Every finding on record at Berlin Nursing and Rehabilitation Center

Based on record reviews, observations and interviews it was determined that the facility failed to 1) ensure residents were free of accidents, and 2) provide adequate supervision to prevent falls. This was found to be evident for 1 (Resident #82) out of 3 Residents reviewed for accidents during the recertification and complaint survey. This deficient practice resulted in actual harm to Resident #82. The findings include: Tracheostomy (trach) - a surgical opening made through the front of the neck to help a person breathe when their regular airway is blocked, damaged, or they require long term breathing machine support. Activities of Daily Living (ADL) - Basic everyday tasks people must do by themselves to care for their bodies and live independently such as bathing, dressing, eating, toileting, transferring, and continence. Epidural hematoma - A blood clot between the skull and the outside layer of the brain usually caused by a hard hit to the head that breaks a bone and tears an artery. It is a life-threatening medical emergency. Craniotomy - A surgical operation where a neurosurgeon temporarily removes a piece of the skull to reach the brain. This procedure is used to reduce swelling inside the brain. The Minimum Data Set (MDS) is a standardized, comprehensive assessment used in long-term care facilities to evaluate a resident's health status, functional abilities, and care needs and to support development of an individualized care plan. Total Dependence - 2 staff full assistance in performance of Activities of Daily Living (ADL) with complete non-participation by the resident. Staff do 100% of the work. The Brief Interview for Mental Status (BIMS) is a short, standardized cognitive screening tool used primarily in skilled nursing and long-term care facilities. It evaluates three specific areas of brain function-repetition, temporal orientation, and short-term recall yielding a total score from 0 to 15.1)Investigation of facility-reported incident #3056135, reviewed on 08/11/2026 at 1:30 PM, indicated that Resident #82, who had a tracheostomy and was ventilator-dependent for respiratory support, sustained a fall from the bed while receiving assistance with Activities of Daily Living (ADL).On 8/11/2026 at 1:30 PM, further review of the facility reported incident # 3056135 investigation revealed that On 06/24/2026, while GNA #23 was providing a bed bath alone, Resident #82 began coughing and sliding off the bed. Despite GNA #23 attempting to intervene, the resident fell face down to the floor and became disconnected from the ventilator. The resident was lifted back into the bed with the use of a Hoyer lift. Upon further nursing assessment, the resident was observed to have had bleeding from their gums and right sided facial swelling post fall. The resident was reconnected by Respiratory Therapy and sent to the emergency room, where a CT scan revealed a right-sided epidural hematoma requiring an emergency craniotomy. A Minimum Data Set (MDS) assessment completed on 4/01/2026, reviewed on 08/11/2026 at 8:00 AM, assessed the resident as Dependent (01) for all ADLs. This classification indicated that the resident contributed none of the effort and required the assistance of 2 or more staff to complete the activity.A review of the medical records for Resident #82, conducted on 08/11/2026 at 8:30 AM, revealed Resident #82 was evaluated by physical therapy on 11/13/2025 and coded as nonverbal and unable to follow verbal commands, while a speech therapy evaluation on the same date noted the resident was unable to verbalize speech and was inconsistent with eye movement. On 08/11/2026 at 10:00 AM, a medical record review confirmed staff documented 1-person assist ADL care prior to the 06/24/2026 fall.During an interview conducted on 08/11/26 at 9:45 AM, the GNA #23 reported she provides care for residents with a tracheotomy and ventilator and they are provided a daily bed bath. She stated a resident is determined to be 1 or 2 person assist by their cognitive function; if they are able to follow verbal cues and aid with holding on to the bed railing then its a 1 person assist. She identified Resident #82 to this surveyor as one of the residents on the unit that required a 2-person assist for ADL care. GNA #23 explained that a 2-person assist is required for residents that are unable to assist in any way, that meant total dependence. She stated 1-person assist residents are independent with most of their care and able to move their upper extremities on their own. GNA #23 reported they are updated on a resident's level daily by the floor Registered Nurse (RN) and have access to the residents' medical record and can review the care plans On 08/11/2026 at 10:00 AM, a review of Resident #82's medical records showed that staff documented that the resident received ADL care with 1 person assist prior to the fall that resulted in a significant injury on 06/24/26. During an interview on 08/11/2026 at 11:00 AM, the Director of Nursing (DON) stated that all residents who are nonverbal with involuntary movement are care planned as automatic 2- person assist now after the incident. DON stated the facility does not have any specific written criteria that she is aware of. The DON stated that the resident should have 2 people assisting when providing care.08/11/2026 3:30 PM meeting with DON, NHA, clinical specialist, and regulatory specialist to make them aware of our findings.

Based on record review and interviews it was determined the facility failed to ensure Residents were informed in writing of the facility bed hold policy and associated costs at the time of discharge. This was evident for 2 (Resident #3 and Resident #8) of 4 residents reviewed for discharge process during the recertification and complaint survey. The findings include:1) On 08/13/2026 at11:00 AM, a review of the facility bed hold policy revealed it is the facility's policy that residents will receive a written bed hold notice at time of discharge or within 24 hours for an emergency discharge for hospital transfer. On 08/13/2026 at 11:46 AM, a review of Resident #3 medical record confirmed the resident was transferred and admitted to the hospital on [DATE]. Upon further review of the medical record, this surveyor was unable to locate evidence that the written bed hold policy and associated cost were provided to Resident #3 or to their representative within 24 hours after the emergency discharge. A request was submitted to the Director of Nursing (DON) on 08/13/2026 at11:49 AM for a copy of the written bed hold provided to Resident #3 for their discharge on [DATE]. On 08/13/2026 at 3:03 PM, an interview with the DON and Clinical Services Director confirmed they were unable to locate any evidence of the written bed hold policy or cost provided to the resident in the medical record and they verified there was no record of a written or signed bed hold notification for Resident #3 discharge on [DATE]. 2) On 08/13/2026 at 9:21 AM, a review of Resident #8 medical record revealed the resident was most recently hospitalized on [DATE]. A copy of the written and signed bed hold policy and associated cost was not located within Resident #8 medical record for the emergency discharge.On 08/13/2026 at11:00 AM, a review of the facility bed hold policy revealed it is the facility's policy that residents will receive a written bed hold notice at time of discharge or within 24 hours for an emergency discharge for hospital transferA request was submitted to the Director of Nursing (DON) on 08/13/2026 at11:49 AM for a copy of the written bed hold provided to Resident #8 for their discharge on [DATE]. On 08/13/2026 at 3:03 PM, an interview with the DON and Clinical Services Director confirmed they were unable to locate any evidence of the written bed hold policy or cost provided to Resident #8 in their medical record and verified there was no documentation of a written or signed bed hold notification for Resident #8 discharge on [DATE].

Based on record reviews and interviews it was determined that the facility failed to ensure medications were administered as ordered. This was found to be evident for 1 (Resident #102) out of 1 Resident reviewed for a significant medication error during the re-certification survey. This deficient practice resulted in an actual harm cited as past compliance. The findings include: On 07/20/25 at 5:32 PM a review of the Facility Reported Incident (FRI) #348424 revealed a report that advised Resident #102 was mistakenly administered all of Resident #115's morning medications. As a result, the Resident experienced a significant adverse event and was admitted to the local hospital's Intensive Care Unit (ICU) for treatment. A review of Resident #115's Medication Administration Record (MAR) was conducted on 07/20/25 at 5:35 PM. The review of the MAR showed the following morning medications were scheduled to be administered on the day of the incident (8/19/24): Cyanocobalamin (vitamin B-12), Gabapentin capsule 900 mg, Ibuprofen tablet; 800 mg, MiraLAX (polyethylene glycol 3350) 17 gram/dose; MS Contin (morphine) extended release 30 mg, Nubeqa (darolutamide) tablet 300 mg (cancer medication), Senna - S (8.6- 50 mg), and Tamsulosin capsule; 0.4 mg. During an interview conducted on 07/20/25 at 5:49 PM, the Director of Nursing (DON) confirmed that Registered Nurse (RN) 16 administered Resident #115's morning medications to Resident #102. The DON reviewed the MAR with this Surveyor and confirmed that Resident #102 received the following medications: Cyanocobalamin (vitamin B-12), Gabapentin capsule 900 mg, Ibuprofen tablet; 800 mg, MiraLAX (polyethylene glycol 3350) 17 gram/dose; MS Contin (morphine) extended release 30 mg, Nubeqa (darolutamide) tablet 300 mg (cancer medication), Senna - S (8.6- 50 mg), and Tamsulosin capsule; 0.4 mg. A review of Resident #102's progress note dated 08/19/24 from the DON was conducted on 07/20/25 at 6:56PM. The note reported that RN #16 immediately reported her oversight that she administered Resident #102 incorrect medications during the AM (before noon) medication pass. The DON stated, this writer was called to the resident room approximately 0930, immediately after medication was given, resident was noted alert and verbal, and oriented x 2-3.The DON further stated that the Resident was able to follow commands, speech was clear, continued with O2 (oxygen) via nasal cannula for treatment of COPD, bilateral strong hand grasp, pushes, pulls, bilateral strong pedal pushes and pulls. The Physician was notified, gave new orders for neuro checks every 15 minutes, administer Narcan and send to the emergency room for decreased/change in mental status. The Physician also stated that he would be in today to assess the Resident.According to the World Health Organization (WHO) Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease causing restricted airflow and breathing problems. It is sometimes called emphysema or chronic bronchitis. In people with COPD, the lungs can get damaged or clogged with phlegm.According to the National Institute of Drug Abuse Naloxone (Narcan) is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. The DON reported that at approximately 12:45 PM, Resident #102 was noted with decreased mentation, hard to arouse, 911 was called and arrived, Narcan was administered, and the Resident was transported to the local hospital emergency room. A review of Resident #102's hospital discharge summary was conducted on 07/20/25 at 7:04 PM. The discharge summary reported that in the ED (emergency department) the Resident was started on 1 milligram of Narcan infusion and placed on a BiPAP. The Resident was arousable to moderate sternal rub and was able to follow simple commands like moving legs and squeezing hand. The Resident was admitted to the ICU (Intensive Care Unit) for management of unintentional/accidental overdose, acute on chronic hypoxic hypercapnic respiratory failure due to drug overdose as well as hypotension/shock. The report showed that the resident was admitted to the hospital on [DATE] and discharged back to [NAME] Nursing and Rehabilitation on 08/24/24. Biphasic Positive Airway Pressure (BiPAP) is a type of noninvasive ventilation that helps you breathe. Providers can use it to treat you if you're not getting enough oxygen or can't get rid of carbon dioxide. A machine delivers air through a mask on your face.Acute on chronic hypoxic hypercapnic respiratory failure is a serious condition where a patient with an existing chronic respiratory problem experiences a sudden worsening of their breathing, leading to dangerously low oxygen levels (hypoxia) and high carbon dioxide levels (hypercapnia) in the blood. This means the lungs are not effectively exchanging gases, and the body's organs are not getting enough oxygen while accumulating excess carbon dioxide. Hypotension, or low blood pressure, can lead to shock when it becomes severe enough to prevent the body's organs from receiving adequate oxygen and nutrients. Shock is a life-threatening condition characterized by circulatory failure and inadequate tissue perfusion. A review of the facility's mitigation plan was conducted on 07/20/25 at 7:49 PM. The plan consisted of an in-service to all permanent and agency licensed nurses and certified medication assistants (CMA) on education of medication administration on 08/20/24. Staff who were not present on 08/20/24 to receive the in-service could not start their shift until they received the medication administration in-service. The facility also conducted observations of all staff that administered medications on 08/20/24. Ongoing medication administration observations were conducted weekly for 6 weeks. The results of the 6 weeks of observations were reviewed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting. This deficient practice was cited as past noncompliance with corrective measures completed on 08/20/24.

Based on observation and staff interview, it was determined that the facility failed to store and label food items to maintain the integrity of the specific items. This was evident during the initial tour of the kitchen. This deficient practice has the potential to affect all residents. The findings include: On 7/17/2025, at 8:21 AM, during an initial kitchen tour with the Dietary Manager, the surveyor observed three opened, unlabeled bags of bread on a steel cart located in the corner of the room. The Dietary Manager confirmed that opened bags of bread were expected to be labeled. Further observations in the kitchen revealed three 14-ounce containers of Beef flavored base that were unlabeled and located on a cart with other seasonings. According to the Dietary Manager, two of these containers actually held Chicken flavored base, which had been transferred from a 24-pound container stored in the cooler. The Dietary Manager acknowledged these concerns and stated that she would address them immediately. On 7/17/2025 at 4:09 PM, the Nursing Home Administrator (NHA) was made aware of these findings.

Based on interviews and record reviews it was determined that the facility failed to ensure Residents received accurate comprehensive assessments. This was found to be evident for 4 (Resident #74, #83,#100 & #11) out of 19 Residents reviewed for accuracy of assessment during the re-certification survey.The findings include: 1) During the interview conducted on 07/15/2025 at 2:19 PM, it was discovered that Resident #74 was hard of hearing and could communicate only using a whiteboard. The Resident stated that he/she could not hear and did not have hearing aids. On 07/18/2025 at 6:16 AM a review of Resident #74’s medical records revealed a diagnosis for unspecified hearing loss, bilateral. The Care Plan is a document that outlines the care and support a Resident needs, often created for individuals receiving healthcare, personal care or other types of support. It’s a personalized roadmap for managing a Resident’s health and well-being, ensuring consistent and coordinated care. Care Plans are not just for nurses; they can be used by various healthcare professionals, caregivers and even the individuals receiving care themselves. Care plans are tailored to the individual’s specific needs, goals and preferences. During a continued review of the resident's medical records, it was discovered that the Resident had a care plan for hearing loss. The care plan stated that Resident #74 will “compensate for hearing loss by utilizing a whiteboard with marker to communicate with staff.” According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. During an interview conducted on 07/18/23 at 6:49 AM, the Director of Nursing (DON) stated that the Resident hearing was severely impaired and required the use of a white board to communicate with the Resident. This Surveyor questioned why Resident #74’s MDS assessment for hearing assessed the Resident with moderate hearing loss. The DON reviewed the MDS assessment dated [DATE] and confirmed the assessment was not accurate. During an interview conducted on 07/18/25 at 8:42 AM, the DON advised that Resident #74’s MDS hearing assessment was corrected and now showed that the resident’s hearing was highly impaired. 2) The surveyor conducted a record review of Resident #83 electronic medical record on 7/18/2025 at 11:45 AM. Review of the medical record revealed documentation in the progress notes that Resident #83 had a fall (observed sitting on the floor in room on buttock) on 9/29/2024 at 1:03 PM. Further review of the medical record revealed that Resident had a care plan for history of falling related to decreased strength and mobility, but the quarterly MDS assessment dated [DATE] was coded that Resident #83 had no falls. In an interview with the Director of Nursing (DON) at 12:50 PM on 7/18/2025 the surveyor conveyed to DON that Resident #83 had an unwitnessed fall (found on the floor in room on buttock) on 9/29/2024 at 1:03 PM, but the quarterly MDS assessment dated [DATE] indicated that Resident #83 did not have any falls. The DON acknowledged the surveyor and confirmed that Resident had a fall, and it was not coded accurately on the quarterly MDS assessment. DON stated that she would review with the MDS Coordinator. An indwelling Foley catheter is a flexible tube inserted through the urethra (the tube that carries urine from the urinary bladder to the outside of the body) into the bladder to drain urine. A small balloon inflated with sterile water secures it in place. The indwelling Foley catheter is connected to a drainage bag for urine collection. 3) On 7/21/2025 at 3:15 PM the surveyor conducted a record review of Resident #100’s electronic medical record. The medical record review revealed that Resident #100 had a physician order for an indwelling Foley catheter dated 10/9/2023 and a care plan for an indwelling urinary catheter. Further review of the medical record revealed that Resident #100’s discharge MDS dated [DATE] was coded that Resident had an indwelling catheter, but urinary continence was coded as “occasionally incontinent”. The surveyor conveyed to the Licensed Nursing Home Administrator (LNHA) at 8:10 AM on 7/22/2025 that Resident #100 had a Foley catheter on discharge to the hospital on [DATE], but the discharge MDS assessment dated [DATE] was coded that Resident had an indwelling catheter and coded that Resident was “occasionally incontinent”. The surveyor stated that if the MDS assessment was coded that the Resident had an indwelling catheter then urinary continence should be coded as “Not rated” on the MDS assessment. The LNHA acknowledged the surveyor. In an interview with the Director of Nursing (DON) at 9:00 AM on 7/22/2025 the surveyor conveyed that Resident #100 had an indwelling Foley catheter on discharge11/12/2023 to the hospital, and the discharge MDS assessment dated [DATE] was coded that Resident #100 had an indwelling catheter, but urinary continence was coded as “occasionally incontinent”. Urinary continence should have been coded as “Not rated”. The DON acknowledged and confirmed that Resident #100 had a Foley catheter on discharge and that the discharge MDS dated [DATE] was coded inaccurately for urinary continence and should have been coded as “Not rated”. DON stated that she would review with the MDS Coordinator. No additional information was provided by the facility at the time of exit. 4) Resident #11 was admitted to the facility with diagnoses which included Dementia and Diabetes Mellitus. On 07/16/25 at 8:00 AM the surveyor reviewed Resident #11’s clinical record. The review revealed that the resident fell on [DATE] and complained of pain at the back of the head. Resident #11 was sent to the Hospital emergency room and returned to the facility on [DATE]. Further review of the resident’s clinical record revealed that a quarterly MDS was completed on 09/13/24. The MDS coded the resident under Section J1800 (Falls) as not having any falls since re-entry or the prior assessment. The prior MDS assessment was completed on 06/13/24. On 07/16/25 at 9:20 AM the surveyor interviewed the MDS Coordinator and enquired about the fall which occurred on 07/03/24 not being coded on the quarterly MDS dated [DATE]. The MDS coordinator reviewed the clinical records during the interview, confirmed the surveyor’s findings and stated that the fall should have been coded. “I will speak with my supervisor and make a correction if that is possible” On 07/17/2025 at 9:05 AM the DON was notified of the surveyor's findings and stated that she was already aware of them.

Based on record reviews and interviews, it was determined that the facility failed to develop and implement comprehensive care plans. This was found to be evident for 3 (Resident #6, #8, & #44) out of 19 Residents reviewed for Care Plans during the re-certification survey.The findings include: 1) During an interview with Resident #6 on 7/15/25 at 3:09 PM it was revealed that the Resident was on dialysis, and he/she also reported having concerns with continuous constipation. During a review of Resident #6’s medical records conducted on 7/16/25 at 11:30 AM it was discovered that the Resident had a history of constipation and was receiving dialysis three days a week. A review of a progress note dated 5/22/25 at 5:37 PM reported that the Resident had complained of constipation and Lactulose was given. The note also stated that the Resident was scheduled for “hemodialysis in the morning.” A review of the Medication Administration Record (MAR) for Resident #6 revealed a physician’s order for Senna and Bisacodyl tablets for constipation which had been administered daily. There was an additional order for a Dulcolax suppository to be taken when needed. A Care Plan is used in nursing facilities to summarize a resident’s health conditions and care needs. It is used to ensure resident’s needs are met and consistent care is provided to the resident based on those needs. During a continued review of medical records for Resident #6 it was determined that constipation and dialysis was not included in the Care Plan. During an interview with the Director of Nursing (DON) on 7/17/25 at 11:04 AM, she reported she would have expected constipation and dialysis to have been included in Resident #6’s Care plan. She reported his/her Care Plan was audited yesterday after discussing other Care Plan issues with another Surveyor. An additional review of the Care Plan on for Resident #6 on 7/17/25 at 11:12 AM revealed the Care Plan was updated on 7/16/25 to include; Resident is receiving Hemodialysis, Due to End Stage Renal Disease” and “Bowel and Bladder – Ensure adequate bowel elimination”. 2) During an interview with Resident #8 on 7/15/25 at 11:30 AM he/she reported having concerns with constipation and reported that it has not improved with treatment. The Resident also reported “I’m always in pain, they say it’s arthritis.” During a review of Resident #8’s medical records conducted on 7/17/25 at 8:23 AM it was discovered that he/she was admitted [DATE] and had a history of Type II Diabetes, Constipation, Major Depressive Disorder and Chronic Pain Syndrome. During a review of the Medication Administration Record (MAR) for Resident #8 it was discovered that the Resident had an order for Lactulose and Sennosides-docusate sodium for constipation which had been administered daily, Eliquis an anticoagulant which had been administered daily, Venlafaxine for Major Depressive Disorder and an order for Humalog KwikPen Insulin for Diabetes when needed for a blood sugar of 200. During a continued review of Resident #8’s medical records it was determined Constipation, Anticoagulant medication, Depression, Diabetes and Chronic Pain were not included in the Care Plan. During an interview with the DON on 7/18/25 at 9:51 AM she reported Constipation, Anticoagulant due to Eliquis, Depression, Diabetes and pain would be expected to be included in Resident #8’s Care Plan. During an additional review of Resident #8’s Care plan on 7/22/25 at 7:11 AM it was revealed it had been updated on 7/21/25 and the following was added, “constipation related to mobility.” Diabetes, Anticoagulant and pain were not included in the Care Plan update. 3) According to the Mayo Clinic, a contracture is a condition where muscles, tendons ligaments, or skin tighten, restricting the normal movement of the body part. This can lead to a joint being stuck in a bent or flexed position. A splint is a device that supports or immobilizes a joint to prevent or correct the tightening and shortening of soft tissues (like muscles, tendons and ligaments) that restricts movements. On 7/15/2025 at 9:50 AM, during the initial facility tour, Resident #44 was observed in bed with contractures of the left elbow, left hand and right hand and was not wearing any splints on either hand. On 7/21/2025 at 8:19 AM, a review of the Resident #44’s medical records confirmed an admission on [DATE], with diagnoses including but not limited to: · Contracture, left elbow; Contracture, right hand; Contracture, left hand. A Minimum Data Set (MDS) is a standardized set of data elements used in healthcare to ensure consistent and comprehensive assessment of individuals, particularly in nursing homes. It provides a foundation for care planning and quality improvement by capturing key information about a resident's functional status, health conditions, and other relevant factors. · The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/2025 also confirmed upper extremity impairment on both sides. A review of the Evaluation & Plan of Treatment notes signed by Occupational Therapist (OT #18) signed on 3/14/2025 revealed: contractures of left hand and left elbow, recommending “Orthotics Splint/ Orthotic recommendation: towel rolls. A review of Resident #44’s care plan revealed no evidence that a care plan was formulated to address contractures since the resident’s admission. A care plan meeting note written by the Social Worker on 4/10/2025 indicated “Resident is seen by occupational therapy for bracing and splinting of hand.” On 7/21/2025 at 9:26 AM, the Director of Nursing (DON) confirmed the absence of a care plan to address contractures. The DON stated that it was expected that if the Therapy department had recommendations, they were supposed to discuss it in our meetings. The DON acknowledged the concern.

Based on interviews and record reviews it was determined that the facility failed to ensure timely and accurate documentation of medical records. This was found to be evident for 3 (#42, #2, #6, & #96) out of 5 residents reviewed for record documentation during the annual survey.The findings include: 1) During an interview with Resident #42 on 7/21/25 at 08:46 AM he/she reported often receiving medications late at night and stated medications were received “sometimes almost at midnight”. During a review of the Medication Administration Record (MAR) for Resident #42 on 7/22/25 at 6:32 AM it was discovered that there were medication documentations past 11 PM. The documentation in the MAR revealed the following medication administration notes. On 7/03/25 - The following medications were due at 9 PM: Xarelto, Trazadone, Tamsulosin, Simvastatin, Senna, Remeron, Pregabalin and Guaifenesin. The medications were signed off as complete at 11:44 PM with a note stating “Charted late, administered on time” by LPN #26. On 7/04/25 – The following medications were due at 9 PM: Xarelto, Trazadone, Tamsulosin, Simvastatin, Senna, Remeron, Pregabalin and Guaifenesin. The medication were signed off as complete at 11:17 PM with a note stating “Charted late, administered on time” by LPN #26 On 7/12/25 - The following medications were due at 9 PM: Xarelto, Trazadone, Tamsulosin, Simvastatin, Senna, Remeron, Pregabalin and Guaifenesin. The medications were signed off as complete at 11:43 PM with a note stating “Charted late, administered on time” by LPN #26. On 7/13/25 - The following medications were due at 9 PM: Xarelto, Trazadone, Tamsulosin, Simvastatin, Senna, Remeron, Pregabalin and Guaifenesin. The medications were signed off as complete at 11:49 PM with a note stating “Charted late, administered on time” by LPN #26. During an interview with the Director of Nursing (DON) on 07/22/2025 at 6:58 AM she reported medications are supposed to be administered within the timeframe of one hour before to one hour after the scheduled administration times. Nighttime medications are expected to be administered between 8PM and 10PM. She reported medications should be documented immediately after being administered. She reviewed the MAR of Resident #42 and agreed that the medications were not being documented at the time they were administered. Additional reviews of MAR’s were completed on Residents #2 and #6 which showed additional documentations of late charting for administered medications. 2) During a review of the Medication Administration Record (MAR) for Resident #2 on 7/22/25 at 7:06 AM it was discovered that there were late documentations. The documentation in the MAR revealed the following medication administration notes. 7/03/25 - The following medications were due at 4:30 PM: Humalog Kwik Pen Insulin and Lantus Solostar Insulin. The medications were signed off as complete at 11:35 PM with a note stating “Charted late, administered on time” by LPN #26. The following medications were due at 9 PM: Tamsulosin, Potassium Chloride, Famotidine, Carvedilol and Atorvastatin. The medications were signed off as complete at 11:35 PM with a note stating “Charted late, administered on time” by LPN #26. 7/04/25 - The following medications were due at 4:30 PM: Humalog KwikPen Insulin and Lantus Solostar Insulin. The medications were signed off as complete at 11:06 PM with a note stating “Charted late, administered on time” by LPN #26. The following medications were due at 9 PM: Tamsulosin capsule, Potassium Chloride, Famotidine, Carvedilol and Atorvastatin. The medications were signed off as complete at 11:06 PM with a note stating “Charted late, administered on time” by LPN #26. 7/12/25 – The following medications were due at 4:30 PM: Humalog KwikPen Insulin and Lantus Solostar Insulin. The medications were signed off as complete at 11:37 PM with a note stating “Charted late, administered on time” by LPN #26. The following medications were due at 9 PM: Tamsulosin, Potassium Chloride, Famotidine, Carvedilol and Atorvastatin. The medications were signed off as complete at 11:37 PM with a note stating “Charted late, administered on time” by LPN #26. 7/13/25 – The following medications were due at 4:30 PM: Humalog KwikPen Insulin and Lantus Solostar Insulin. The medications signed off as complete at 11:44 PM with a note stating “Charted late, administered on time” by LPN #26 – The following medications were due at 9 PM Tamsulosin, Potassium Chloride, Famotidine, Carvedilol and Atorvastatin, The medications were signed off as complete at 11:44 PM with a note stating “Charted late, administered on time” by LPN #26. 3) During a review of the Medication Administration Record (MAR) for Resident #6 on 7/22/25 at 7:06 AM it was discovered that there were delayed documentations. The documentation in the MAR revealed the following medication administration notes. 7/15/25 - The following medication was due at 6 PM: Cephalexin and it was signed off as complete at 10:12 PM with a note stating, “Charted late, given on time” by LPN #27. 7/21/25 - The following medication was due at 6 PM: Cephalexin and it was signed off as complete at 8:46 PM with a note stating “Charted late, given on time” by LPN #26. During a review of the Medication Management Program Policy, it was discovered that “Medications are administered no more than one hour before to one hour after the designated medication pass time” and “Immediately after administering the medication to the Resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR.” 4) On 7/16/2025 at 8:41 AM, a review of Resident #96's medical records indicated that he/she was admitted on [DATE] and discharged to the hospital on 6/2/25. On 7/16/2025 at 10:39 AM, the Nursing Home Administrator (NHA) confirmed that only one progress note was written for Resident #96 between 6/1/25 and 6/2/25. On 7/16/2025 at 10:59 AM, the Director of Nursing also confirmed that there was no nursing note for Resident #96. Instead, a note dated 6/2/2025 for Resident #114 was provided. The DON explained that Resident #114 is the spouse of Resident #96 and initiated the transfer to the hospital. The DON acknowledged this as a concern, stating that the nurse should have documented in the right resident’s medical record. The Nurse’s note indicated that on 6/2/25 at 10:43 AM, Resident #114 called 911 for his/her spouse, whom he/she shared a room with. He/she stated that Resident #96 reportedly was in pain and was experiencing trouble breathing. The Nurse indicated that he/she assessed Resident #96’s vital signs which were normal. On 7/16/2025 at 1:15 PM, the Nursing Home Administrator (NHA) was informed of the concern.

Based on surveyor observation, facility staff interview and surveyor record review it was determined that the facility staff failed to ensure the dignity of a Resident. This finding was found to be evident for 1 (Resident #68) out of 1 Resident reviewed for Resident Rights.The findings include:An indwelling Foley catheter is a flexible tube inserted through the urethra (the tube that carries urine from the urinary bladder to the outside of the body) into the bladder to drain urine. A small balloon inflated with sterile water secures it in place. The indwelling Foley catheter is connected to a drainage bag for urine collection.On the initial tour of the facility at 8:25 AM on 7/15/2025 the surveyor observed Resident #68 in bed. It was observed that a Foley catheter drainage bag was attached to the Resident's bed frame. The Foley catheter drainage bag was not covered with a privacy barrier and urine was visible in the Foley catheter drainage bag.The surveyor conducted a record review of Resident #68's electronic medical record on 7/17/2025 at 7:35 AM and the review revealed that Resident #68 had a physician order dated 7/9/2025 for an indwelling Foley catheter. Additionally, there was a physician order for a privacy bag in place every shift for Resident #68.In an interview with the Director of Nursing (DON) on 7/22/2025 at 11:00 AM that surveyor asked what the expectation was for Foley catheter drainage bags to be covered with a privacy barrier. The DON stated that the facility had Foley catheter drainage bags that had a grayish-blue color privacy barrier that covered the Foley catheter drainage bag. The surveyor conveyed to the DON that Resident #68 (who was admitted to the facility on [DATE]) did not have a privacy barrier cover on the Foley catheter drainage bag on the initial tour of the facility. The DON stated that it was the responsibility of the nursing staff to change the Foley catheter drainage bags to the bags that the facility provided when Residents were admitted to the facility. Additionally, the surveyor conveyed that Resident #68 was observed earlier today and had a privacy barrier cover on the Foley catheter drainage bag.

Based on interviews and record reviews it was determined that the facility failed to ensure showers were provided to a Resident as scheduled. This was found to be evident for 1 (Resident #65) out of 1 Resident reviewed for self-determination during the recertification survey.The findings include:During an in-person interview with Resident #65's Power of Attorney (POA) conducted on 07/15/25 at 2:51 PM, the POA expressed concern that the Resident had not received routine showers.On 07/17/25 at 3:12 PM, a review of Resident #65's physician orders revealed an order for Bathing (Bath/Shower/Days/Shift): Tues./Fri. 7-3 Shift. During a review of Resident #65's POC (Point of Care) conducted on 07/17/25 at 3:19 PM, it was discovered that the Resident had not received a shower from 04/01/25 - 07/17/25 with the exception of 1 day on 04/14/25.On 07/18/2025 at 5:50 AM a review was conducted of Resident #65's care plan. The review did not reveal that the Resident refused care or showers. During an interview conducted on 07/18/2025 at 7:08 am, the DON stated that showers are documented in the POC as well as refusals. The DON reviewed the Resident #65's POC with this Surveyor and confirmed that the Resident had 1 shower during the period of 04/01/25 through 07/17/25 and that there was no documentation that the Resident had refused showers. The DON also reviewed the Resident's care pan with this Surveyor and confirmed that the Resident did not have a care plan for refusal of care or showers.

Based on record reviews and interviews it was determined that the facility failed to ensure complete medical records were provided in a timely manner. This was found to be evident for 1 (Resident # 107) out of 1 Resident reviewed for medical records during the re-certification survey. The findings include: A review of complaint #348368 reported to the Office of Health Care Quality (OHCQ) was conducted on 07/21/25 at 11:22 AM. The complainant reported that we have attempted on many occasions to obtain the medical records for Resident #107. We received 8 pages not including the cover page on 01/17/23 and 13 pages on 09/20/23 not including the cover page. We have requested to receive the complete medical records for Resident #107 multiple times since 12/22.On 07/21/25 at 11:30 AM a review of the medical records request confirmed that on 1/17/23 the facility faxed 9 pages that included the cover page and faxed 14 pages on 09/20/23 that included the cover page. These dates and number of pages faxed confirmed the complainant's concerns. No other fax confirmations were present that showed the complete medical records packet had been provided to the complainant. A further review of the medical record requests revealed a letter from the complainant that requested all medical records from the patient chart on 10/08/23 which was 10 months after the initial request. During an interview conducted on 07/21/25 at 11:33 AM, the medical record staff #7 provided this Surveyor with a complete packet of Resident #107's medical records. This Surveyor asked Medical Record staff #7 when the packet was sent to the complainant. The Medical Records Staff member stated that she was unsure, but she thought she emailed the complete packet of medical records. She stated that she would reach out to her IT department to retrieve her emails to show when she emailed the Resident's complete medical records to the complainant. The Medical Records Staff #7 stated that it would take a couple of days for IT to retrieve her emails. During an interview with the Nursing Home Administrator (NHA) conducted on 07/21/25 at 11:37 AM, the NHA stated that she would work on getting IT to retrieve the Medical Record Staff #7 emails. During an interview conducted on 07/22/25 and 07/23/25, the Director of Nursing (DON) stated that IT retrieved Medical Records Staff #7's incoming emails but had not retrieved the outgoing emails and therefore was unable to provide confirmation that complete medical records were provided to the complainant. This Surveyor expressed concern based on what was provided that the facility failed to provide a complete medical record for the complainant.

Based on review of the facility's records and interview, it was determined that the facility failed to ensure Residents were free from abuse. This was found to be evident for 2 (Resident #108 & #7) out of 4 Residents reviewed for abuse during the re-certification survey.The findings include: 1) A review of the Facility’s Reported Incident (FRI) #348430 was conducted on 07/17/25 at 11:48 AM. The FRI’s investigation stated that the Resident reported that Geriatric Nursing Assistant (GNA) # 6 pushed him/her by the back of the neck, shoved him/her onto the bed and injured the Resident’s arm. The facility investigated the complaint, suspended GNA #7 on 09/13/24 (the day of the incident) pending the investigation and then terminated her for the allegation of abuse on 09/19/24. During an interview conducted on 07/17/25 at 12:09 PM, the Staff Educator /Infection Control Preventionist stated during the time of the incident she was the acting Director of Nursing (DON) and had conducted the investigation. She advised that she concluded that the GNA abused the Resident and observed a red bruise on the Resident’s arm that was consistent with the Resident’s statement. As a result, GNA #7 was terminated. 2) On 7/22/2025 at 2:30 PM the surveyor conducted a record of the facility’s investigation file for the Facility Reported Incident (FRI) MD#00209510/348428 dated 9/5/2024 that was submitted to the Office of Healthcare Quality (OHCQ). Review of the facility’s investigation file revealed that on 9/5/2024 Geriatric Nursing Assistant (GNA) #24 was accused of hitting Resident #108 on the finger for pointing at the meal tray. According to the facility report, the Resident put his/her right hand in GNA’s face and GNA pushed Resident’s hand out of GNA’s face. Additionally, the facility report indicated that the GNA stated “I did not hit him/her, if I had hit him/her, he/she would know it; no one puts their hand in my face”. Further review of the facility’s investigation file revealed that based on the interviews, the facility verified/substantiated that there was direct contact between GNA #24’s hand and Resident #108’s right hand. The review of the investigation file and the facility reported incident (FRI) form did not reveal that a complaint was filed with the Maryland Board of Nursing (MBON) on GNA #24 for the allegation of physical abuse. The facility suspended GNA #24 immediately for Resident #108’s allegation of physical abuse. Local Law Enforcement was notified of the allegation of physical abuse and Resident #108 was interviewed by an officer from the [NAME] Police Department. The interview revealed that Resident #108 was physically abused by GNA #24. Review of the facility’s Leadership Policies and Procedures for Abuse, Neglect and Exploitation, or Mistreatment on 7/22/2025 revealed that all alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). The surveyor conducted a review on 7/23/20254 of GNA #24’s Human Resources personnel file. Review of the personnel file revealed that the facility terminated GNA #24 on 9/11/2024; however, there was no documentation in the personnel file that the facility filed a complaint with the Maryland Board of Nursing (MBON). In an interview with the Licensed Nursing Home Administrator (LNHA) on 7/23/2025 at 9:15 AM the surveyor confirmed that the facility verified/substantiated that physical abuse had occurred to Resident #108 by GNA #24 as concluded on the facility reported incident (FRI) that was submitted to the OHCQ. The LNHA acknowledged the surveyor. During the interview, the surveyor asked the LNHA if the facility filed a complaint on GNA #24 with the Maryland Board of Nursing (MBON) since an allegation of physical abuse was verified and the GNA was terminated by the facility. The LNHA stated that the facility did not file a complaint on GNA #24 with the Maryland Board of Nursing (MBON), but going forward allegations of abuse on licensed staff will be reported to the appropriate licensing board.

Based on record reviews, and interview, it was determined that the facility failed to develop and implement a Baseline care plan for a resident requiring hemodialysis treatments. This was evident for 1 (Resident #69) out of 2 residents requiring hemodialysis treatments reviewed during the annual recertification survey.The findings include:A Baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be provided to the resident and their responsible party.On 07/17/25 at 8:55 AM the surveyor conducted a review of Resident #69' s clinical records. The records revealed that Resident # 69 was admitted to the facility in February 2024 with Diagnoses which included Atherosclerotic Heart Disease, Dementia and End Stage Renal Disease. The resident receives hemodialysis treatments three days a week. Further review of Resident #69's clinical record failed to reveal any evidence that a Baseline care plan was completed and provided to the resident and their responsible party. During an interview on 07/22/25 at 10:35 AM the Director of Nursing (DON) stated that Baseline care plans are created by the Admitting Nurse within 48 hours of a resident's admission to the facility and that residents and /or their responsible parties are given copies of the care plan after signing them. The DON reviewed the clinical record of Resident #69 and confirmed that a Baseline care plan was not completed for that resident. The DON stated, I do not know why a Baseline care plan was not completed, I will provide education to the nurses and do chart audits on new admissions.

Based on record reviews and interviews, it was determined that the facility failed to review and revise the Interdisciplinary Care Plans to reveal accurate interventions for Residents. This was evident for 2 (Resident #69 & #5) out of 19 Residents reviewed for care plan timing and revision.The findings include: 1) On 07/15/2025 at 11:19 AM Resident #69 informed the surveyor that he /she had a wound on their bottom. On 07/18/25 at 11:30 AM a review of Resident #69’s clinical record revealed that the resident had been receiving daily dressing changes to the Right Thigh from 05/09/25. The physician’s order stated Cleanse Posterior Right Thigh with Soap and water, pat dry apply border gauze daily - Order Date 05/09/25. According to CMS (Centers for Medicare and Medicaid Services), a care plan meeting is a structured, interdisciplinary conference where staff, residents, and families discuss and review the resident's care plan, ensuring needs are met and goals are achieved. In long-term care facilities, a care plan meeting should occur within 7 days of completing the comprehensive assessment. Further review of Resident #69’s clinical record failed to reveal a care plan related to the resident’s actual skin impairment with specific interventions and approaches to manage the affected area on the Right Thigh. A review of the documentation dated 6/20/25 written by a Licensed Nurse who performed a skin check on that date, stated “(Resident’s Name) has a wound on inner R thigh that has a treatment ordered. (Resident’s Name) has no new alteration of skin integrity.” The clinical records also failed to reveal the measurements or description of the wound. On 07/20/25 at 07:35AM in an interview with the surveyor, the Director of Nursing confirmed, the resident’s care plan was not revised to include Resident #69’s actual skin impairment. She also confirmed that there was no description in the clinical record of the affected area at the Right Thigh. The DON stated that she would do an in-service on wound documentation with the nurses and would ask the wound team to do an assessment of the resident’s wound. On 07/21/2025 at 02:15 PM the surveyor was informed by Director of Nursing that Resident #69 was assessed by the wound team and that the area affected on the Right Thigh was diagnosed as Dermatitis. Further, the care plan and clinical records were updated in keeping with the resident’s condition. 2) On 7/21/2025 at 12:00 PM, Resident #5's significant other expressed frustration about not being invited to a care plan meeting. He/she stated that Resident #5 was admitted on [DATE], and he/she had not received any calls or notices from the Social Worker regarding a meeting. On 7/21/2025 at 2:18 PM, in an interview with the Social Worker, she confirmed that no care plan meeting had been scheduled for Resident #5. She stated that while she typically scheduled meetings within 2 weeks of admission, she would schedule one sooner if requested by the family. He/she added that invitations were sent via email, phone calls, or notices. On 7/21/25 at 3:05 PM, the Social Worker provided a copy of a care plan meeting invitation dated June 22, 2025, at 3:00 PM. However, there was no documentation in the medical record to indicate that the Responsible Party declined the invitation or a meeting occurred. On 7/22/2025 at 7:50 AM, the Director of Nursing (DON) was informed and acknowledged the concern, stating that a care plan meeting was scheduled for that day. On 7/23/2025 at 7:44 AM, following surveyor intervention, the Social Worker confirmed that a care plan meeting was held on 7/22/25 at 3:00 PM, attended by the Interdisciplinary Team (IDT). A sign in sheet for this meeting was also provided to the surveyor.

Based on observation and interviews it was determined that the facility failed to ensure care provided to a Resident met the professional standards of practice. This was found to be evident for 2 (Resident #65 & #55) out of 2 Residents reviewed for Services Provided Meet Professional Standards during the re-certification survey.The findings include: 1) The Surveyor observed Resident #55 in bed on 7/15/2025 at 9:00 AM during the initial tour of the facility. Resident #55 was observed with a soft cast to his/her left arm and dried blood and sutures to left forehead laceration. On 7/17/2025 at 12:30 PM the surveyor reviewed the facility’s investigation file for the facility reported incident (FRI) MD#00219326/348447 dated 7/1/2025 that the facility submitted to the Office of Healthcare Quality (OHCQ) for an unwitnessed fall with injury. Additionally, the surveyor conducted a record review of Resident #55’s electronic medical record. Review of these records revealed that Resident #55 had an unwitnessed fall (found lying on the floor in room) on 7/1/2025 resulting in an emergent 911 transfer to the local hospital for evaluation of forehead laceration and open area on left wrist. Resident #55 returned from the hospital emergency room (ER) on 7/2/2025 with a fracture of the left wrist and dissolvable sutures to the left forehead. Further review of Resident #55’s medical record revealed that there was lack of evidence of follow-up documentation of nursing care for Resident. Resident #55’s medical record lacked documentation that neurological checks for the forehead laceration and circulation checks for the left arm fracture were performed by nursing staff and lacked documentation of follow-up progress notes for the Resident’s condition related to the fall and injuries. In an interview with the Director of Nursing (DON) at 3:00 PM on 7/17/2025 the surveyor conveyed to DON that there was lack of documentation of follow-up nursing care in the medical record for Resident #55 related to the unwitnessed fall, forehead laceration and fracture of left wrist. The DON acknowledged the surveyor and confirmed that there was lack of documentation of the nursing care related to the Resident #55’s fall which included lack of neurological checks, circulation checks and follow-up progress notes on Resident’s condition after a fall with major injury. No additional information was provided by the facility at the time of exit. 2) During a random observation conducted on 07/18/2025 at 10:00 AM, this surveyor observed Resident #65 lying in a bed in a high position from the floor. The Resident was yelling, please help me. The Resident was completely naked lying on his/her right side and holding on to the right bed side rail. This Surveyor observed a soiled disposable diaper on the floor next to the Resident's bed. In the bathroom the water was running on feces soiled wash cloth that laid at the bottom of the sink. At the time of the observation the privacy curtain had not been pulled and there were no staff in the room. A continued observation of the unattended Resident was conducted from 10:00 AM to 10:10 AM. During this time no staff returned to Resident #65’s room. On 07/18/25 at 10:11 AM, this Surveyor observed the assignment board and learned that Geriatric Nursing Assistant (GNA) #15 was assigned to care for Resident #65. During an interview conducted on 07/18/26 at 10:12 AM, Unit Manager (UM) #14 confirmed that GNA #15 was assigned to Resident #65. When asked where the GNA was at the time the Unit Manager stated that the GNA was assisting another GNA in Resident room [ROOM NUMBER]. This Surveyor expressed concern for the condition Resident #65 was left in. On 07/18/2025 at 10:13 AM both this Surveyor and the Unit Manager returned to Resident #65’s room. The Unit Manager was visibly upset and immediately assisted the Resident. The UM lowered the bed, covered the resident and attempted to calm him/her. The UM observed the soiled disposable diaper on the floor and the water running on the feces soiled wash cloth in the Resident’s bathroom sink. On 07/18/2025 at 10:16 AM this Surveyor asked the Regional Clinical Services Director to come and observe the condition Resident #65 was left in. When the Surveyor and Regional Clinical Service Director returned to the room GNA #15 and the Unit Manager were in the room. The GNA explained that the Resident had refused care and became combative, so she left the Resident. Both the Unit Manager and Regional Clinical Service Director provided education to the GNA for safety, privacy, dignity, infection control, and proper handling of a resident who refused care or was combative. On 07/20/25 at 7:32 PM the Director of Nursing (DON) reported that an in-service was in progress for all nursing staff on safety, privacy, dignity, infection control, and caring for a resident who refused care or combative. She also stated that GNA #15 had been suspended for the lack of care provided to Resident #65.

Based on observation, record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met in accordance with the residents' plan of care. This was evident in 1 (Resident# 69) of 1 resident reviewed for Activities of Daily Living (ADL).The findings include: Resident # 69 was admitted to the facility in February 2024 with Diagnoses which included Atherosclerotic Heart Disease, Dementia and End Stage Renal Disease. On 07/15/2025 at 10:25 AM and on 07/18/25 at 7:40 AM the surveyor observed Resident #69 lying in bed with unshaven facial hair. On 07/20/25 at 06:30 PM the surveyor again observed the resident with unshaven facial hair approximately I/8 inch long sitting in a wheelchair in his/her room. During an interview on 07/20/2025 at 06:30 PM the Resident #69 stated I need assistance with shaving because I cannot do it myselfOn 07/17/25 at 08:55 AM a review of Resident 69's clinical record revealed a care plan initiated on 08/06/24 which stated Resident #69 had limited ability to maintain grooming/personal hygiene. The Goal was that the resident would be well groomed, and the approach was Provide (assistance/full staff performance) for facial hair.On 07/20/25 at 5:21PM in an interview, GNA Staff #22 was asked if she helps Resident #69 with shaving. GNA Staff#22 seemed unaware of the resident's needs and stated that the resident was independent, and assistance would be provided when requested by the resident.During an interview on 07/21/2025 at 8:22 AM Staff Infection Preventionist/Staff Educator (IP/SE) confirmed Resident # 69 had a care plan for grooming with an intervention for assistance with facial hair. The surveyor informed Staff IP/SE that in an interview, the Geriatric Nursing Assistant (GNA) seemed unaware of the needs of the resident as regards shaving. Upon reviewing the clinical record, Staff IP/SE stated that the person who created the care plan did not check the box to transfer the data to the resident's profile. As such, the GNA was unaware of the resident's grooming needs. Staff # IP/SE immediately checked the box and provided the surveyor with a copy of the updated record. On 07/21/2025 at 9:07 AM in an interview, the Director of Nursing was notified of the surveyor's findings. The DON reviewed the clinical record and confirmed the findings.On 07/23/25 the surveyor observed Resident #69 in a wheelchair sitting at the receptionist's desk clean shaven with no facial hair.

Based on observation, record review and interview, it was determined that the facility failed to 1) obtain an order for the use of a splint and 2) properly assess and address the resident's condition prior to hospital transfer. This was evident for 2 (Resident #44 and #96) of 2 resident reviewed for position and mobility and 1 resident reviewed for hospitalization during the recertification survey.The findings include:1) According to the Mayo Clinic, a contracture is a condition where muscles, tendons ligaments, or skin tighten, restricting the normal movement of the body part. This can lead to a joint being stuck in a bent or flexed position.A splint is a device that supports or immobilizes a joint to prevent or correct the tightening and shortening of soft tissues (like muscles, tendons and ligaments) that restricts movements.On 7/15/2025 at 9:50 AM, during the initial facility tour, Resident #44 was observed in bed with contractures of the left elbow, left hand and right hand and was not wearing any splints on either hand.On 7/21/2025 at 8:19 AM, a review of the Resident #44's medical records confirmed an admission on [DATE], with diagnoses including but not limited to: Contracture, left elbow Contracture, right hand Contracture, left handThe Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/2025 also confirmed upper extremity impairment on both sides.A review of the Evaluation & Plan of Treatment notes signed by Occupational Therapist (OT #18) on 3/14/2025 revealed: contractures of left hand and left elbow, recommending Orthotics Splint/ Orthotic recommendation: towel rolls. However, no splint order was written on the Physician orders.On 7/21/2025 at 8:45 AM, a follow-up observation of Resident #44 showed no splints or braces on his/her bilateral hands. On 7/21/2025 at 9:26 AM, in an interview with the Director of Nursing (DON), she confirmed the absence splint orders to address contractures. The DON stated that the Therapy department was expected to share their recommendations in their meetings. The DON acknowledged the concern.On 7/21/2025 at 12:50 PM, during an interview with OT #18, he/she confirmed recommending the continued use of towel rolls for Resident #44's right and left hand in her OT discharge summary (dates of service 2/26/24- 4/26/24, with the note was signed on 4/26/2024 at 9:20 AM. He/she indicated that he/she verbally educated the Geriatric Nurse Assistants (GNAs) and notified the charge nurse of the recommendation. 2) On 7/16/2025 at 8:41 AM, a review of Resident #96's medical records indicated that he/she was admitted on [DATE] and discharged to the hospital on 6/2/25. On 7/16/2025 at 10:39 AM, the Nursing Home Administrator (NHA) confirmed that only one progress note for Resident #96 was written between 6/1/25 and 6/2/25. On 7/16/2025 at 10:59 AM, the surveyor received a copy of the progress note from the Director of Nursing (DON) dated 6/2/2025 for Resident #114, Resident #96's spouse, who initiated the transfer to the hospital. Further review of documents provided by the Director of Nursing (DON) revealed the following: The Nurse's note written on 6/2/25 at 10:43 AM, indicated that Resident #114 called 911 for his/her spouse, whom he/she shared a room with. He/she reported that Resident #96 was having pain and experiencing trouble with breathing. The Nurse indicated that he/she assessed Resident #96's vital signs which were normal. However, no vital signs have been recorded from 6/1/ 25- 6/2/25. The DON confirmed the finding and stated that vital signs were expected to be obtained and documented in the medical record. The Medication Administration Record (MAR) indicated that Tylenol (Acetaminophen) 325 mg tablet, every 6 hours as needed was administered on 6/2/2025 at 6:12 AM for pain. However, there was no documentation to indicate that the complaint of trouble breathing was addressed. On 6/2/25 at 5:02 PM, Occupational Therapist (OT #18) conducted a Brief Interview of Mental Status (BIMS) assessment of Resident #96, who scored 14 out of 15, indicating intact cognition. Brief Interview for Mental Status (BIMS) is a screening tool used to assess basic cognitive function in patients in long-term care facilities. On 7/16/2025 at 1:15 PM, the Nursing Home Administrator (NHA) was informed of the concern.

Based on observation, interviews and record reviews it was determined that the facility failed to ensure a Resident received audiology services. This was found to be evident for 1 (Resident #74) out of 1 Resident reviewed for treatment to maintain hearing during the annual recertification survey. The findings include: During an observation and interviews conducted on 07/15/2025 at 2:19 PM, it was discovered Resident # 74 was hard of hearing. When this Surveyor asked Resident #74 a question the Resident responded, you must use the whiteboard on the table because I cannot hear. When asked if the Resident had hearing aids by writing my question on the whiteboard, Resident #74 read the question and responded no. When asked if he/she had seen an Audiologist for the loss of hearing via the whiteboard, the Resident responded no, not since he/she had been at the facility. A review of Resident #74's medical records was conducted on 07/18/2025 at 6:16 AM. The medical records revealed a diagnosis for Unspecified Hearing Loss, bilateral. A review of Resident 74's care plan stated that the Resident had hearing loss and as the intervention the Resident would utilize a whiteboard with a marker to communicate with staff. According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. A review of Resident 74's MDS quarterly assessment was conducted on 07/18/2025 at 6:23 AM. The MDS assessment dated [DATE] revealed that the Resident's hearing was assessed as having moderate difficulty. During a review of Resident #74's medical records conducted on 07/18/25 at 6:27 AM it was discovered that the Resident had not received an Audiology consultation since admission of 11/21/23. During an interview conducted on 07/18/25 at 9:22 AM, the Clinical Service Director stated that the facility had not ordered an audiology consult to have the Resident hearing assessed. The Clinical Service Director stated that an appointment would be scheduled for audiology.

Based on record reviews and interviews it was determined that the facility failed to ensure Residents received proper dialysis care. This was found to be evident for 2 (Resident #6 & #69) out of 2 Residents observed for dialysis care during the recertification survey. The findings include: 1) Hemodialysis is a treatment that filters waste and excess fluid from the blood when kidneys are not functioning properly. During an interview with Resident #6 on 7/15/25 at 3:09 PM it was discovered that the Resident has dialysis three times a week. During a review of the Treatment Administration Record (TAR) for Resident #6 on 07/21/2025 at 8:25 AM it was discovered that the Resident had several orders pertaining to dialysis care and monitoring. There was an order for “Dialysis three times per week”, “Once a Day on Monday, Wednesday, Friday.” Dialysis visits for July included 7/02/25, 7/04/25, 7/07/25, 7/09/25, 7/11/25, 7/14/25, 7/16/25, 7/18/25 and 7/21/25. There was an order for “Dialysis Communication Sheet Returned with Resident? Yes/No” and “Nurse must scan Dialysis Communication Sheet into matrix after Dialysis. If the Dialysis Communication sheet was not returned, notify Dialysis Center Supervisor sheet was not returned and to fax communication sheet to facility.” It was documented that the Dialysis Communication Sheet was not returned on 7/02/25, 7/04/25, 7/11/25, 7/14/25, 7/18/25 and 7/21/25. There were no Dialysis Communication Sheets found scanned into the matrix electronic medical record. There was an order for “Document Vital Signs post-dialysis treatment” and vital signs were not obtained on the following dates. On 7/2/25 - it was documented “Not Administered: Due to condition.” On 7/07/25 - it was documented as “Due to Condition, not taken.” On 7/18/25 - there were no vital signs documented, no note written. On 7/21/25 - it was documented, “Not Administered, Resident here when nurse came on, unable to find post dialysis papers.” There was an order for “Document Vital Signs pre-dialysis treatment” and vital signs were not obtained on the following dates. On 7/4/25 it was documented “Not Administered: Leave of absence – Dialysis” On 7/16/25 it was documented “Not Administered: Due to Condition” On 7/18/25 it was documented “Not Administered: Due to Condition” On 7/21/25 it was documented “Not Administered: At Dialysis” There was an order for “Weight Pre/Post Dialysis Treatment” and weights were not documented on the following dates. On 7/02/25 it was documented “Not Administered: Due to condition”, “Await Dialysis weights” On 7/04/25 it was documented “Not Administered:”, “Leave of Absence Dialysis” On 7/07/25 it was documented “Not Administered:”, “Leave of Absence Dialysis” On 7/09/25 it was documented “Not Administered:”, “Await Dialysis Paperwork” On 7/11/25 it was documented “Not Administered:”, “Await Dialysis Paperwork” On 7/14/25 it was documented “Not Administered:”, “Await Dialysis Paperwork” On 7/16/25 it was documented “Not Administered:”, “Due to Condition” On 7/18/25 it was documented “Not Administered:”, “Discontinued” On 7/21/25 it was documented “Not Administered:”, “Discontinued” During a review of the Care Plan for Resident #6 on 07/21/25 at 8:32 AM it was revealed that the “Resident is receiving Hemodialysis” was added to the Care Plan on 7/16/25 and “Monitor vital signs as ordered’ and “Weigh Resident as ordered” was added to the approaches to be taken for care provided for the Resident. During an interview with Licensed Practical Nurse (LPN) #20 on 7/22/25 at 7:34 AM she reported the completed Dialysis Communication Logs would be sent with the Resident when he/she goes to dialysis. The completed Logs would be put into the “Provider Communication Book” when the Resident returns. After reviewed by the doctor the Dialysis Communication Log is placed into another file to be sent to Medical Records to be scanned into Matrix. During a search of the “Provider Communication Log” on 7/22/25 at 7:22 AM it was found to contain the following Dialysis Communication Logs for Resident #6. On 7/18/25 the Dialysis Communication Log had no pre or post dialysis weights or blood pressures documented. On 7/16/25 the Dialysis Communication Log had no pre or post dialysis weights or blood pressures documented. On 7/14/25 the Dialysis Communication Log had no post dialysis weights, or blood pressures documented. On 6/27/25 the Dialysis Communication Log had no pre dialysis weights or pre/post blood pressure documented. On 6/20/25 the Dialysis Communication Log had no pre or post dialysis weights or blood pressures documented. On 6/16/25 the Dialysis Communication Log had no post dialysis weights documented. During an interview with the Director of Nursing (DON) on 7/23/25 at 6:02 AM she reported that the facility should be getting vital signs and weights if not provided by dialysis. She confirmed there were missing Dialysis Communication Logs and that the nursing staff should attempt to obtain any missing logs from the dialysis center. She advised she would have to look into the order referring to nurses downloading the reports into the electronic chart because medical records would need to upload them into Matrix. 2) A dialysis shunt, also known as a dialysis fistula, is a surgically created connection between an artery and a vein, used to provide access for hemodialysis in patients with kidney failure. This connection allows for efficient blood flow to and from the dialysis machine during treatment. On 07/15/25 at 9:10: AM the surveyor conducted a review of Resident #69’ s clinical records. The records revealed that Resident # 69 was admitted to the facility in February 2024 with diagnoses which included Atherosclerotic Heart Disease, Dementia and End Stage Renal Disease. The resident receives hemodialysis treatments three days a week. Further review of Resident #69’s clinical record failed to reveal: 1. The type of Shunt and where the resident’s Shunt site was located 2. A physician’s order to monitor the Shunt site for signs and symptoms of infection 3. Documentation by the nursing staff regarding monitoring of the Shunt site and 4. A care plan with interventions and approaches relating to the Shunt site A review of the facility’s policy on “Shunt Care - Arteriovenous,” Complete Revision Date May 5, 2023, stated Routine Shunt Care - Item D “Inspect shunt sites every shift for color, warmth, redness and edema and drainage.” During an interview on 07/16/25 at 01:25 PM the Staff Infection Preventionist/Staff Educator (IP/SE) stated that the resident’s Shunt site was monitored daily for redness, swelling and other signs of infection. Staff (IP/SE) reviewed the resident’s clinical record and was unable to identify where the resident’s Shunt was located. Staff (IP/SE) stated that there should have been a physician’s order to monitor the Shunt site but there was none on the record. The surveyor informed Staff (IP/SE) of the concerns regarding Resident #69’s Shunt care and reported the findings. Staff (IP/SE) reviewed the resident’s clinical record and confirmed the surveyor’s findings. On 07/17/2025 at 07:00 AM after the surveyor's intervention, a review of Resident #69’s clinical record revealed as follows: Physician Order: “Monitor R chest dialysis port for s/s (signs and symptoms) of infection or bleeding Every Shift: Order Date 07/16/2025 - Open Ended.” Care Plan: Dialysis Care Plan Goal: (Resident’s Name) will not develop complications from Dialysis. Approach - Monitor R chest port q shift per orders. Start Date: 07/16/25 On 07/17/2025 at 8:59 AM in an interview, the Director of Nursing (DON) was made aware of the surveyor's findings. The DON stated that she was already notified by Staff (IP/SE) and that physician’s orders were obtained. Later, around 01:00PM on 07/17/25 the DON stated that she received a document from [NAME] Dialysis Center which she provided to the surveyor. The document stated that the resident had a Central Venous Catheter to the Right Chest, and it was last used on 07/16/25. The document was printed on 07/17/25 at 09:49 AM

Based on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months for 1 (Staff#21) of 5 staff members reviewed. The findings included:Performance reviews are to be completed at least every 12 months to identify what in-service education the geriatric nursing assistants need to address their competencies. On 07/16/25 at 2:30 PM the surveyor conducted a review of 5 Geriatric Nursing Assistants' personnel files. The records revealed that the facility failed to conduct a performance review for the calendar year 2023 for Staff #21 who had been employed by the facility for over 8 years.During an interview with the surveyor on 07/17/25 at 8:34 AM, the Director of Nursing (DON) stated that annual performance reviews for geriatric nursing assistants were conducted annually in keeping with the facility's policy. The DON reviewed the records and confirmed the surveyor's findings.

Based on staff interview and surveyor record review it was determined that the facility failed to act on recommendations from pharmacist drug regimen review reports. This finding was found to be evident in 1 (Resident #12) out of 1 Resident reviewed for unnecessary medication.The findings include:A pharmacist drug regimen review (DRR), also known as a medication regimen review (MRR), is a comprehensive evaluation of all medications a Resident is currently using. This includes prescribed medications, over the counter drugs, herbal products, dietary supplements, and even total parenteral ((intravenous) nutrition and oxygen therapy. The primary purpose of a DRR is to promote positive outcomes and minimize adverse consequences associated with medication use. A pain scale is a tool used to measure and describe the intensity of pain, which is a subjective experience. The pain scale helps individuals communicate their pain levels to healthcare professionals and can be used to track pain over time.The surveyor conducted a record review of Resident #12's electronic medical record on 7/16/2025 at 1:50 PM. The review of the medical record revealed that Resident #12 had a pharmacist drug regimen review (DRR) report dated 3/15/2025 that was not addressed by the Resident's physician. The pharmacist DRR report indicated that Tylenol and Tramadol (narcotic pain medication) were prescribed for pain PRN (as needed). Tylenol was ordered every 6 hours PRN for chronic pain and Tramadol was ordered three times a day PRN for chronic pain; however, the physician orders did not indicate what pain scale rating the nurses would use to administer Tylenol versus Tramadol. According to the pharmacist DRR report, the pharmacist made a recommendation for clarification of the physician orders to include the pain scale rating that nurses would use to administer Tylenol vs Tramadol.Further review of Resident #12's medical record on 7/16/2025 revealed that there was an additional pharmacist drug regimen review (DRR) report dated 6/14/2025 that was not addressed by the Resident's physician. The pharmacist DRR report indicated that Resident #12 was ordered Tramadol PRN for pain. According to the pharmacist DRR report, the medication had not been utilized in the past 60 days, and the pharmacist made a recommendation to discontinue the medication to save costs, reduce nursing time needed to maintain drug storage and decrease the possibility for outdated drugs being stored in the nursing facility.Review of Resident #12's physician orders on 7/17/2025 indicated that Resident still had orders for both Tylenol PRN and Tramadol PRN for pain without a pain scale rating.In an interview with the Director of Nursing (DON) on 7/17/2025 at 11:05 AM the surveyor conveyed that Resident #12 had a pharmacist DRR report dated 3/15/2025 that indicated that there were two physician orders for different PRN pain medications (Tylenol and Tramadol), but neither physician order included the pain scale rating. The pharmacist recommended a clarification of these physician orders to include the pain scale rating that nurses would use to administer Tylenol PRN vs Tramadol PRN. The DON acknowledged the surveyor. Additionally, the surveyor conveyed to the DON that Resident #12 had another pharmacist DRR report dated 6/14/2025 that indicated that the pharmacist recommended that Tramadol PRN be discontinued as the medication had not been utilized in the last 60 days. The DON acknowledged the surveyor. During the interview the DON confirmed that both pharmacist DRR reports dated 3/15/2025 and 6/14/2025 had not been acted on by the physician for Resident #12. The DON provided the surveyor with a copy of the pharmacist DRR reports dated 3/15/2025 and 6/14/2025, but there was no response or signature from Resident #12's physician indicating whether he/she agreed or disagreed with the pharmacist recommendations. No additional information was provided by the facility at the time of exit.

Based on review of facility investigation documentation and medical records; interviews and observations, it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility (Resident #41) and failed to supervise a resident outside who had been assessed to be an elopement risk (Resident #4). This failure lead to Resident #41 eloping from the facility on 8/16/23 and Resident #4 self- propelling down the facility driveway on 8/26/22 causing the Resident harm. This deficient practice was evident for 2 of 9 residents reviewed for elopement/wandering during a complaint survey. These actions resulted in the finding of an Immediate Jeopardy (IJ) which was identified on 9/19/23 at 4:20 PM for Resident #41 and 9/21/23 at 10:50 AM for Resident #4. For Resident #41, an IJ summary tool was provided to the facility on [DATE] at 4:44 PM. The facility submitted their plan to remove the immediacy on 9/19/23 at 6:09 PM and it was not accepted. The facility submitted a second plan to remove the immediacy on 9/19/23 at 7:01 PM and it was not accepted. The facility submitted a third plan on 9/19/23 at 7:20 PM and a fourth plan on 9/19/23 at 8:20 PM that were not accepted. The facility submitted a fifth plan on 9/19/23 at 8:46 PM that was accepted. The immediacy was removed on 9/19/23 at 9:15 PM. For Resident #4, an IJ summary tool was provided to the facility on [DATE] at 10:55 AM. The facility submitted a draft of their plan to remove the immediacy on 9/21/23 at 12:21 PM and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 9/21/23 at 12:47 PM and it was not accepted. The facility submitted a third plan on 9/21/23 at 12:55 PM and it was accepted at 2:44 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of G. An extended survey was completed on 9/25/23 and 9/26/23. The Immediate Jeopardy was removed on 9/26/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The findings include: 1. On 9/18/23 at 7:40 PM a review of facility-reported incident MD00195646 revealed on 8/16/23 at approximately 3:00 PM a geriatric nursing assistant (GNA) was unable to locate Resident #41 and a code yellow was announced. Resident #41 was subsequently found across the street at the Crisis Center and brought back to the facility. On 9/18/23 at 7:42 PM a review of Resident #41's medical record revealed a hospital discharge summary dated 8/10/23 that documented Resident #41 was admitted to the hospital for a change in mental status and due to the resident ' s history of alcohol use, Resident #41 was suspected to have [NAME] ' s encephalopathy. According to the National Institute of Neurological Disorders and Stroke, [NAME] ' s encephalopathy is a degenerative brain disorder caused by the lack of vitamin B1 which may result from alcohol abuse, dietary deficiencies, prolonged vomiting, eating disorders or the effects of chemotherapy. An Elopement Risk Evaluation dated, 8/10/23 at 7:41 PM, identified the resident was not at risk for elopement, however answered the question, does the patient/resident have safe decision- making capabilities? as no. The question, is the patient/resident easily re-directed? was answered, no. The question, does the patient/resident have a diagnosis that requires supervision? was answered, no. Review of progress notes in Resident #41 ' s medical record dated 8/11/23 at 1:42 AM documented the resident was alert and oriented times 3. An 8/12/23 at 10:33 PM nursing note documented, intermittent confusion noted during shift. During morning med pass, resident confused about knowing why [he/she] is here. Redirection effective. After breakfast, resident ambulating on unit. An 8/13/23 at 3:47 AM nursing note documented, [Resident #41] is confused to time, situation and occasionally to place. [Resident #41] has been up and walking up and down the halls. [Resident #41] is exit seeking and asking staff to let [him/her] out. At one point [Resident #41] thought [he/she] had reported to duty and wanted a sign-in sheet. [Resident #41] asked writer to check the computer to make sure [he/she] was logged in to ensure payment. Patient generally pleasant and polite, easily redirected. Patient is a risk for elopement. An 8/14/23 at 1:09 PM note documented, is confused at times of what is going on. Stated, hopes [he/she] will not be in trouble but [he/she] did not punch in for work today. The note continued, also does not want to be in trouble with the military for having [his/her] tube in. An 8/16/23 at 7:58 PM nursing note documented, GNA approached writer at approx. 3 PM stating that she came up to bring [Resident #41] back to the unit and she could not find [him/her]. Writer immediately began to announce Code yellow to staff and began searching for the patient. The note continued, while writer was attempting to call police, facility received a call from crisis center that the patient had went there and was banging on the back door. The note documented that staff members retrieved the resident, and a head-to-toe assessment was done, and the resident was found to have a small open area to nose, which was new. Patient was started on neuro checks upon return. On 9/19/23 at 7:13 AM an interview was conducted with the receptionist, Staff #12 who stated that he was here that day that Resident #41 eloped. Staff #12 stated that Resident #41 walked out somehow. Staff #12 stated the front door was unlocked when staff exit in the morning. He stated the doors are locked at night at 7:00 PM. He stated that day Resident #41 was walking around but did not have a wander guard on so the alarm would not have gone off. On 9/19/23 at 7:22 AM an interview was conducted with RN #13, the nurse that wrote the 8/14/23 at 3:47 AM nurse ' s note. RN #13 stated the resident, was confused, especially in the evening. Would walk up and down the hall and sometimes thought was working and on duty and wanted to sign in and off at night. RN #13 stated that Resident #41 would wander, and she would follow the resident. RN #13 stated that the resident thought he/she was at work. RN #13 stated Resident #41 would go through the double doors to the hallway where the elevator was. She would have to follow the resident so he/she would not get on the elevator. RN #13 stated, at that time I felt [he/she] was an elopement risk if we were not watching. I felt Resident #41 should have a wander guard on. RN #13 was asked if she reported her concerns to anyone and she said she told the oncoming nurse, LPN #14. RN #13 stated, we don ' t have the wander guards available so I would just do a one to one and followed the resident. RN #13 was not aware that Resident #41 had eloped and stated, I do know that [he/she] should have had a wander guard and I should have had access to one. On 9/19/23 at 8:33 AM LPN #14 was interviewed and stated what RN #13 had told her in report. LPN #14 stated, I passed it on to the powers to be, my supervisors, Assistant Director of Nursing (ADON) and Director of Nursing (DON). We told them [Resident #41] was exit seeking and we caught [him/her] down the hallway towards station 4, past medical records. We recommended a wander guard and they said they would consider it. We told the Nurse Practitioner (NP) that morning. She knew [Resident #41] was a problem and was trying to exit seek and was asking staff if [he/she] could leave and wanted to go upstairs. LPN #14 stated, She (NP) just can ' t order, it has to go through a process. We have to get permission through the family and go through the proper channels. We always knew where [Resident #41] was unless [he/she] slipped by us. [Resident #41] got down that hall prior to that day. We also told them prior to that incident. When asked if LPN #14 documented her observations she responded that she did not document but she told the ADON and DON her concerns, however did not document that either. LPN #14 was asked since she was the nurse that day how Resident #41 got out of the unit. LPN #14 thought Resident #41 was taken to activities upstairs. LPN #14 stated she did not know how the resident got out of the building. LPN #14 stated that if you saw the resident, you would not think anything but if you got to know the resident, the resident was very paranoid. When asked if there was education afterwards LPN #14 stated only about elopement procedures and protocols and what to know about what the resident was wearing. They did not educate on how to prevent an elopement, just what to do if there was an elopement. LPN #14 stated that the front door was the only door the resident would be able to get out and if the resident had a wander guard on the alarm would have sounded. On 9/19/23 at 8:54 AM NP #15 was interviewed and stated she had never seen the resident and only found out about the resident on the day of the elopement. The nurses never called me prior to the elopement. I did not know any concerns about elopement. If I would have known about it that morning, I would have seen the resident and then would have put a plan in place to prevent exit seeking. I never gave an order for a wander guard. I always thought it was a nursing judgment. I think the issue was how [Resident #41] scored on the assessment. They went off [his/her] BIMS score even though [Resident #41] had the [NAME] ' s and short-term memory loss because of how tested on [his/her] admission. NP #15 stated, I would have considered [him/her] a risk considering what the history was. On 9/19/23 at 9:08 AM an interview was conducted with the Activities Director, Staff #16 who stated she walked Resident #41 up to activities hand in hand. Staff #16 stated she did have concerns about the resident because he/she was asking where he/she was and how far was he/she from a specific city. Staff #16 stated Resident #41 was good for about 15-20 minutes and then wanted to start wandering. Staff #16 stated she took the resident back to the unit and informed the GNA that she brought the resident back. Staff #16 stated she and the GNA were discussing the resident because the GNA had a concern too. Staff #16 stated she went to the DON and informed her that she had some concerns about the resident. Staff #16 stated the DON stated she would call the social worker and get the resident ' s BIMS score. Staff #16 stated, I am very vocal. I let it be known about my concerns for this resident. On 9/19/23 at 8:55 AM GNA #8 was interviewed and stated Resident #41 walked constantly. She stated Resident #41 was oriented and sometimes [he/she] knew what [he/she] was talking about and sometimes not. Always wanted to go to the store and try to get out and would walk to the double doors. Always wanted to leave, go to store. The nurse told us to keep an eye on [him/her]. GNA #8 stated Resident #41 must have gone up on the elevator. GNA #8 stated Resident #41 should have had a wander guard on. On 9/19/23 at 9:40 AM the DON was interviewed and asked if Staff #16 informed her of the concerns related to Resident #41 ' s wandering and exit seeking. The DON stated that Staff #16 did tell her and that she looked up the resident ' s BIMS and it was a 15 which meant the resident was alert and oriented. The DON stated that she called the social worker and informed her and stated she was under the impression that we could not put a wander guard on an alert and oriented patient. The DON stated, I was just under that impression. When the DON was asked if RN #13 or LPN #14 told her about the change in Resident #41 ' s behavior, the DON stated, I think they did come to me the day before and just that [Resident #41] was wandering up and down the hallway. They seemed concerned but as far as I knew [he/she] was on the unit and was just wandering on the unit. I think someone said [Resident #41] wanted tobacco chew and I had talked to the social worker which was prior to, and I double-checked the BIMS and according to the BIMS [he/she] was alert and oriented. Review of the Elopement Risk Assessment Policy, Procedure Number 2 documented, all residents are re-assessed for elopement potential by the MDS Nurse/Social Service or designee periodically throughout a patient ' s/resident ' s stay and with a significant change. Number four documented, the licensed nurse or social service designee completes an elopement risk assessment and presents the information to the Interdisciplinary Team for further interventions. Further review of Resident #41 ' s medical record revealed there was no re-assessment of the resident ' s elopement risk after documentation of a change in mental status and exit seeking/ wandering behaviors. The DON stated on 9/19/23 at 9:43 AM that because Resident #41 had a BIMS of 15 and was assessed as being alert and oriented and their own responsible party that they could not put a wander guard on the resident. When asked if the staff were educated after the elopement, the DON stated, we educated the people that day and educated as they worked. We educated them on the policy of elopement, and I gave a copy of the policy to the staff. The surveyor reviewed the 1-page signature sheet with the DON and the policy that was attached that stated, Subject: Elopement Drill. Policy: All staff will be trained on practice guidelines for elopements through periodic drills. The facility will determine an overhead page to signal an elopement drill. The DON confirmed that staff was educated on what was attached to the signature page. The DON was asked if a QAPI meeting was held, and she said she was out for the August meeting and was not sure if the ADON did one. The ADON was currently out for the week. On 9/19/23 at 10:35 AM the surveyor walked over to the crisis center and interviewed the intake staff who stated, we were back here in the office and a crisis client came in by foot. He/she was very disoriented, confused and thought they were in an airport terminal. We noticed a lot of confusion, disorientation. We suspected a memory issue. Stated [Resident #41] got here driving a truck from the airport and there was aircraft in the parking lot. Mission was from NASA. The staff stated that they did a test on the resident and the resident scored a 0 out of 5 for season, date and month and a mini-mental exam which the resident scored a 15 out of 30. They stated the resident appeared scared and did know what was going on. The triage nurse looked for belongings and the resident let them have access to the cell phone. At that time, they found a lunch menu from the nursing facility, and they called the facility, and they came down right away. It was noted that on 9/18/23 around 1:00 PM the surveyor was walking up the hallway and a male and female visitor were standing at the receptionist desk. There were no staff present and the visitors mistook the surveyor for a staff member. Staff eventually came back to the receptionist area. Observation was made on 9/19/23 at 11:11 AM of no one at the receptionist desk for approximately 2 minutes. The doors to the entrance were unlocked. 34484 2. On 9/20/23 review of facility reported incident MD00182923 revealed on 8/26/22 Resident #4 fell out of his/her wheelchair. Review of Resident #4 ' s medical record on 9/20/23 revealed the The Resident had diagnoses to include altered mental status, cognitive communication deficit and disorientation. Further review of Resident #4 ' s medical record revealed a nurse ' s note dated 7/11/22 that stated, Elopement attempts made by resident today starting at approximately 9:00 AM. Resident confused of time and place where [he/she] was. Resident stated [he/she] was looking for a little boy that he/she needed to help at a fire department. Resident typically goes onto outside porch without supervision. Today resident attempting to go off the porch. Resident was re-directed into the building by staff. Writer called and notified in house NP [Nurse Practitioner]. Per NP, okay to order wander guard for safety and order to check placement of wander guard daily on each shift. Writer notified DON. Unit manager obtained working wander guard and brought to writer. Writer applied wander guard to resident's right ankle without any issues or complaints. Review of an elopement assessment completed on 7/11/22 revealed an elopement assessment completed that stated to proceed with a new order for wander guard for safety and to check placement everyday on every shift. On 8/25/22 the Social Worker documented; Resident scored 5 on BIMS. BIMS is a Brief Interview for Mental Status. A score of 5 of 15 indicates a severe cognitive impairment. Further review of Resident #4 ' s medical record revealed a nurse ' s note on 8/26/22 that stated, Resident was outside unattended and rolled out of porch like area onto the driveway when according to resident the wind made [his/her] wheelchair start to go down the driveway hill and he/she couldn ' t stop. Resident rolled down driveway until [he/she] stopped due to wheelchair hitting side of driveway making resident fall forward out of wheelchair landing on left side on his/her head and left arm underneath his/her body. Back was against the curb. Review of a facility statement on 8/26/22 from the Former Receptionist stated the resident was in wheelchair and tried to go out so I held the door open and turned off the alarm. There was a bunch of activities outside and the Activities Aide was bringing people in. During interview with Activities Aide on 9/20/23 at 12:00 PM, she remembered seeing Resident #4 in a wheelchair self-propelling down the hallway towards the front lobby when she was taking another resident back to their room. The Activities Aide stated Resident #4 was alone at the time. During interview with MDS Coordinator on 9/20/23 at 12:26 PM, she stated on 8/26/22 she was in her office and saw a wheelchair empty by the curb and something on ground and immediately went outside and saw Resident #4 laying on the ground against the curb. She stated Resident #4 was moaning and bleeding from the head, 911 was called and the Resident was sent to the emergency room . During interview with Staff #23 on 9/20/23 at 3:41 PM, Staff #23 stated she was the nurse caring for Resident #4 on 8/26/22 and the Resident was an elopement risk and was wearing a Wander Guard. Staff #23 stated the Resident was able to self-propel in his/her wheelchair and would go to the front lobby. During interview with Staff #20 (Former Receptionist) on 9/20/23 at 4:00 PM, Staff #20 stated she worked here about a month and half prior to the incident on 8/26/22. Staff #20 stated Resident #4 was pushing the front lobby door open and the alarm was going off. Staff #20 stated I got up and turned off the alarm so the Resident could go outside. Staff #20 stated she remembered seeing the Activities Aide outside with other residents so didn ' t think anything of it. Staff #20 was asked if the Activities Aide was made aware Resident #4 was outside and Staff #20 said, no. Review on 9/21/23 of the Resident #4 ' s hospital record from 8/26/22 revealed the Resident had a diagnosis of scalp laceration with sutures. Further review of Resident #4 ' s medical record revealed a nurse ' s note on 8/27/22 that stated, Resident returned to facility at approximately 8:00 AM via EMS (Emergency Medical Services) by stretcher. Resident sent back with 2 liters of oxygen via nasal cannula related to hypoxemia. [Hypoxemia is a low level of oxygen in the blood.] Writer observed large bandage on residents left side of his/her forehead that are covering sutures for a scalp laceration, dried blood in resident ' s hair to left side of [his/her head], large dark blue-purple bruises to bilateral knees, contusion to left forearm and left hand and left finger bruised. Further review of Resident #4 ' s medical record revealed the Resident was sent back to theER on 8/30/22 and received a diagnosis of left ring finger fracture and rupture of tendon of finger. On 9/1/22 a nurse ' s note revealed the nurse documented when picking up both legs, the resident would scream in pain, the doctor was notified and the Resident was sent back to hospital via 911. Review of Resident #4 ' s hospital record on 9/21/23 revealed the Resident was admitted to the hospital on 9/1/22 and discharged back to the facility on [DATE]. The hospital record stated the patient presented back toER on [DATE] due to persistent left lower extremity pain. At that time the patient underwent CT scan which showed a comminuted left distal femur fracture which was not seen on imaging [Xray] done on 8/26/22. A family meeting was held and due to patient ' s declining functionality, poor mentation, worsening renal function and poor quality of life they elected to pursue comfort care measures. Further review of Resident #4 ' s medical record revealed a nurse ' s note on 9/26/22, Resident readmitted on [DATE] under hospice services. [He/she] discharged to Hospice by the Lake on 9/17/22 and passed away the next day. The provisions of the plan to remove the immediacy for the Immediate Jeopardy identified on 9/19/23 at 4:20 PM for Resident #41 and 9/21/23 at 10:50 AM for Resident #4 with a completion date of 9/25/23 include the following: 1. Facility staff will be posted at the front desk at all times until doors are secured with a mag lock keypad system by an outside vendor 9/19/23. 2. Maintenance did a security check of all exit doors and they are functioning appropriately locked and secured 9/19/23. 3. All residents will be assessed for elopement risk by 9/21/23. If any resident is determined to be an elopement risk, interventions will be put in place immediately, which may include but not limited to activities, toileting, snacks, redirection, increased supervision, or wander guard. Residents will be monitored for exit seeking behaviors and care planned with individual interventions based on resident needs. 4. Residents who are at risk for elopement have the potential to be affected by the alleged deficient practice. 9/19/23. 5. Clinical consultant educated Director of Nursing and licensed nurses regarding the expectation that all change in resident mental status, wandering and exit seeking behaviors will be documented, investigated immediately and Director of Nursing will be notified immediately and interventions will immediately be put in place. Any resident with a change in condition will be reassessed immediately for elopement risk and front desk will be verbally notified. 9/21/23. 6.The Department heads will be educated by the Clinical consultant and the Director of Nursing regarding the expectation that there be front desk coverage at all times to validate that a resident cannot go out the front door unattended. A schedule has been put in place to provide coverage at all times at the front desk. 9/19/23 7. This education will be completed by 9/21/23 by midnight for all staff. Any staff member not completing this education will be done by Director of Nursing 8. An ad hoc Quality Assurance Performance Improvement meeting will be held 9/19/23 to discuss the contents of this plan. 9. The medical director was notified of the immediate jeopardy and the contents of the plan of removal on 9/19/23 at 6:05 PM. 10. Facility staff posted at front desk will be educated by Director of Nursing on residents who wear wanderguards are not permitted to be outside by themselves. The front desk staff should immediately call the Director of nursing or Administrator to alert them of resident who is wearing a wander guard wanting to go outside so supervision can be provided for resident during the week and the manager on duty on the weekends. Those residents who like to go outside that wear a wander guard will be taken outside by activity staff daily if weather permits. 9/25/23 11. Education with staff on residents with wander guards needing supervision when going outside will be completed by 9/25/23 by the Director of Nursing. 12. Department heads will be educated by Director of Nursing that all residents with wander guards will be supervised when going to sit outside on the porch and will need to assist covering this activity. 9/25/23 13. This education for example #2 will be completed by 9/25/23 by midnight for all staff. Any staff member not completing this education will complete prior to the next scheduled shift. Validation of completed education will be done by Director of Nursing. 14. An ad hoc Quality Assurance Performance Improvement meeting to discuss the second example added to IJ will be held 9/21/23 to discuss the contents of this plan. 15. The medical director was notified of the Immediate Jeopardy second example and the contents of the plan of removal on 9/21/23 at 12:00 PM. The Immediate Jeopardy was removed on 9/26/23 at 1:00 PM after on-site confirmation of the completion of the facility & #39's plan of removal.

Based on a review of complaints MD00196300, MD00194233, facility-reported incidents MD00196345, MD00193981, hospital records, medical record, facility documentation and interviews, it was determined the facility failed to protect a vulnerable resident ' s skin from injury resulting in harm to Resident #44, and failed to put measures in place to prevent further skin breakdown (Resident #38, #39, #23, #13). This was evident for 5 ( #44, #38, #39, #23, #13) of 43 residents reviewed during a complaint survey. The findings include: 1.) On 9/14/23 at 12:30 PM a review of facility-reported incident MD00196345 revealed that Resident #44 obtained a wound under the trach collar that was located on the back of the neck. The report documented that Resident #44 was sent to the hospital and was subsequently admitted for other symptoms not related to the area on the neck, but other preexisting conditions that the facility had been managing. On 9/14/23 at 12:30 PM a review of complaint MD00196300 revealed Resident #44 was taken to the emergency room for evaluation of a posterior (back) neck laceration due to a trach (tracheostomy) collar tie. On 9/14/23 at 12:35 PM a review of Resident #44 ' s medical record revealed a 4/20/23 physician ' s note which documented Resident #44, who was in their 30 ' s, was admitted to the facility for care following a cardiac arrest which resulted in an anoxic brain injury and was deemed unable to recover brain function. Resident #44 had a tracheostomy placed and was sent to the facility for further care. Review of an 8/26/23 at 11:00 PM nursing note documented that the nurse was called to the resident ' s room by a geriatric nursing assistant (GNA) for a wound on the back of the resident ' s neck. The note documented the resident was observed with an approximate 15 cm. (centimeter) laceration along the back of the neck. The respiratory therapist removed the trach collar, and the nurse applied a dressing over the area. The resident was sent to the emergency room . Review of the emergency room ' s triage note dated 8/26/23 at 23:36 (11:36 PM) documented chief complaint, pt presents to ED (emergency department) from facility due to laceration to back of pts. neck from trach collar strap. The patient ' s temperature was 99.1, blood pressure 97/62, and a heart rate of 142 beats per minute. The note documented the presenting problem as, positive for laceration, fever, redness and swelling. The ED disposition documented in the following order, diagnosis: pressure injury of skin, posterior neck, infected wound, tachycardia (rapid heart rate), hypotension (low blood pressure), leukocytosis (high white blood cell count), dehydration, and symptomatic anemia. The disposition was, admitted . Review of the ED provider disposition note dated 8/27/23 at 1:25 AM documented, medical decision making and included, Trach collar is in place. Patient with open wound posterior neck at the level the trach collar stye. Malodorous serous discharge. Macerated skin at the edges of wound. No bleeding no warmth no erythema. Appears to be approximately 1 centimeter at its deepest. Review of the hospital general admission note dated 8/27/23 at 4:16 AM documented, reason for admission: sepsis, cellulitis of the back of the neck, laceration back of neck, symptomatic anemia. The note documented, the patient has a tracheostomy collar and where it ties in the back there is now a deep laceration which is why the nursing home sent [him/her] here. The note continued, when [he/she] present to the ER [his/her] heart rate was found to be high at 142 and bp low at 97/62. The note documented a temperature of 99.1 and a white blood cell count at 14.31 and a hemoglobin of 6.8 with a hematocrit of 22.1. A central line was inserted, and the resident received IV (intravenous) fluids and IV vancomycin (antibiotic). Further review of the 9/5/23 at 6:40 AM hospital note documented, discharge - wound care active orders: type: pressure posterior neck, Schedule: Routine, Frequency: 3 times per week, as ordered, Additional instructions: wash with soap and water. Apply wound gel/hydrogel to wound bed, Aquacel Ag to wound bed, and secure with ABD. On 9/14/23 at 1:17 PM an interview was conducted with the respiratory program manager, Staff #11. Staff #11 was asked how often the straps were changed prior to the laceration. He stated weekly and prn (when necessary) if wet or dirty. Staff #11 stated they were changed out the Wednesday or Thursday before the laceration was found. Staff #11 stated, when they do trach are they release the trach collar and inspect. Staff #11 stated, the collar has a green strap, and we think when pulling it tight it caused a laceration. When asked how a strap could cause a laceration, he stated that sometimes there are rough edges from pulling and tightening up. Staff #11 stated that they removed all the green straps from the trachs and now put a soft collar on to provide cushioning, a softer gray collar. Staff #11 stated that they are now changed every 2 days and there was someone with the therapist to look at the back of the neck. Staff #11 was informed that documentation could not be found of the therapists signing off that the trach ties were changed. Staff #11 stated, they don ' t document changing the straps, that it is part of the respiratory protocol. Some do document for certain patients. On 9/14/23 at 1:29 PM an interview was conducted with respiratory therapist (RT) #10. Staff #10 stated, I worked with the resident that day and I did not change the trach ties. I look under as best as I can. I did not change the ties that day. They were not due to be changed that day. Originally the ties were changed weekly and as needed. Always on Monday and PRN. Now we change every 2 days. Now we do skin assessment every shift which are 12-hour shifts. Staff #10 was asked if there was any documentation that the ties were changed and she stated, it was not an outright order before so there was no documentation unless it was put in a note, but now it is an order, and we document. Staff #10 stated, the laceration was like a half-moon scar. I really did not look hard because the straps were not due to be changed. Staff #10 was asked if she would normally check the back of the neck. Staff #10 stated, when in school we were not taught specific skin conditions except for around the stoma. It was not on my radar before this happened and I have never seen it before. On 9/14/23 at 2:57 PM an interview was conducted with geriatric nursing assistant (GNA) #9. GNA #9 was asked if she typically would bathe the back of the neck when giving a bed bath. GNA #9 stated, I don ' t wash the neck. I wash the resident ' s back. We check to see if there are scratches under the straps. When asked if she lifted the trach straps, GNA #9 stated, I do not lift the strap up. When you turn the patient, you can see the back of the neck. On 9/14/23 at 4:23 PM GNA #8 was interviewed and stated that she always worked on the ventilator unit. GNA #8 was asked how she washed Resident #44, and she stated, I give a bed bath and I wash the whole body. When asked if she ever lifted the trach collar straps to wash, GNA #8 said, no. GNA stated that she washed the resident ' s hair a couple of weeks before and braided the hair, but it wasn ' t that day. GNA #8 stated, we change the sheets every other day and the pillowcases. I change the sheets frequently. There was nothing on the sheets or pillowcases. On 9/14/23 at 4:00 PM a review of the August 2023 Treatment Administration Record (TAR) was conducted. There was an order, weekly skin check by licensed nurse. The nurses initialed on the TAR when a skin check was done. A skin check was initialed on 8/3/23, 8/10/23 and 8/17/23. On 8/24/23 there were initials, however they were in parenthesis. On 9/14/23 at 4:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #7. The TAR was shown to LPN #7, and she was asked if those initials were her initials on 8/24/23 and what did the parenthesis mean. LPN #7 stated they were her initials and the parenthesis meant that she did not do the skin check. When asked why she did not do the skin check, LPN #7 stated, because I only had 1 GNA that night and had multiple admissions and I was on the floor by myself. I was the only nurse. I got 2 admissions that night. There were about 17 residents because I had to do both hallways. I had to do the vent hallway and the rehab hallway. When asked if they worked short-staffed, LPN #7 stated, we do work short often, sometimes we have 1 GNA and sometimes we have 2 GNAs. LPN #7 was asked when she did a skin assessment to describe how she did it. LPN #7 stated, a weekly skin check is a whole assessment head to toe. The GNAs help me roll the patient. I don ' t look under gauze, respiratory does that. When asked if respiratory was with her when she did a skin assessment, she said, no, the GNA is. On 9/14/23 at 4:48 PM an interview was conducted with the Assistant Director of Nursing (ADON) #6 who stated that she helped with the nursing scheduling. Staff #6 stated on the 500 unit, which was the ventilator and rehab unit, they have 1 nurse, 1 respiratory therapist and 2 GNAs for each shift, except the overnight shift has 1 GNA. Staff #6 stated she was working that evening and said, I became aware of the laceration about a half hour before we sent [him/her] out. It looked like a cut; no drainage and it was not bleeding. It did not smell. It did look kind of fresh, there was no drainage. The trach collar was clean, so I wasn ' t sure if it was fresh or had been there since there was no blood or drainage. Until you pushed [his/her] head forward you could not see it. If the head was kept back, you couldn ' t see it. It was red and beefy, was not actively bleeding. I was not the nurse on the unit. The GNA came and got me and asked me to look at it. The nurse on the unit was not certain if he should put a bandage on it and he was on the fence as to sending [Resident #44] out. I looked at it and I felt [he/she] should be sent out. Just eyeballing it about half a centimeter or more. You had to bend the head down to see it and I didn ' t want to do that and make it worse. Staff #6 continued, I would have expected the nurses to inspect the neck and look under the trach cover. [Resident #44] didn ' t have folds on [his/her] neck. I don ' t know if I would push the neck down because it would make [him/her] uncomfortable, but I would take the trach collar off. Respiratory therapy does it as far as changing. I would assume they do that. But during a skin check I would expect it and I would expect the GNA ' s to wash the neck. Staff #6 stated that since the incident, the respiratory therapist is doing more skin checks when doing the trach ties and when they put a new tie on. On 9/15/23 at 7:16 AM an interview was conducted with the Director of Nursing (DON), and she was asked if they did any education with the staff. The DON said, respiratory did their education and I know some nurses had skin education. When asked if they did any kind of QAPI (Quality Assurance and Performance Improvement), she stated, no, we did not do an AD hoc meeting. The DON provided the surveyor with a sign-in sheet for the 6 respiratory therapists that were educated. The DON stated they educated all the nurses verbally but did not have documentation of the education. The DON stated they did a whole building skin audit. On 9/15/23 at 7:43 AM an interview with the ADON revealed that an action plan was typed up but the only thing that had been started was the facility-wide skin sweep. The ADON said they verbally educated the nursing staff, especially on that unit, but there was no documentation of the education. 2) On 9/14/23 at 8:13 PM a review of facility-reported incident MD00193981 for Resident #38 revealed an allegation that the resident, who resided on the dementia unit, was found by a family member on 6/28/23 laying in urine and feces and also had sores. Review of a 6/30/23 at 4:43 PM note documented that the resident had an old discolored blister to the left heel measuring 6 x 4, a popped blister area to the left calf measuring 3 x 2 and also had a stage 2 to the sacral area. Review of wound notes dated 7/3/23 to 9/18/23 documented that Resident #38 had an unstageable pressure ulcer to the left heel. Further review of the 9/18/23 wound notes documented Resident #38 had a stage 3 pressure ulcer to the right medial ankle that was acquired in house on 9/18/23, a deep tissue injury (DTI) pressure area to the right lateral foot that was acquired in house on 9/18/23, and a stage 2 pressure ulcer to the left lateral foot acquired in house on 9/4/23. On 9/21/23 at 1:16 PM, Resident #38 was observed lying in bed on his/her back with legs and knees facing the side wall. On 9/21/23 at 4:07 PM the surveyor walked into Resident #38 ' s room and asked GNA #30 if she could lift Resident #38 ' s sheet so the surveyor could see Resident #38 ' s feet. GNA #30 walked over and lifted Resident #38 ' s sheet and said, look at the way [he/she] was left. Resident #38 ' s diaper was saturated, and Resident #38 had bowel movement on the buttocks. Resident #38 ' s legs were contracted sideways. The resident ' s heels were not floated on pillows. There was no pillow between the knees. There was no padding around the ankle area as both legs and feet were touching each other. The resident was not on an air mattress. Resident #38 had been in the same position as when the surveyor observed the resident at 1:16 PM. Review of Resident #38 ' s care plan, resident is at risk for skin breakdown r/t decline in cognition, decline in mobility and ADL function documented interventions, Keep clean and dry as possible. Minimize skin exposure to moisture, Use under pads/briefs. Check q 2 hrs. and change prn for soiling. There were no interventions on the care plan about applying an air mattress to the bed, floating heels, placing a pillow between the knees to keep them from rubbing together or pillows between the ankles to keep them from rubbing together and having pressure on them. On 9/20/23 at 4:58 PM LPN # 31 was interviewed and said the resident was total care. LPN #31 stated that Resident #38 got changed at least twice per shift, maybe 3 times per shift if a heavy wetter. On 9/21/23 at 3:47 PM the DON was interviewed and stated when the family complained on 6/30/23 she immediately did a full body assessment. The DON stated that the spouse stated the resident had some sores and one on the heel and leg from when the resident fell before admission. The DON stated, during my assessment [Resident #38] did have the wounds and had a stage 2 on [his/her] sacrum. The one on the bottom was new. The DON stated, during a shift they should be checked and turned every 2 hours. Approximately every 2 to 2 1/2 hours they should be checked. It should be 3 to 4 times. They should be checked more than twice. On 9/25/23 at 3:01 PM an interview was done with the wound care NP, Staff #36 who stated that the resident had multiple areas on the feet and heel that had resolved as of 9/25/23. Staff #36 stated that they classified the pressure ulcers as unavoidable as the resident has had a decline in general condition, was made palliative care and had overall weight loss. Staff #36 was asked if there was an air mattress on the bed and she said, no air mattress prior to now. When asked if there were pillows between the resident ' s contracted knees, Staff #36 stated, normally I do not see with pillows between the knees. Sometimes I do and sometimes I don ' t. Staff #36 stated she would expect the resident to be turned every 2 hours and the heels elevated. The surveyor asked Staff #36 if she would expect nursing measures for a susceptible resident to have pillows between the heels and ankles and to be on an air mattress and turned and repositioned every 2 hours. Staff #36 stated, yes. Staff #36 was asked how she could determine the pressure ulcers were unavoidable if nursing measures were observed not in place. Staff #36 did not answer. On 9/26/23 at 2:40 PM an interview was conducted with LPN #35. LPN #35 was asked about staffing on the dementia unit and her response was, we are usually short. The other day I had 1 GNA. We do as best as our ability allows, especially dealing with behaviors. Residents are supposed to be turned and repositioned every 2 hours, but if we don ' t have the staff, it is 2 times per shift. On 9/26/23 at 2:42 PM GNA #32 was interviewed and asked how often they check and change residents on the unit. GNA #2 stated, twice per shift. Staffing is awful. We have baths, rounding, charting, behaviors, and feeders. We try our best. 3) On 9/18/23 at 10:30 AM a review of complaint MD00194233 revealed an allegation that Resident #39 obtained a stage 4 pressure sore on the buttocks while in the facility. On 9/18/23 at 10:30 AM a review of Resident #39 ' s medical record revealed that the resident was initially admitted to the facility on [DATE] for rehabilitation. A 5/1/23 at 12:10 PM nursing note documented a new admission skin check was done from the wound care Nurse Practitioner (NP) which documented the resident had 2 scabs to the upper abdomen that were dry. There were no other noted skin alterations. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident''s individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of a 5/2/23 MDS note documented Resident #39 was extensive assistance with the help of 2 people for bed mobility on more than 1 or 2 occasions. According to the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. A score of 19 or higher is not at risk. A score of 15-18 is at risk, 13-14 is moderate risk, 10-12 is high risk and 9 or less is very high risk. A Braden scale was done on 5/8/23 and documented a score of 10 which indicated Resident #39 was at high risk to develop a pressure ulcer. A 6/7/23 note documented that Resident #39 was sent out to the hospital and a 6/9/23 note documented the resident returned on 6/9/23. There was no readmission assessment of the resident in the progress notes or under the assessments section of the medical record. There were no nursing notes after 6/9/23 until the next assessment which was on 6/11/23. There were no skin issues documented in that assessment. A review of the hospital discharge summary dated 6/9/23 did not have any documentation of active skin issues. On 6/12/23 at 4:51 PM a wound assessment was done and revealed a Stage III pressure ulcer was discovered and it documented, present on admission. The pressure ulcer was 1.7 cm (centimeters) in length, 1.5 cm in width and 0.5 cm in depth. The note was documented by the Assistant Director of Nursing (ADON). Review of the June 2023 Treatment Administration Record (TAR) documented that a treatment to the pressure ulcer was not started until 6/15/23, 3 days after the pressure ulcer was found. On 6/19/23 at 3:37 PM the ADON documented the pressure ulcer was larger and the wound healing status was declining. The pressure ulcer was 5 cm. in length, 4 cm. in width. And 0.5 cm in depth. On 6/26/23 at 3:39 PM the ADON documented the pressure ulcer was now 9 cm. in length, 14 cm. in width and 0.5 cm in depth. The pressure ulcer was unstageable due to slough and necrotic tissue. On 6/26/23 at 10:28 AM a progress note documented, resident seen by wound NP (nurse practitioner) this morning. Sacrum wound worsening; area debrided at bedside by NP. Resident noted to feel warm to touch. VS (vital signs) taken by GNA, Temp 99.7. The resident was sent to the hospital and was admitted for sepsis. According to the Centers for Disease Control (CDC) sepsis is a life-threatening infection when an infection that someone already has triggers a chain reaction throughout the body. Continued review of the medical record revealed Resident #39 had precipitating risk factors for breakdown such as immobility, incontinence of bowel and bladder, albumin level of 1.9 (5/21/23 dietary note) (albumin is the most common protein found in the blood and is used by the body for growth and tissue repair. A normal albumin level is 3.4 to 5.4), chronic anemia, and frequent transfers to the hospital and physician ' s office via ambulance. Further review of the medical record demonstrated that the facility failed to put preventive measures in place to help reduce the risk of developing a pressure ulcer. The only intervention that was found was to elevate the heels. There was no turning and repositioning every 2 hours, no air mattress, no timing for changing of incontinence products. There was no altered skin/pressure ulcer care plan in place. On 9/26/23 at 7:22 AM the DON was interviewed and stated that Resident #39, eventually did get a pressure ulcer and I think it was in-house acquired initially but [he/she] was transferred back and forth to the hospital. Our wound team was seeing [him/her] and it was progressively getting worse. On 9/26/23 at 9:31 AM the ADON was interviewed and asked about the wound found on 6/12/23 as she was the one that documented on it in the medical record. The ADON stated she did not remember and that she just puts in what the wound nurse states. The ADON was asked about how they determined it was not a facility acquired pressure ulcer when there was no documentation that the resident was assessed on readmission to the facility on [DATE]. When asked if there should have been a re-admission assessment, the ADON said yes. It was pointed out to the ADON that the treatment was not started on 6/12/23 when the pressure ulcer was found. The ADON stated, we would do the treatment that day but not do anything else until the wound NP would email the orders and that may be a couple of days. The ADON stated, she (NP) is on top of it now because she did wound rounds on Monday, and they received the orders by the end of day on Monday. On 9/26/23 at 12:40 PM the DON was asked about the nurses not doing a re-admission assessment when a resident comes back from the hospital. The DON stated, we have an admission checklist and admission observation which is a total history and complete physical. The DON acknowledged that it was not done. The DON stated, a lot of documentation stuff that has been missing that we are trying to improve on. The DON acknowledged there was no care plan for skin/pressure ulcer prevention and there was no documentation of turning and repositioning every 2 hours and any other preventive measures. The DON was also informed that physician documentation could not be found for the pressure ulcer. When asked if she expected the wound care provider or nurse to notify the attending physician, the DON stated, yes. 4) On 9/20/23 at 8:16 AM a review of Resident #23 ' s medical record revealed a 8/26/22 progress note that documented that Resident #23 had a history of a sacral ulcer. Review of Resident #23 's admission MDS with an assessment reference date of 8/26/22 documented that Resident #23 was extensive assistance for bed mobility and total dependence on staff for personal hygiene and bathing. The MDS also documented that there was impairment on the upper and lower extremities on one side. Review of the Braden Scale Risk Assessment for Resident #23 on 8/19/22 at 7:07 PM documented Resident #23 ' s score was 10 which put the resident in a high-risk category. Review of a 9/15/22 at 6:56 PM dietician note documented Resident #23 had lost 9.6 pounds in 1 month since admission. Review of a 10/9/22 at 12:17 PM progress note documented that an approximate 4 centimeter (cm) crescent shaped open area was noted to the resident ' s left buttocks area by the GNA during morning care. The note documented, wound bed noted to be red/white in color. Review of a 10/10/22 at 6:50 PM dietician note documented, nurse reported today that open skin area on buttock is pressure ulcer. Review of Resident #23 ' s care plans failed to produce a care plan for prevention of pressure ulcers even though it was documented that the resident had a history of a sacral ulcer. A care plan was not developed until 10/10/22, after a pressure ulcer was found. There was no evidence in the medical record that Resident #23 was turned and repositioned every 2 hours or that any interventions were put into place to prevent the development of pressure ulcers. On 9/26/23 at 2:42 PM an interview was conducted with GNA #32 who stated that the resident would scream when turned, did not roll, and pretty much laid in bed. When asked how often Resident #23 was turned and checked on she said that the resident was rounded on twice per shift. GNA #32 stated that staffing was a problem, and with only 2 GNAs on the unit they could not get to baths, rounding, and charting. 5) The facility staff failed to provide treatment for Resident #13 ' s sacral pressure ulcer and failed to complete a weekly skin assessment with measurements. Review of Resident #13 ' s medical record on 9/19/23 revealed the resident's admission assessment conducted on 5/19/22 revealed the Resident had a sacral pressure ulcer measuring 2.1 cm by .2 cm by .1 cm and was coded on the Resident's MDS (Minimum Data Set) Admission assessment on 5/24/22 as a Stage III pressure ulcer. Review of the Resident #13 's May 2022 Treatment Administration Record revealed the facility staff failed to document any treatment provided to the sacral pressure ulcer until 5/26/22, 7 days after the Resident was admitted . Further review of Resident #13& #39's medical record revealed no weekly assessment of the Resident & #39's sacral pressure ulcer on 5/26/23. Weekly assessments of pressure ulcers allow the facility staff to determine if the treatment needs to be changed. Interview with the Director of Nursing on 9/19/23 at 1:45 PM confirmed the facility staff failed to document if the facility staff provided treatment to Resident #13''s sacral pressure ulcer from 5/19/22 until 5/26/22 and failed to do a weekly assessment of the pressure ulcer on 5/26/22. On 9/26/23 at 5:15 PM the surveyors expressed their concerns to the Nursing Home Administrator, Director of Nursing, and the Director of Clinical Services. 34484

Based on medical record review and staff interviews, it was determined that the facility staff failed to follow physician orders [REDACTED]. (Resident #1). This was evident for 1 of 3 residents reviewed during a complaint survey. As a result of this failure, immediate jeopardy was found on [DATE] at 3:03 PM. The facility submitted an acceptable plan on [DATE] at 6:45 PM that was accepted by the surveyors while they remained onsite and the immediate jeopardy was lifted at that time. After removal of the immediate jeopardy, the potential for more than minimal harm remained for all existing residents at a scope and severity of D. The findings include: Per facility policy for Advance Directives, with a revision date of [DATE], in the absence of appropriate DNR identification or orders, the Facility Staff will respond to medical emergencies with CPR measures and a full code will be instituted. Review of Resident #1's medical record on [DATE] revealed he/she was admitted to the facility on [DATE]. On [DATE] the Resident's physician completed a [NAME]land Medical Orders for Life-Sustaining Treatment (MOLST) with the Resident. The completed MOLST form dated [DATE] indicated Resident #1's medical order was Attempt CPR: If cardiac and/or [MEDICAL CONDITION] arrest occurs, attempt cardiopulmonary resuscitation (CPR). This will include any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function. [NAME]land MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's directions about medical treatments. Further review of the medical record revealed Resident #1 had a physician order [REDACTED]. Review of the Resident's care plans revealed a care plan for: Advance Care Planning initiated [DATE] with the following approach: Resident has completed the following advanced directive: Full code. The Advance Care Planning care plan was last reviewed/revised on [DATE]. Review of Resident #1's medical record revealed a nurse's (LPN#1) note on [DATE] at 6:45 AM stating Resident expired this AM. There is no evidence in the medical record the facility staff performed CPR on Resident #1 or called 911. Review of LPN #1's statement on [DATE] read, LPN #1 states that at approximately at 5:00 AM Resident #1 rang his/her call bell and asked for something to drink. LPN #1 provided him/her with a glass of water. Approximately a half hour later, LPN #1 entered his/her room with his/her morning medications. LPN #1 found him/her to be unresponsive and without a pulse. LPN #1 immediately checked his/her chart and read that he/she was a DNR (Do Not Resuscitate). LPN #1 called RN #1 who responded and confirmed the Resident was without a pulse and not breathing. The Resident was pronounced at that time. Further statement on [DATE] by the DON (Director of Nursing) revealed the Resident's chart was reviewed with LPN #1 and LPN #1 confirmed there was no documentation that the Resident was a DNR but rather a full code. LPN #1 stated she must have pulled the wrong chart and read the code status for a different resident. During interview with LPN #1 on [DATE] at 11:40 AM, LPN #1 stated on [DATE] at approximately 5:00 AM, Resident #1 rang his/her call bell and asked for water, she gave the Resident water and the Resident thanked her. LPN #1 stated she went back about ½ hour later to start medication pass and when she went in Resident #1's room, he/she was unresponsive, no pulse and not breathing. LPN #1 then stated she hollered for help and grabbed the Resident's chart, looked at MOLST and said was DNR. LPN #1 stated RN #1 came in the Resident's room and confirmed no pulse. LPN #1 stated RN #1 asked code status and LPN told RN #1 the Resident was a DNR. LPN #1 stated CPR was not performed and no other facility staff looked at chart. LPN #1 was asked when realized the Resident was a full code, she stated when she got a phone call after she got home on [DATE] asking where I saw code status. I was told then the Resident was a full code. LPN #1 stated I must have pulled the wrong chart. During interview with DON on [DATE] at 11:50 AM, the DON stated she was notified by dayshift nurse, RN #2, on [DATE] that Resident #1 had died , was a full code and CPR was not performed. During interview with RN #1 on [DATE] at 12:12 PM, RN #1 stated on [DATE] at approximately 5:30 AM, LPN #1 called her and said she couldn't find a pulse on Resident #1. RN #1 went to Resident #1's room and confirmed there was no pulse. RN #1 stated she asked LPN #1 are we doing CPR and LPN #1 stated no, Resident #1 is a DNR. During interview with RN #2 on [DATE] at 3:20 PM, RN #2 stated she came to work on [DATE] at 7:00 AM and received report from LPN #1 that Resident #1 had passed away. RN #2 stated she asked what had happened and if LPN #1 had performed CPR and LPN #1 stated no. RN #2 stated after report, she went over to the chart to see what needed to be done before the funeral home arrived. RN #2 stated that is when she saw the Resident was a full code on the MOLST. RN #2 stated she then called the DON and notified her of the error. The facility began the MOLST education on [DATE] but as of [DATE] had not yet completed the training for all facility licensed nurses and certified nursing assistants. Interview with the DON on [DATE] at 11:50 AM revealed the facility also plans to provide weekly education in the form of mock code drills weekly. Interview with the DON and Administrator on [DATE] at 3:40 PM revealed the facility staff failed to educate all nurses and certified nurse assistants on the revised process for MOLST code status identification and failed to provide CPR to a resident that was a full code. An immediate jeopardy was determined on [DATE] at 3:03 PM. The facility submitted an acceptable plan on [DATE] at 6:45 PM that was accepted by the surveyors while they remained onsite. The facility's actions included: The facility responded with training to nursing staff on MOLST education with purpose to educate nurses and certified nursing assistants that the MOLST form is only resident identifier that will be used to determine code status and nurse will verify code status with second check performed by nursing staff, either nurse or nursing assistant. Per the interview with the DON and Administrator on [DATE] at 6:45 PM and review of in-service education documentation provided by the facility, all nurses and certified nursing assistants have received MOLST code status identification education as of [DATE] other than 11 facility staff who have been informed they can not work until the education is completed. The immediate jeopardy was lifted at 6:45 PM on [DATE] upon confirmation the the facility's completed plan.