #20, he did not recall documenting the assessment. RN #20 stated he did not remember who helped him assist the resident off the floor but stated it would have taken at least two people because the resident was not capable of getting up on their own. He stated the resident did not voice any complaints while moving them. Per RN #20, he interacted with Resident #41 after the fall and took the resident to smoke and to the snack machines and did not remember anything else about the event. RN #20 stated he wrote a witness statement and gave it to LPN #22. During an interview on 10/10/2025 at 4:04 PM, UM #18 stated that Resident #41 had just informed them, minutes ago, that about two weeks prior RN #20 had squeezed the resident's head and twisted the resident's arm. Per UM #18, prior to that day, she had no knowledge of an incident with Resident #41 and RN #20. During an interview on 10/10/2025 at 3:43 PM, the DON stated that she expected staff to report abuse allegations to her or the Administrator. Per the DON, LPN #22 reported that Resident #41 had fallen and that the RN hurt them while getting them up off the floor. The DON stated that she just found out about the alleged abuse from UM #18, had just reported it to the State Agency, obtained a witness statement from the resident, and notified the police. During a follow-up interview on 10/11/2025 at 2:09 PM, the DON stated that she was not aware that Resident #41 accused RN #20 of squeezing their head and twisting their arms until 10/09/2025. She stated had she known about the allegation from the resident, RN #20 would have been suspended then. The DON she had no witness statements for Resident #41 from 09/13/2025. During an interview on 10/16/2025 at 10:08 AM, the Regional Director of Operations (RDO) stated the Administrator and DON should be involved in the investigation of an allegation of abuse. Per the RDO, the investigation should include interviews of staff and residents, skin assessments, interviews of the individual's assignments, and notification of the appropriate agencies, Physicians, emergency contacts if the individual was not their own representative, and other documentation related to the individual. The RDO stated a folder was comprised of documents with a checklist that ensured the investigation had been completed and was thorough. He stated the checklist listed exactly what to look at and what to have on file for the facility. The RDO said the investigation file was maintained for 10 years. Per the RDO, staff had been trained and were expected to ensure interviews with all parties, skin assessments, notifications to the appropriate agencies, and the checklist had been completed. During an interview on 10/16/2025 at 3:04 PM, the Interim Director of Nursing (Int. DON) stated she expected staff to know that when they were aware of an incident they needed to bring the allegation to the attention of their supervisor, ADON (Assistant Director of Nursing), and DON immediately. She stated the first expectation was to keep the residents safe and to report the allegation. The Int. DON stated that for a complete investigation staff should collect statements and make sure they had all the pieces of the investigation to do a thorough investigation. She stated she expected the DON/Administrator to do a complete investigation. She said if a staff member were part of the allegation, they would be suspended immediately during the investigation. 2. An admission Record revealed the facility admitted Resident #11 on 12/12/2024. According to the admission Record, the resident had diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/22/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #11's Care Plan Report included a focus area initiated 07/26/2025, that indicated the resident had a behavior problem and became aggressive and accusatory with staff when frustrated. Interventions directed staff to assist the resident to develop more appropriate methods of coping and interacting and to meet the resident's needs. A report titled, Maryland Department of Health Office of Health Care Quality Facility Reported Incident Initial Report Form, dated 07/26/2025, revealed that Resident #11 alleged that Housekeeper #28 pushed them at approximately 11:30 AM. The report indicated the incident was witnessed by a nurse and Certified Medication Aide (CMA) #26. A report titled, Maryland Department of Health Office of Health Care Quality Facility Reported Incident Follow-Up Investigation Report Form, dated 07/28/2025, included a summary of an interview with the witness, CMA #26 and with the alleged perpetrator, Housekeeper #28. The summary with CMA #26 indicated Resident #11 followed Housekeeper #28 insisting that she go back to the resident's room to clean more. The summary indicated Resident #11 was angry and fell into the wall; Housekeeper #28 attempted to help the resident and the resident said Housekeeper #28 pushed the resident. The summary with Housekeeper #28 indicated Resident #11 came to find her to tell her that the resident's room was not clean, so she went back to the resident's room. The summary indicated Resident #11 fell into the doorway of their room and then yelled out that she [Housekeeper #28] had pushed the resident. There was no statement, however, from Resident #11 included in the report. There was no skin audit or trauma assessment for Resident #11 and no interviews from other residents included in the facility's investigation. During an interview on 10/11/2025 at 1:03 PM, the Regional Director of Operations stated there was no skin audit for Resident #11 on the date of the incident (07/26/2025) and no trauma assessment after the incident. During an interview on 10/11/2025 at 2:02 PM, the DON stated she could not recall whether a written statement was obtained from Housekeeper #28 even though the housekeeper's statement was summarized in the report. The DON also could not recall whether a written statement was obtained from Resident #11. Per the DON, other residents on the hallway were not interviewed about Housekeeper #28, since CMA #26 was present and witnessed the incident and they were able to unsubstantiate the abuse allegation in the moment. 3. An admission Record revealed the facility most recently admitted Resident #33 on 09/15/2020. According to the admission Record, Resident #33 had a medical history that included diagnoses of muscular dystrophy, unspecified heart failure, and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident was independent with a motorized wheelchair. Resident #33's Care Plan Report included a focus area initiated 10/03/2024, that indicated the resident was independent in fulfilling their leisure time and had a general willingness to participate in group programs. Interventions directed staff to check in with Resident #33 often to ensure their contentment with items provided for self-directed independent leisure (initiated 10/03/2024), and indicated the resident enjoyed various group programs and socializing with other residents/staff (initiated 10/03/2024). An admission Record revealed the facility admitted Resident #22 on 10/17/2025. According to the admission Record, Resident #22 had a medical history that included diagnoses of demyelinating disease of the central nervous system, other intervertebral disc degeneration, fibromyalgia, ataxia, bipolar disorder, muscular dystrophy, unspecified heart failure, and generalized muscle weakness A quarterly MDS, with an ARD of 07/26/2025, revealed Resident #22 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS revealed the resident did not exhibit any behavioral symptoms during the assessment look-back period. The MDS revealed Resident #22 was also independent with a motorized wheelchair. Resident #22's Care Plan Report included a focus area dated 07/17/2025 that indicated the resident smoked and was able to smoke independently. A Social Service Assessment, dated 07/09/2025, revealed Resident #33 reported they had not had any event that was unusually or especially frightening, horrible, or traumatic. Observation of and interview with Resident #33 on 10/08/2025 at 2:27 PM revealed they were in their room sitting upright in bed. Resident #33 was willing to discuss the details of the incident but was noted to have changes in voice quality during retelling. During an interview, Resident #33 stated that Resident #22 had been acting differently that day (08/24/2025) and Resident #33 believed that Resident #22 was intoxicated with an unknown substance. Resident #33 stated they were outside in the gazebo area and the resident was assisting Resident #22 with lighting their cigarette when Resident #22 started asking for some [vulgar slang term for a body part] Resident #33 stated they told Resident #22 to chill, and Resident #22 reached over and attempted to grab Resident #33's genital area. Resident #33 stated they blocked Resident #22's hands and then attempted to show them the ring worn on their left hand fourth finger. Per Resident #33, Resident #22 then grabbed Resident #33's left hand and attempted to open it and due to Resident #33's medical condition, they had to utilize their right hand to remove Resident #22's hands. At that time, Resident #33 left the gazebo and went back to their room. Resident #33 stated they limited their activity in the facility to prevent contact with Resident #22 and Resident #22's significant other, Resident #40. Resident #33 stated they felt like R#22's significant other had been watching them. The resident stated that on one occasion Resident #33 was waiting for a family member in the main lobby and Resident #22 and Resident #40 stared at the resident, making them feel uncomfortable and the resident elected to return to their room to wait for their family. Resident #33 stated this incident had triggered memories of childhood sexual molestation which had also led to their self-imposed isolation to their room. Resident #33 stated they had told everyone about the incident, but nothing had been done. During an interview on 10/08/2025 at 3:10 PM, Resident #22 stated that they had made a gesture of a male performing sexual self-gratification, and Resident #33 reported them for sexual harassment. Resident #22 denied having touched Resident #33 but reported they were unable to recall what was said during the incident on 08/24/2025. During an interview with Resident #40 on 10/09/2025 at 11:53 AM, it was revealed that they were present when the alleged incident occurred in the gazabo on 08/24/2025. They were reporting that Resident #33 made a gesture of a male sexually self-pleasuring themself towards Resident #22 and Resident #40. Resident #22 then repeated the act, and that offended Resident #33. They believed the allegation was due to Resident #33 being jealous of Resident #22 and Resident #40's relationship status. During an interview on 10/09/2025 at 10:02 AM, Geriatric Nurse Aide (GNA) #27 revealed she did not know exactly what happened, but that it had to be something pretty drastic for Resident #33 and Resident #22 to stop interacting. She reported that since that time, Resident #33 did not seem to want to get out of bed. During an interview on 10/09/2025 at 10:45 AM, GNA #24 stated that Resident #33 and Resident #22 were not friends anymore, and Resident #33 was no longer visiting the 200 and 300 Units. During an interview on 10/14/2025 at 2:16 PM, Licensed Practical Nurse (LPN) #15 stated that on Sunday, 08/31/2025 at approximately 10:00 PM, Resident #33 activated their call light and asked to speak with her specifically. She stated Resident #33 was crying and visibly upset. Per LPN #15, Resident #33 reported that Resident #22 had previously touched them and on that night, Resident #33 had gone to the lobby to await family and Resident #22 and Resident #40 cursed at the resident. LPN #15 stated she immediately reported the incident to her supervisor, LPN #22, who contacted the Director of Nursing (DON). LPN #15 stated the DON instructed her to move Resident #33 to another unit. She stated she moved the resident; however, she stated when she returned to work on Monday, Resident #33 was back in their old room. LPN #15 stated that Resident #33 had not been coming out of the resident's room since the incident because the resident was scared. She stated she had noticed the resident coming out more that week. During an interview on 10/16/2025 at 9:05 AM, LPN #22 stated that she had contacted the DON and the Administrator on Sunday (08/31/2025) with the allegation (unable to recall allegation details) and the decision was made to move Resident #33 to the 500 Unit. During an interview on 10/11/2025 at 3:18 PM, Unit Manager (UM) #10 stated Resident #33 told her about the incident several days after the occurrence (unable to recall the exact date). She stated that the resident reported that they were helping Resident #22 to smoke when something sexual was said, but she could not remember the details. UM #10 stated they also recalled something about Resident #33 showing their promise ring and talking about the importance of the item to them. Per UM #10, Resident #33 was worried that Resident #22 and Resident #40 would retaliate against them; however, she stated that she had not seen any retaliation against Resident #33. She stated that she was unable to recall any further details from the report. UM #10 stated she immediately reported the allegation to the DON, and the Mental Health Nurse Practitioner had seen the resident. According to UM #10, there had been no changes in Resident #33's behavior since the incident. During an interview on 10/09/2025 at 11:25 AM, the DON and the Regional Director of Operations (RDO) revealed that Resident #33 had reported that Resident #22 made a comment about wanting [vulgar slang term for a body part], which made Resident #33 uncomfortable. The DON stated that she was also aware that Resident #33 felt like Resident #40 was watching them and that Resident #33 had elected to keep to themselves and not interact with the residents. Per the DON, they had treated this incident more from the perspective of the loss of friendship as the three residents had been friends prior to the incident. The RDO reported that they had interviewed Resident #33 the previous evening, and there was no report of physical contact made, and Resident #33 reported the incident as being an uncomfortable situation and did not describe the incident as being abuse or sexual abuse. Per the DON, the decision was made to have the Mental Health Nurse Practitioner provide talk therapy to both parties involved and she felt like the therapy had been helping. The DON reported that Residents #33, #22, and #40 had all been very good friends prior to the incident and believed that the loss of a friendship played some part in Resident #33's self-imposed isolation. However, due to Resident #33 not labelling the incident as abuse, she did not investigate the incident. On 10/12/2025 at 1:59 AM, a Removal Plan was submitted by the facility and accepted by the State Agency as follows: Corrective actions which will be accomplished for those residents found to have been affected. 1. Statements were obtained from involved residents #41, #22 and #33. Resident #11 is no longer in the facility. For resident #41, no new findings. For resident #22, no new findings. For resident #33, no new findings. Statements were completed on 10/11/25 by the nurse manager. 2. Residents #41, #22, and #33 were assessed to ensure no injuries, physical or psychological, were present. For resident #41, no new findings. For resident #22, no new findings. For resident #33, no new findings. Assessments were completed on 10/12/25 by the nurse manager. 3. RN #20 and Housekeeper #28 have been suspended on10/11 /25 by the Regional Director of Operations. 4. The administrator and director of nursing have been suspended on 10/11/25 by the Regional Director of Operations. 5. Statements were obtained from the accused employees #20 and #28 by the Regional Nurse on 10/11/25. 6. Social Services has met with involved residents #41, #22 and #33 to address any psychosocial concerns. There were no additional findings for Residents #41, #22, or #33, and Resident #11 is no longer in the facility. This was completed on 10/12/25 by the Director of Social Services. 7. Residents #41 (allegation of physical abuse on 10/9/25) and #33 (allegation of sexual abuse on 10/11/25) responsible parties were made aware of the allegations. 8. Police were notified of the allegations of physical and sexual abuse on 10/9/25 and 10/10/25. 9. Maryland Department of Health was notified of the allegations of physical and sexual abuse by 10/11/25. 10. Medical Directors were notified of the allegations of physical and sexual abuse for residents #41 and #33 on 10/11/25. 11. Ombudsman was notified of the allegations of physical and verbal abuse by 10/12/25. 12. Trauma informed evaluations were completed for identified residents #41 and #33 on 10/11/25. Measures that will be put in place and systemic changes that will be made to ensure that the practices do not recur. 1. 248 current employees will receive education regarding investigation of abuse. Education began on 10/10/25 and to be completed by 10/12/25 by the nurse manager. 2. Nurse managers and social workers will be educated on abuse investigation. This started on 10/10/25 and was completed on 10/11/25 by the nurse manager. How the corrective actions will be monitored to ensure the practices will not re-occur. 1. AD Hoc QAPI was held on 10/11/25. To ensure all residents were free from abuse, the decision was made to place the Administrator and Director of Nursing on Administrative leave. 2. The QAPI was reviewed by the Medical Director on 10/12/25. Allegation of Compliance 1. The facility alleges compliance with this plan on 10/12/25. 2. The immediacy of the IJ was removed on 10/12/25. Onsite Verification of Removal Plan: The IJ was removed on 10/13/2025 after the survey team completed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of G. Verification was completed as follows: 1. Witness statements from Residents #22, #33, and #41 were obtained by the DON. 2. Resident #22's weekly skin check assessment dated [DATE] revealed no new skin impairments were identified, and the social services assessment dated [DATE] revealed the facility identified that the resident had a history of past sexual/physical abuse and was currently receiving psychiatric services. Resident #33's weekly skin assessment dated [DATE] revealed no new skin impairments were identified, and a social service assessment dated [DATE] revealed the resident had felt numb and detached, been on guard, watchful, or easily startled, and been trying hard to not think about the events. Resident #41's weekly skin check dated 10/09/2025 revealed no new skin impairments were identified, and a social service assessment dated [DATE] revealed the resident had no verbal indicators or emotional distress/anxiety. 3. Registered Nurse (RN) #20's timecard sheet revealed their last date worked was on 09/29/2025 and Housekeeper #28's last date worked was on 10/11/2025. 4. Record review revealed the RDO placed the Administrator and DON on administrative leave on 10/11/2025. 5. Record review revealed the facility obtained statements from RN #20 and Housekeeper #28 of their witness accounts of the allegations against them. 6. Record review revealed social services staff met with Resident #33 on 10/11/2025 and identified the resident as self-isolating and feeling guilty. Record review revealed social services staff met with Resident #41 on 10/11/2025 and identified no verbal indicators or emotional distress/anxiety during assessment. 7. Record review revealed Resident #33's representative was made aware of the abuse allegation on 10/11/2025 at 9:56 PM, and Resident #41's representative was made aware of the abuse allegations on 10/09/2025 at 3:15 PM. 8. Record review revealed the RDO notified the Medical Director of the allegation of physical abuse for Resident #41 and sexual abuse for Resident #33. 9. Record review revealed Local Law Enforcement were notified of Resident #33's allegation of sexual abuse allegation and Resident #41's allegation of physical abuse allegation on 10/10/2025 and 10/09/2025, respectively. 10. Record review revealed the facility notified the SSA of Resident #41's physical abuse allegation on 10/09/2025 and Resident #33's allegation of sexual abuse on 10/09/2025. 11. Record review revealed Medical Directors were notified of the allegations of abuse on 10/11/2025. 12. Record review revealed the facility notified the Ombudsman of the allegations of abuse Resident #41 and Resident #33 on 10/12/2025. 13. Record review revealed Resident #33's trauma assessment completed on 10/11/2025 identified past sexual abuse and Resident #41's trauma assessment completed on 10/11/2025 [NAME]

Based upon medical record review, facility documentation review and staff interview it was determined that facility staff failed to safely secure a resident during a Hoyer Lift transfer resulting in the resident's subsequent injury and a hospital emergency visit. This was evident for 1 of 1 residents reviewed (Resident #50) during the Complaint survey investigation. The findings included: On 2/22/24 at 1:30 PM a review of Resident #50's Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 6/9/22 was conducted. 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. MDS Section G: Functional Status is coded to reflect that Resident #50 was totally dependent on staff for transfers (how the resident moved between surfaces including to or from the bed, chair, and wheelchair) and required the support of two or more individuals to transfer. Resident # 50 ' s care plan was reviewed on 07/06/20202. 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. Resident #50 was determined to have an ADL (Activities of Daily Living) self-care performance deficit related to abnormal gait/muscle weakness and cognitive impairment. Interventions included use of the Hoyer Lift with the assistance of two staff members for transfers. A Hoyer patient lift is a portable assistive medical device. The lift typically uses electric, hydraulic, or battery power, and specialized sling-style pads that slide under the patient's body to securely transfer an individual from one surface to another. On 2/22/24 at 2 PM further review reveals that Resident #50 sustained a fall from the Hoyer Lift on 06/04/2022. A change of condition Status Note entered into the medical record by RN #35 on 6/4/22 at 6:10 PM reads: GNA #36 (Geriatric Nursing Assistants) was putting the resident to bed with the lift. Pt fell to the floor from the lift. She was lifted back into bed. Injuries were noted to the elbow with swelling and discoloration. The physician was called at that time, and the resident was sent to the emergency room for evaluation. On 2/22/24 at PM an interview of RN #35 revealed that the GNA used the Hoyer lift by herself while talking on her phone. All staff understand that there has to be two people to transfer residents using the Hoyer lift for safety reasons. The GNA was new to the floor and worked as a GNA for less than a year. The GNA was terminated from the facility immediately. Resident #50 had injuries to her neck, shoulder, hip, and elbow with swelling and bruising. Resident #50 ' s anxiety level was very high with the fear of falling and she/he was in a lot of pain. On 2/23/24 at 7:25 AM medical record review reveals that Resident #50 was transferred to the emergency room at Tidal Health on 6/5/24. It was noted that the resident had swelling, bruising and tenderness to the right elbow, tenderness over the right hip and small abrasion over the right knee. The resident was discharged and returned to the facility on [DATE] with discharge instructions for Tylenol for pain and ice pack. Further review of the Electronic medical record revealed a physician ordered on 6/4/22 at 8 PM to apply ice to the right. elbow when needed every 15 min each hour. The physician ordered Tramadol 25 mg by mouth every 6 hours as needed for pain when needed on 9/21/21. A review of the medication administration record revealed that the resident received Tramadol for pain on 6/5, 6/6, 6/7 and 6/8 and then 6/14/22. A nursing progress note on 6/5/22 at 11 PM reported that the resident is complaining of severe pain and was treated with Tylenol, Tramadol, and ice packs. On 2/23/24 at 8 AM an interview with CMA #37 stated the resident told her that the GNA #36 dropped her/him on the floor while GNA #36 was on the phone. The resident was upset and crying that it happened. On 2/23/24 at 10:54 AM an interview with the Director of Nursing revealed that she reviewed the Quality Assurance and Performance Improvement for the year 2022 and it was never reviewed. DON was unable to provide a list of License staff that were re-educated for this incident. On 2/23/24 at 11 AM a review of the facility Nursing Policies for Safe Resident Handling and Transfer Equipment revealed that two train persons are required to operate a Hoyer lift. On 2/23/24 at 11:30 AM the Director of Nursing confirmed that staff failure to safely operate the Hoyer Lift resulted in Resident #50's fall with injury and an emergency room visit with treatment.

Based on observation, medical record review and staff interviews it was determined the facility failed to: 1) provide adequate supervision to ensure the safety of a cognitively and functionally impaired resident (Residents #3) who was assessed as an elopement risk, exited the facility and sustained an injury; and 2) provide ongoing supervision for a cognitively impaired resident (Resident #9), who was prescribed a pureed diet due to the risk of choking, while in the dining room resulting in the resident consuming grapes from the tray of Resident #10, placing the resident at risk for choking; and 2) This was evident for 2 of 3 residents reviewed for accidents during this complaint survey. Elopement is defined as a resident that is not pre-authorized to leave the agency or activity site but does so intentionally and the resident's location is unknown. 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 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. The findings include: 1) The facility failed to provide adequate supervision to ensure the safety of a cognitively and functionally impaired resident (Residents #3) who was determined to be an elopement risk and sustained an injury when he/she exited the facility unaccompanied by facility staff or family. The Wander Guard management system is utilized to protect residents, at risk for wandering and elopement. If a resident wearing a Wander Guard bracelet signaling device passes through a monitored area, an alarm sounds to alert staff of a possible departure. The Wander Guard alarm will continue to sound until staff respond to the door to reset the alarm. Review of complaint #MD 664 revealed a concern that Resident #3 who was admitted to the facility after sustaining a serious head injury was able to exit the facility, unaccompanied by facility staff, fell and sustained a laceration to the back of his/her head. Medical record review revealed that Resident #3 was readmitted to the facility for long-term care with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 5/16/18, noted that the resident was admitted with a laceration to the right scalp area with 3 staples. The injury was sustained because of a fall. A physician's note reported that the resident fell down several flights of steps while in a wheelchair, sustaining a head injury. The medical record contained an Elopement Risk Assessment, dated 5/18/18, that did not note any wandering behavior. The assessment did not have a numerical score or other indications of the severity of the risk for elopement for Resident #3. Review of the admission MDS Assessment, dated 5/23/18, revealed facility staff entered a BIMS score of 3 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 E Behaviors revealed the resident was not noted to have wandering behavior. On 5/25/18 the physician ordered the placement of a Wander Guard, at all times, and to check the Wander Guard functioning daily related to the risk of elopement. A Care Plan, with an initiation date of 5/29/18, addressed the risk for elopement related to Dementia and included the use of the Wander Guard as an intervention. The facility's Elopement Policy, with a revision date of 5/15/14, noted that residents are assessed for the risk of elopement with a change in condition. The medical record failed to reveal a reassessment of the resident's risk for elopement, including behaviors that necessitated the application of the Wander Guard. A Change in Condition form, dated 6/4/18, reported Resident #3 fell , sustained a laceration, and was sent to the emergency room for further evaluation. The form noted new onset pain related to the injury. A Skilled Nurses Note, dated 6/4/18 at 9:36 PM reported the resident returned from the hospital. Administrative records noted, that on 6/4/18, Resident #3 sustained an abrasion to the back of the head when s/he exited the facility, in a wheelchair, through the front door. The resident's wheelchair flipped over, and the resident landed on the parking lot sidewalk. The facility investigation concluded that the front door, which is linked to the Wander Guard system, malfunctioned and the resident exited the facility without the alarm sounding. During an interview with the surveyor, on 9/13/18 at 3:45 PM, Staff #16 stated the resident was originally admitted to the transitional care unit (not locked). S/he did not recall a specific incident that triggered the application of the Wander Guard, but the resident started to self-propel about the unit looking for certain things. In interview with the surveyor on 9/13/18 at 1:55 PM, Staff #6 stated that when a resident, wearing a security bracelet, approaches the front door the alarm sounds. To stop the alarm staff at the reception desk must enter a code and when the system stops beeping and the indicator light turns red the system is reset. Prior to the alarm resetting it is possible for a resident to exit the facility without the alarm sounding, so it is necessary to keep the resident in the line of sight until the alarm resets. During an interview with the surveyor on 9/13/18 at 2:15 PM, Staff #4 stated that all exit doors have alarms and they are checked 3 times a day. Staff #4 stated the alarm system did not malfunction. In interview with Staff #5, on 9/14/18 at 2:30 PM, s/he stated that on 6/4/18 Resident #3 triggered the alarm when s/he approached the door. The resident was redirected and according to Staff #5 moved away from the doors. Staff #5 stated s/he entered the code to reset the alarm at which time s/he was approached by another resident. Staff #5 stated that Resident #3 turned around and exited the facility while the alarm was still resetting and his/her attention was focused on another resident. Staff #5 stated s/he learned this upon reviewing video footage. Staff #5 stated s/he now understands that staff must pay attention to the light and keep an eye on the resident until the system resets. Medical record review and staff interview revealed the facility failed to clearly establish the severity of the resident's risk for elopement including the behaviors noted by staff and ensure that there was ongoing supervision to maintain the resident's safety. Staff interviews revealed there was a lack of knowledge of how the Wander Guard system operated which resulted in Resident #3 exiting the building, unaccompanied, falling out of the wheelchair, and sustaining an injury that required further evaluation at the hospital. 2)The facility failed to maintain ongoing supervision of resident #9 resulting in the resident consuming food that was not according to her/his prescribed diet and placed the resident at risk for choking. Medical record review revealed that Resident# 9 was a long-term care resident with [DIAGNOSES REDACTED]. Dysphagia, difficulty swallowing, means it takes more time and effort to move food or liquid from your mouth to your stomach. The medical record contained a care plan, with an initiation date of 12/10/12, that addressed ADL's and noted the resident was dependent for all ADLs due to Dementia. Activities of Daily Living, ADLs refer to daily self-care activities such as bathing, grooming, eating and dressing. There were no interventions that addressed eating/dining. A care plan, with an initiation date of 12/8/11, addressed nutritional risk related to a mechanically altered and therapeutic diet. Interventions included provide a dysphagia advanced diet, supervise/assist/cue as needed with meals and monitor for changes in nutritional status, including the resident's ability to feed herself/himself. The care plans did not address the need for supervision with meals and while dining with other residents. Review of the quarterly MDS assessment, dated 8/15/18, revealed facility staff entered a BIMS score of 3/15 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 a speech evaluation, dated 8/9/18 revealed the resident was downgraded from a dysphagia advanced diet to pureed foods. The speech services summary goals included tolerance of pureed solids without signs or symptoms of aspiration, care givers would demonstrate 100% compliance with safe swallowing strategies and the resident would tolerate the least restrictive diet to maximize nutritional needs without signs and symptoms of aspiration. Aspiration means you're breathing foreign objects into your airways. Review of the physician's orders [REDACTED]. During a tour of the facility, on 9/14/18 at 11:45 AM, the surveyor observed Residents #9 and #10 seated at the same table in the Station 4 lounge. Resident #10 had a meal tray which consisted of a regular diet. Resident #9 was eating pudding. At 11:55 AM the surveyor observed Resident #9 eating grapes from Resident #10's tray. The surveyor alerted Staff #12, who confirmed that Resident #9 was prescribed a pureed diet. Staff #3 removed the grape skins from Resident #9's mouth and moved her/him to another table. I n interview with the surveyor, on 9/14/18 at 12:05 PM, Staff #11 stated there were no staff assigned to the lounge because Resident #10 was independent with meals and Resident #9 did not have a tray because s/he needed to be fed. There was no explanation as to why and when the residents were seated together and why there were no staff supervising the residents. In interview with the surveyor on 9/14/18 at 2:40 PM Staff #14, the resident's assigned nursing staff, stated that the resident is usually brought to the lounge between 9:00 AM and 10:00 AM. Staff #14 stated that the lounge was empty when the resident entered the lounge on that morning. Medical record review failed to reveal dining interventions that addressed the risk of choking for Resident #9, including the level of assistance and supevision needed during meals. Observations and Staff interviews failed to reveal an attempt to address the lack of supervision at the time of the incident. The findings were discussed with the Director of Nursing on 9/14/18 at 2:54 PM at which time s/he stated an investigation would be completed.

Based on resident and staff interviews and review of medical record and other pertinent documentation, it was deternubed that the facility staff failed to ensure there is an effective system/(s) to maintain an environment free of abuse when on 10/28/17, GNA #12 pushed a vulnerable resident (#11) in a shower chair out into an open hallway while this resident was not fully clothed/covered, cursed at the same resident, threatened the resident and failed to provide assistance to the bathroom, thereby leaving resident #11 to defecate in the public hallway where/while other staff and visitors were present. The (NAME)land Office of Health Care Quality (OHCQ) determined the concern constituted verbal, emotional and psychological abuse of the vulnerable resident and met the Federal definition for immediate jeopardy. The concern was evident for 1 of 25 residents (#11) reviewed during a complaint survey. The concern was determined to be past-noncompliance because staff had immediately reported the abuse, staff #12 was removed from working the unit, an investigation was promptly conducted, and corrective action were completed. The facility plan to address this noncompliance included: 1. Resident #11 remained in the facility and was assessed for safety. On 10/30/17, the primary care physician was notified and orders were obtained for the resident to see Psychiatric services to treat increased anxiety. 2. On 10/28/17, Staff #12 was immediately removed from the property by the Nursing Supervisor pending investigation. 3. The local county Sheriff's Department was notified, and an officer responded at 10:30 PM on 10/28/17 and the (NAME)land Office of Health Care Quality (OHCQ) was notified via facility self-report when the incident occurred at 10/28/17 at 11:00 PM. 4. Witness interviews were initiated on 10/28/17 regarding this staff to resident abuse incident. 5. Abuse prohibition in-servicing for staff was initiated on October 29, 2017 and completed on 11/30/17. 6. Staff #12 was terminated on 11/1/17 after the investigation was completed. 7. Staff #12 was reported to the (NAME)land Board of Nursing on 11/1/17. The complaint survey began on 12/11/17 and review of corrective action documentation revealed that education of all the facility staff was completed by 11/30/17; therefore, the (NAME)land Office of Health Care Quality (OHCQ) determined the concern was immediate jeopardy, past-noncompliance. The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures resident's in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident's needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions (also referred to as MDS Items). Each triggered care area must then be assessed in order to determine if care planning is needed; and if so, to drive an effective plan that will ensure the assessed needs of each resident is met when care is delivered. Review of the medical record on 12/18/17 revealed that Resident #11 was admitted to the facility during March 2017, with known [DIAGNOSES REDACTED]. In the comprehensive MDS assessment with reference date of 4/5/17, facility assessment staff determined that resident #11 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. Review of the facility reported incident and investigation revealed that during the evening shift on 10/28/17, GNA #12 was scheduled and was assigned to work with Resident #11. In an interview on 12/18/17 at 10:15 AM, Resident #11 described an incident that occurred on 10/28/17. Resident #11 stated that he/she asked GNA #12 to give him/her ascheduled shower and GNA #12 said Ok after dinner. Resident #11 stated that when GNA #12 returned to assist with giving a shower, GNA# 12's attitude had also changed. Resident #11 stated that GNA staff #12 brought in a shower chair that was too small for the resident and was not my assigned shower chair. GNA #12 placed Resident #11 in a lift-to-stand device for transfer into the shower chair and told me, you better listen to everything I say, cause it's going to be cold when you are on the floor with no help to get up from the floor. Resident #11 stated that GNA #12 only gave him/her a sheet to cover the front part of his/her body and stated that with his/her entire back and buttocks uncovered, GNA #12 pushed the resident in the chair out to the public hallway. Resident #11 stated that the medicine aide was giving med's and saw him/her in hallway exposed in the shower chair when GNA #12 started cursing me out. Resident #11 stated that there were visitors and staff in the hallway at this time and stated that it was very embarrassing. Resident #11 stated that he/she asked to be covered but GNA staff #12 kept cursing at me. Resident #11 told GNA #12 that he/she needed to use the bathroom but he/she was not assisted to the bathroom, and he/she reported then having a bowel movement in the shower chair in the public hallway. Resident #11 reported that he/she was in tears and was called a cry baby at this time while still in the hallway. Resident #11 reported that he/she then had a second bowel movement when being moved from the public hallway and before he/she was actually taken into the bathroom. Witness statements from staff #13, #14, #15 and #16 corroborated Resident #11's account and indicated that Staff tried to intervene for Resident #11 but GNA staff #12 began to curse and use foul language towards the co-workers. Review of the summary statement from the Manager on Duty (MOD) who initially investigated the concern, revealed the MOD documented that Resident #11 reported that during ADL (activity of daily living) care his/her GNA #12 placed Resident #11 in a shower chair without covering his/her back or buttocks. Resident #11 asked GNA staff #12 to cover him/her; however, GNA staff #12 replied you're going to end up on the floor and be there for a while. It's cold down there. Resident #11 was placed in shower chair and his/she front was covered with only a sheet leaving his/her back and buttocks exposed for staff and residents to see. Resident #11 then told GNA #12 that he/she felt like she/he needed to have a bowel movement. GNA staff #12 attempted to push the shower chair down the hall, but he/she was unable to move it. Although the resident had been pushed out into the hallway in the shower chair, GNA #12 told Resident #11, you weigh too much for me to push the chair. Resident #11 then had a bowel movement in the hallway on the floor. GNA staff #12 asked GNA staff #15 and #16 for help and began cursing at Resident #11 and then at both of the GNA staff members. Review of witness statements of the incident revealed that GNA #15 reported he/she suggested resident #11 be placed in the proper sized shower chair because the Resident was naked and crying hysterically. GNA #15 reported that s/he witnessed GNA #12 angrily whip Resident #11 down the hall and into the shower room. GNA #15 contacted the MOD and reported GNA #12 for emotionally and verbally abusing Resident #11. GNA #15 reported that GNA #12 then started yelling on the phone, leaving Resident #11 naked and crying hysterically in the shower room. Witness statements from GNA staff #14 also corroborated the concern that GNA staff # 12 was abusive to resident # 11. Additional facility documentation revealed that GNA #12 was removed from providing care to resident #11 and another GNA was assigned to provide care to resident for the remainder of that shift. Resident #11 stated that when he/she was then placed in the correct shower chair and covered appropriately, he/she was still crying over what had happened. Review of Resident #11's medical record revealed that a new psychiatric consult order was written on 10/30/17 for psych therapy 3 to 5 times weekly for 30 days. Review of the 11/3/17 psych therapy notes for resident #11 revealed that the psych consult request to see the resident was related to the alleged traumatic experience involving his/her care. Resident #11 reported having increased panic attacks daily. Psych notes further revealed that Resident #11 was assessed as anxious and tearful with reported increased panic attacks. Staff were noted as supportive, but it was documented that Resident #11 still was embarrassed by the incident . Documentation of new medication orders revealed an increase in the dose of medication used to treat the resident's depression and continued Psych Therapy Assessment notes revealed that on 11/24/17 Resident #11 voiced concerns that she/he visited their daughter for the holidays and had two panic attacks. Both panic attacks occurred in the bathroom.

Based on medical record review, review of facility investigation and interview of staff, it was determined that a geriatric nursing assistant (GNA) was abusive to two residents (Resident #6 and #7) and a nurse failed to prevent an incident of abuse in one (Residents #6) of eight sampled resident records. Additionally, the administrative staff failed to report a GNA to her licensing board after they had substantiated abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm or saying things to frighten a resident. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The findings included: Resident #6 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #7 was also admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of Resident #7's medical record revealed the following nursing note: 05/01/2014 at 10:00 a.m.: "Very upset in shower room. Observed by nurse to be smacked on buttocks by GNA when (resident) was attempting (to) sit on a chair in the shower room. Behavior after shower was guarded with arms crossed, tears in her eyes and isolating herself - different from baseline behavior of smiling and happy." Review of the facility's investigation revealed that on 05/01/2014, GNA #4 was showering Resident #7. While GNA #4 was showering Resident #7, another GNA (#5) was assisting another resident with a shower. GNA #5 describes GNA #4 speaking "loudly and with force" while showering Resident #7. According to the facility's investigation and interview with Charge Nurse #1 on 05/29/2014 at 1:45 p.m., Charge Nurse #1 entered the shower room and observed GNA #4 smack Resident #7, who was naked on the buttocks. Interview with Charge Nurse #1 on 05/30/2014 at 9:45 a.m., revealed that after this nurses' observation of GNA #4 smacking Resident #7 on the buttocks both dressed the resident. According to a statement from Charge Nurse #1 and interview with Charge Nurse #1 on 05/29/2014 at 1:45 p.m., she assessed the resident and Resident #7 "appeared very distressed and anxious". Charge Nurse #1 allowed GNA #4, despite Resident #7 being very distressed and anxious, to continue to provide care to this resident. Charge Nurse #1 statement continues: "When resident left shower room she ran down the hall and then into the quiet room where she isolated herself. I assessed resident in quiet room and tears appeared in her eyes. Resident seemed very distressed." According to an interview with Charge Nurse #1 on 05/29/2014 at 1:45 p.m., she stayed with the resident for approximately 20 minutes. During this time period, GNA #4 remained on the unit providing care to other vulnerable residents. It is worth noting, that according to GNA #4's termination paperwork, "This action put the resident in distress for the next few hours." ..."In addition, the resident was guarded and observed holding her arms tightly across her chest, tears were observed in her eyes and she was not answering questions or tapping her feet to music. All of the behaviors above are behaviors which are not within the baseline of the resident's natural behaviors. (GNA #4)'s actions in the shower room resulted in resident harm and abuse." Further review of the facility's investigation and interview with Charge Nurse #1 on 05/29/2014 at 1:45 p.m., revealed that after assessing and consoling Resident #7 she was walking in the hallway toward the nursing station. Charge Nurse #1 "witnessed GNA (#4) pushing resident (Resident #6) down the hallway extremely fast. Residents feet kept dragging the ground because she was unable to hold them up. GNA (#4) kept pushing her saying 'keep your feet up'. When close to the table in the dining room, GNA (#4) pushed resident (#6) in the wheelchair aggressively into the table. The resident yelled and moaned." Review of Resident #6's medical record revealed the following nursing note: 05/01/2014 at 3:59 p.m.: "(Resident #6) was being pushed in her wheelchair by GNA (#4) up hallway at a fast pace and the GNA (#4) was repeatedly telling (Resident #6) to hold her feet up. (Resident #6) was unable to hold her feet up. The GNA (#4) continued to push (Resident #6). When the GNA arrived at a table, she pushed (Resident #6) into the table hard enough that (Resident #6) feet hit the bottom of the table legs and she yelled out and moaned. ... ." It is also worth noting, that the administrative staff failed to report a GNA to her licensing board after they had substantiated abuse. Interview with the Administrator on 05/30/2014 at 9:40 a.m., revealed that after they investigated and concluded that GNA #4 was abusive with two residents, that GNA #4 was not reported to her licensing board. Reporting to the licensing board allows for further investigation, monitoring and potential revocation of licensure. In conclusion, GNA #4 was abusive to two residents (Resident #6 and #7) and Charge Nurse #1 failed to prevent the second incident of abuse involving Residents #6 by allowing GNA #4 to remain on the nursing unit and provide care to vulnerable residents. Additionally, the Administrator failed to ensure that GNA #4 was reported to her licensing board.

Based on medical record review and interviews, it was determined the physician and nursing staff failed to determine a specific medical symptom requiring the use of a restraint, failed to complete ongoing assessments for the appropriateness of continued restraint use, failed to attempt restraint reduction and/or failed to discontinue, in a timely manner, the use of a physical restraint in two of 53 residents reviewed in Stage 2. A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Federal regulations prohibit the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of the restraints. The findings included: 1. The physician and nursing staff instituted the use of a restraint, a posey canopy bed, without a specific medical symptom requiring the use of the restraint and failed to discontinue, in a timely manner, the use of the restraint . Resident #387 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a care plan initiated on 10/23/12 for risk of falls secondary to impaired mobility, cognitive loss and lack of safety awareness. A care plan is a written guideline of care based on the individual's needs developed by an interdisciplinary team (including the resident, nursing, rehab, dietary, etc) that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect, or inaccurate care. Further review revealed that the fall risk care plan was updated on 11/02/12 following a hospitalization . The interventions on the 11/02/12 care plan included a bed/chair alarm (to remind the resident to ask for assistance and to alert the staff) and to keep the resident's bed in the low position. Review of the medical record revealed the following falls and care plan interventions: 11/08/12 at 5:00PM "patient on floor trying to transfer self without assistance, patient removed bed/chair alarm and did not lock both wheels on wheelchair." "Patient stated was trying to get to his bed but forgot to lock one of his wheelchair wheels and when he tried to push off the wheelchair it moved." 11/12/12 at 5:45AM "going to bathroom on his own and fell (slipped in stool) patient had removed alarm" Review of the care plan revealed that on 11/12/12 the resident's bed was placed against a wall in his room and a landing strip (floor mat) was placed on the floor next to the bed to prevent an injury if the resident fell out of bed. 11/16/12 at 4:15AM "Resident stated he went to bathroom and slipped coming back to his bed. had removed alarm.' Review of the care plan revealed that on 11/16/12 the bed alarm was changed to a laser alarm and a recliner chair (gerichair) was initiated to support his trunk. Review of the nurses' notes from 11/16/12 through 12/01/12 revealed attempts to self transfer from bed or gerichair but no falls secondary to staff intervening. Review of the medical record revealed that on 12/01/12 the resident began combative and resistant behavior towards staff. At 2:55PM on 12/01/12 a nurse wrote, "...when attempted to bath this morning resident yelled at staff while trying to hit staff with fists...". At 10:42PM on 12/01/12 a nurse wrote, "alert, very disoriented and highly combative. Swinging at GNAs (Geriatric Nursing Assistants) while trying to assist with ADLs (bathing, dressing, toileting, etc). Cursing and spitting at staff tonight...Kept getting out of wheelchair. Keeps trying to get out of bed. Alarms on. Bed in lowest position. Safety maintained. Will continue to monitor." Review of the medical record revealed that this was a change in the resident's behavior. 12/02/12 at 4:00PM "found on floor in TV/dining room- patient sitting on floor -alarm sounding patient stated that he wanted to get out of chair." 12/03/12 a nurse wrote, "resident has been lethargic most of morning but unable to keep resident in bed to rest, resident will wake up just enough to get to edge of bed and try to stand, risk for falling. resident was put into a wheelchair from gerichair to go to therapy at 1250, was sitting up well." 12/04/12 at 11:11AM a nurse wrote, "patient has been in gerichair, has remained fall free will continue to monitor." At 6:45PM on 12/04/12 a nurse wrote, "...OOB (out of bed) to geri chair. Continues to get out of gerichair several times. Fall ;and safety precautions maintained. Poor safety awareness." 12/05/12 at 2:00AM a nurse wrote, "At 0200 patient apparently rolled off the recliner to the floor. Pt was in a recliner across from nurses station prior to incidence..." 12/05/12 at 8:50AM a nurse wrote, "12-5-12 resident sustained [REDACTED].@ 0825. 1st fall resident was in recliner at nsg (nursing) station when nurse heard a thump and resident seen lying on left side on floor. Resident rolled off left side of chair. 2nd fall resident in TV/Dining area eating breakfast. Moved table and was witnessed rolling off right side of chair on to floor. No injuries noted. For review in falls meeting today." Review of the investigation of the 8:25AM fall on 12/05/12 revealed a statement from a staff witness that the resident had eased himself to the ground. The resident was able to stand and the nursing staff was able to assist the resident back into the geri chair. Review of the fall risk care plan revealed an intervention for a posey canopy bed for safety was initiated on 12/05/12. Review of the physician's orders [REDACTED]. The order included the following instructions: "to close all zip bands of bed, check position of pads and resident when in bed every 2 hours. Keep head and foot of bed in low position to prevent pocketing in areas in which resident may be entrapped." The physician order [REDACTED]. A posey canopy bed is a bed that is entirely enclosed. The individual inside the canopy bed cannot unzip the enclosures to exit the bed. The bed can only be opened from the outside. Review of the medical record revealed that the rationale for the posey canopy bed was for fall prevention. Interview on 06/27/13 at 11:30AM the Director of Nursing verified that the rationale for the posey canopy bed was fall prevention. The Director of Nursing stated that the resident had falls from his bed despite the bed being in the lowest position with a fall matt and alarms in place. The resident was then placed in a gerichair. When the resident fell out of the gerichair a posey canopy bed was used. Further review of the medical record revealed that the posey canopy bed was not discontinued until 02/26/13. Review of the resident's falls revealed that the falls were the result of the resident self transferring from bed or chair without asking for assistance. The physician and nursing staff used a restraint as a means of fall prevention and not because the restraint was required to treat a specific medical symptom. During an interview with the resident and social worker # on 06/27/13 at 1:00PM the question was asked, "What was reason for the canopy bed?" The resident replied, "I had falls." " When did you get back in a regular bed?" Resident replied, "I don't remember." "How did you feel in the canopy bed?" The resident replied, "Like a caged animal." 2. The physician and nursing staff instituted the use of a restraint, a Posey Canopy Bed, without a specific medical symptom requiring the use of the restraint, failed to complete ongoing assessments for the appropriateness of continued restraint use, failed to attempt restraint reduction and/or failed to discontinue, the use of a physical restraint. A Posey Canopy Bed is a bed that is entirely enclosed. The individual inside the canopy bed cannot unzip the enclosures to exit the bed. The bed can only be opened from the outside. Resident #223 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This resident is dependent on staff for all of his needs. Review of the medical record revealed the following physician order: 12/19/2011: " POSEY CANOPY BED " . Though the medical record did not reveal a medical rationale for this Posey Canopy Bed, interview with the unit manager on 06/28/1013 at 9:00 a.m. verified that the only rationale for this restraint was " to keep the resident in his bed " . The unit manager went on to state that in his prior bed he would often move around and place his legs and arms over the edge of the bed. Nursing notes and behavior monitoring sheets (completed daily by every shift), revealed no recent evidence that the resident was unsafely attempting to move around in his bed. Further review of the medical record revealed no ongoing assessment for the appropriateness of this continued restraint. It is also worth noting that since 12/19/2011, the medical record revealed no evidence that the physician or nursing staff attempted any form of restraint reduction for this resident. The physician and nursing staff instituted the use of a restraint, a Posey Canopy Bed, without a specific medical symptom requiring the use of the restraint, failed to complete ongoing assessments for the appropriateness of continued restraint use, failed to attempt restraint reduction and/or failed to discontinue, the use of a physical restraint.

Based on medical record review and interviews with the facility staff, it was determined that the nursing staff failed to address or inform the physician that the resident was refusing a medication that was prescribed to treat elevated ammonia levels resulting in the resident needing emergency care in one of 53 sampled residents during the Stage 2 review. An ammonia test is a blood sample that measures the amount of ammonia in the blood. An elevated blood ammonia level occurs when the liver is not working properly, allowing waste to remain and build up in the blood. Ammonia can be poisonous to your cells and an elevated ammonia level can affect the entire body. A normal ammonia level is usually between 9-35. Symptoms of elevated ammonia levels include changes in level of consciousness or alertness, changes in mood, personality or behavior or sudden confusion. The findings included: Resident #415 was admitted to the facility from the hospital after having surgery to treat a subdural hematoma. The resident was admitted with multiple [DIAGNOSES REDACTED]. Subdural hematoma is a blood clot that forms underneath the skull. Review of the hospital transfer summary dated 1/4/13 revealed the resident had an elevated ammonia level on 1/3/13 of 57 which was being treated with [MEDICATION NAME] 20 grams twice a day. An elevated ammonia level is nothing unusual for a person with [MEDICAL CONDITION] unless changes in symptoms are noted. [MEDICATION NAME] is a laxative that reduces ammonia levels by drawing ammonia out of the blood into the colon where it is removed through feces. [MEDICATION NAME] causes diarrhea. According to the admission nursing assessment this resident was alert and oriented to person, place and time. Behaviors according to the admission nursing assessment were "intact." Speech was clear. Nutrition excellent. Resident was continent (able to control bladder and bowel) and utilized a bedpan. Mobility was slightly limited, resident is chair fast and must be assisted to chair. Resident had impairment to the left side. Review of the medical record revealed the following nurse's notes: 1/5/13- 03:56 (3:56 AM) revealed resident alert but confused, wanting to go home. 1/5/13- 22:46 (10:46 PM) revealed resident alert and verbal, speech clear. 1/6/13- 19:20 revealed resident had "PJ and recipe" (homemade laxative) given to aid in bowel elimination. Bowel sounds (BS) x 4 quadrants. Review of the facility "Bowel and Bladder Documentation" form nursing staff documented the following: Resident had no bowel movement (BM) on 1/5/13 or 1/6/13. 1/6/13- 3-11 (evening shift) resident given the "PJ and recipe" 1/713- 11-7 (night shift) had a medium formed BM. 1/713- 7-3 (day shift) resident had a small formed BM Resident now is incontinent (does not have control of Bladder/bowel). Also, during this time nursing had documented on the MAR (Medication Administration Record) that the resident had refused three of the seven doses of [MEDICATION NAME] that was ordered from 1/5/13 to 1/8/13. There is no evidence of nursing addressing or notifying the physician/CRNP that the resident had refused almost half of the [MEDICATION NAME] doses and was not achieving the results that are expected, such as experiencing diarrhea or even daily BMs. The ammonia level was received at facility on 1/7/13 at 12 noon. The level is now 77. There is no documentation indicating that the physician was informed of results. The Director of Nurses (DON) stated on 6/25/13 at 9:15 AM that it appears the physician was not notified of ammonia level. It was not until 1/8/13 at 14:51 (2:51 PM) that the nurse practitioner (CRNP) was seeing the resident to review labs and meds. The CRNP reviewed the ammonia level from 1/7/13 and increased the [MEDICATION NAME] from 20 mg to 45 mg BID and it was to start that night. An ammonia level was to be repeated on 1/11/13. It appears the CRNP was treating the resident unaware that the resident was refusing the treatment. Nutrition note dated 1/10/13 at 09:25 stated resident is a nutrition concern due to inadequate oral intake. A nurse's note dated 1/10/13 at 17:02 revealed resident had poor appetite, bad headache, abdomen soft non-distended and remains incontinent, trace generalized [MEDICAL CONDITION]. CRNP notified of headaches and new orders. Continued to state resident was cooperative and went to therapy, difficult for resident to follow directions. Further review of the facility "Bowel and Bladder Documentation" form nursing staff documented the following: 1/8/13- 3-11 (evening shift) had a formed BM 1/9/13- 7-3 small formed BM 1/9/13- 3-11 large loose BM 1/11/13-medium formed BM The resident continued to be incontinent even though he was documented as continent on admission. On 1/10/13 at 17:35 (5:35PM) states, " Resident seen today due to complaints of headache. Nursing staff reports restlessness/anxiety, confusion. " CRNP notes abdomen is non-distended + BS hypoactive (decreased or absent bowel sounds often indicate constipation.) NP acknowledged the increase of [MEDICATION NAME] to 45 cc BID. The CRNP also stated no other significant changes. Remains at baseline confusion. Again, it appears the CRNP was treating the resident unaware that the resident was refusing the treatment. 1/11/13 at 01:51 Fall risk -6.0 (low risk) A nurse's note dated 1/11/13 at 04:15 revealed resident had a fall at 03:00 (3:00 AM) reaching for remote and had been incontinent x 3 of bladder. No changes in bowel regimen. Physician to be notified on rounds. Facility staff receives ammonia level on 1/11/13 at 12:00 PM. The ammonia level is now 98. A nurse's note dated 1/11/13 at 15:19 revealed resident had tearful episode this afternoon 1:1 New order for enema to be given x 1. 1/11/13 at 22:42 Fleets enema given at 2030 with medium loose BM returned. 1/12/13 Resident remains confused to time and place. Has not been back to sleep as yet. /12/13 at 09:00 Has not been back to sleep yet. 1/13/13 at 03:00- "Awake thus far, alert with confusion. Tearful at times. Voiding on floor on several occasions tonight. Took drawer out of bedside stand stating, ' I just got here.'" 1/13/13 at 12:05 The nurse wrote that the physician was paged regarding change in mental status (MS), non-compliance and staying in bed. 1/13/13 at 12:17 a change of condition report reveals that nursing reports, "A change in MS color pale, level of consciousness lethargic, confused a change from previous state. Disoriented x3 (person, place and time). Pt to be more agitated and talking to himself. Not able to communicate like yesterday. Labs- AMMONIA 98 Physician notified at 0900 (9:00 AM)." Resident was sent to hospital emergency room for elevated ammonia levels and change in MS. Review of the MAR had revealed the resident refused seven of the eleven doses of [MEDICATION NAME] that was ordered from 1/8/13 to 1/13/13. Again, there is no evidence indicating that nursing had addressed or had informed the physician that the resident had refused more than half of the [MEDICATION NAME] doses that were ordered. The resident was continuing to not achieve the results that were expected, most importantly, decreasing the elevating ammonia level. The resident was admitted to the hospital to be treated for [REDACTED]. Review of the hospital discharge summary dated 1/14/13 revealed the resident's ammonia level remained elevated at 84 and the hospital physician had stated, "It was questionable whether he was actually receiving his [MEDICATION NAME]. We started him on [MEDICATION NAME] and his ammonia level came down to 61, and he is now alert, awake and oriented...." The physician continued to state, "My suggestion would be to continue his [MEDICATION NAME] as scheduled, and he will have diarrhea, which is what the [MEDICATION NAME] is supposed to do for him, and evaluate him for mental status changes by checking an ammonia level prior to sending to the hospital." Review of the hospital MAR revealed, that while in the hospital, the resident was receiving [MEDICATION NAME] 20 grams twice a day. During an interview with the Director of Nurses on 6/27/13 at 2:00 PM she was unable to give a reason why nursing didn't follow-up or notify the physician. During a telephone interview with the physician on 6/27/13 at 6:10 PM he stated that it looks like the NP had increased the [MEDICATION NAME] because she thought he was taking it and she increased for full effectiveness. It doesn't look like it was communicated. He continued to state that he agreed that a resident should not have to go to the hospital to be treated for [REDACTED]. Due to the nursing staff failing to address that the resident's treatment was possibly unsuccessful due to the resident refusing more than half of the [MEDICATION NAME] doses ordered; and the nursing staff failing to notify the physician of the resident's refusals indicating a possible medical intervention, resulted in the resident having change in mental status, behaviors and level of consciousness. The resident was then transferred to the emergency room and then admitted to the hospital where he had to be managed for his elevated ammonia levels.

Based on medical record review and interviews with the facility staff, it was determined that the staff failed to intervene, monitor and assess a resident's bowel status in one of 38 sampled residents during the Stage 2 review. The findings included: Resident #363 was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the medical record, this resident is alert and oriented, but limited in mobility. Review of the medical record revealed that the physician wrote the following orders to help prevent and treat constipation: [MEDICATION NAME] (stool softener) 100 mg twice a day, [MEDICATION NAME] (laxative) 30 ml everyday, and [MEDICATION NAME] (laxative) 17 gm every day. Constipation is a condition where the resident has infrequent bowel movements (BM); resulting in hard, dry stools. Constipation may cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. Due to the resident's [DIAGNOSES REDACTED]. According to the "Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Both [MEDICATION NAME] and the [MEDICATION NAME] are used to treat moderate to severe pain and both can cause or worsen constipation. According to the "ADL Flow Record" for May, 2012, it revealed that the resident was documented not to have had a bowel movement on all three shifts for the following days: 05/07/12 05/08/12 05/09/12 05/10/12 05/11/12 05/12/12 (small amt brown loose stool) On 05/09/12, the resident was ordered a one dose to be given "now" and then additional doses of [MEDICATION NAME] 17 gms were to be given twice a day for three days. According to the MAR, the resident had received the single dose ordered on [DATE] and then received five of the six doses of [MEDICATION NAME] from 5/10/12 to 5/12/12. After the [MEDICATION NAME] was given, the resident did not have a bowel movement. At this time, there is no documentation indicating that the nursing staff assessed that, even after receiving daily doses of laxatives plus her added doses of [MEDICATION NAME], the resident was still not able to produce a bowel movement. The physician, according to documentation, was not made aware of the resident's status. On 05/10/12 at 10:46 PM the nurse wrote the following: "Patient was due for a suppository per protocol however because patient has emesis (vomiting) early patient refused." Again, there is no indication that the physician was notified that the resident had not had a bowel movement and was now refusing the suppository. The facility has the following bowel protocol: 1. Milk of Magnesia (MOM) 10 ml if no bowel movement in 3 days 2. [MEDICATION NAME] suppository 10 mg rectally after MOM if pt still does not have bowel movement. 3. Fleet Enema after [MEDICATION NAME] if patient still does not have a bowel movement. Milk of Magnesia (MOM), an oral liquid, will usually stimulate a bowel movement within 24 hours. A Fleets enema is a liquid that is inserted into the rectum to stimulate the intestines to expel stool. On 05/12/12 at 10:06 PM, the nurse writes the following note: "Small amount brownish liquid this shift from enema given at 1500 (3:00 PM). Resident requested pain med twice this shift. Miserable much of the time with lower abd (abdomen) discomfort. Abdomen hard on the right side and tender to touch at the bottom. Does not want to be bothered much of the shift." Two symptoms of severe constipation, which may result in fecal impaction, are passing stool involuntarily because of liquid stool leaking around the impacted mass of feces and abdominal pain. Even though the resident was exhibiting signs and symptoms of severe constipation, or a possible fecal impaction, there is no evidence of nursing notifying the physician. On 05/13/12 at 6:12 AM the nurse wrote the following note: "Continues to expell small amounts brown fluid. Abdomen remains tender to touch. Color pale, skin warm and dry... Moaning several times during the shift. Abd (abdomen) discomfort continues with [MEDICAL CONDITION] (swelling) to rt (right) abd and a hard area beside anus (external opening of rectum). [MEDICATION NAME] 2 tabs given at 0030 (12:30 AM) and 0400 (4:00 AM). Offered to send resident to the hospital if she wanted to go but she refused twice when I asked her. Stated if she didn't feel better this am then she might go." Once again, even though the resident's symptoms appeared to be worsening, the nurse failed to follow-up and fully assess that the resident may have needed medical intervention from the physician. On 5/13/12 the physician was finally notified of the resident's status and he ordered for the resident to be transferred to the emergency room for evaluation and treatment. A nurse's note on 5/13/12 at 2:22 PM revealed the following: "resident sent to ER @ (at) 9:30 am d/t (due to) continues abd pain, hypoactive bs (reduced or sluggish bowel sounds) and no bm (bowel movement) times 7 days...." Reduced (hypoactive) bowel sounds include a reduction in the loudness, tone, or regularity of the sounds. They are a sign that intestinal activity has slowed. Decreased or absent bowel sounds often indicate constipation. The resident was admitted to the hospital on [DATE] to manage her constipation. The hospital report stated the following: "... She presented to the ER with complaints of having severe abdominal pain and constipation. She reports not having any bowel movements since she left the hospital (05/07/12), and her abdominal pain has progressively worsened and she was unable to sleep last night due to severe pain." While in the ER a Fleet enema was administered without success. A CAT scan was performed and it was consistent with retained stool in the rectosigmoid, which is part of large intestine near the rectum. A CAT (Computed Tomography) scan uses X-rays to make detailed pictures of structures inside the body The resident was also treated for [REDACTED]. While in the hospital, the resident had to endure multiple enemas to treat the constipation. During an interview with the Director of Nurses on 05/24/12 at 2:00 PM she was unable to give a reason why nursing didn't follow-up or notify the physician. During a telephone interview with the physician on 05/30/12 at 11:05 AM he stated he was not made aware of the resident's status. He continued to state that he would have definitely sent the resident to the hospital. He also stated that if he would have been notified the resident may have been more compliant to going to the hospital when she was asked. Due to the nursing staff failing to intervene when the current bowel regimen was not successful and the nursing staff failing to notify the physician for medical intervention, resulted in the resident having to be transferred to the emergency room and then admitted to the hospital where she was managed for her constipation. `