Every finding on record at Blue Point Healthcare Center

Based on record reviews and interviews, it was determined that the facility failed to ensure a resident received the recommended durable medical equipment (DME) prior to discharge home. This was evident for 1 (Resident #4) out of 1 reviewed for discharge planning during a complaint survey.The findings include:On 05/08/2026 at 10:40 AM, a review of Complaint #2988404 submitted to the state agency was reviewed. The complaint alleged that the resident was discharged home without the needed medical devices to ensure a safe transition from the facility to home.On 05/08/2026 at 10:59 AM, a review of emails sent to the facility was conducted. In the emails, the complainant addressed the social worker and the administrator alleging concerns of unsafe discharge due to lack of durable medical devices. The emails expressed concerns that the home environment was unsafe, not equipped to meet the residents' needs and that medical devices were needed for safe discharge.On 05/08/2026 at 10:59 AM, a review of Resident #4's medical records was conducted. The review revealed the resident had bilateral below knee surgical amputation and was admitted to the facility on [DATE] and discharged home on 4/22/2026. Further review of the records revealed a note entered by a social worker on 4/15/2026 that the discharge planning and coordination of care was discussed with the complainant. From the note, the complainant had requested medical devices for a safe discharge home. A follow up note entered by social worker on 4/17/2026, revealed that the discharge planning discussion continued and the facility had notified the complainant that medical devices are ordered based on therapy and nursing evaluations and are subject to insurance approval and medical necessity. Further review of Resident #4's documents revealed a note from social services that indicated the complainant had requested several DMEs and indicated that the home had limited space. The complainant reported that they had discussed the needed medical devices with therapy staff and social worker and emailed a list of the needed devices to the facility.On 05/08/2026 at 1:41 PM, an interview with the complainant was conducted. They reported that they had emailed the facility several times including the administrator to notify the facility that the discharge was unsafe and that the home set up was not ready for the resident. Additionally, they reported that the resident had not showered since the time of discharge, and that the resident needed a commode for toileting at home since the wheelchair couldn't pass through the toilet door at home. On 05/08/2026 at 12:30 PM, the surveyor requested the discharge summary notes from therapy. A review of the occupational therapy notes revealed that Resident #4 needed an elevated toilet seat/3 in 1 commode.On 05/08/2026 at 1:11 PM, an interview with Staff #5, Assistant Occupational Therapist, was conducted. He reported that as part of the discharge recommendation, he documented that the resident needed a toilet seat/3 in 1 commode. He also added that he verbally communicated with Staff #3 that the resident needed a shower chair to assist with activities of daily living after discharge.On 05/08/2026 at 2:20 PM, an interview with Staff #3, Social Worker Designee, was conducted. When asked how she is made aware of medical equipment needed for residents before discharge, she reported that the therapy team will notify the social worker verbally. She confirmed that Staff #5 told her that Resident #4 needed a shower chair and that she relayed this information to her supervisor. She further stated that she was aware that the complainant had requested the following items for the resident: a shower chair, wheelchair, sliding board and toilet commode.On 05/08/2026 at 2:33 PM, a review of the utilization report conducted on 4/21/26 indicated only a wheelchair was needed. On 05/08/2026 2:58 PM, a brief follow-up interview with Staff #4 was conducted. When questioned regarding the utility reporting log, he stated that a shower chair and toilet commode were discussed during the utility report meeting as well as the reasons why the resident needed the items. Staff #4 stated he was not sure why the utility report log only had a wheelchair documented.On 05/11/2026 at 9:18 AM, a follow-up interview with Staff #3 was conducted. She reported that the facility could order a shower chair and commode for residents prior to discharge home. The reason why the devices were not ordered for Resident #4 was because the previous social worker had instructed her to order only the wheelchair.On 05/11/2026 at 12:26 PM, the Administrator was notified of the inappropriate discharge concerns.

Based on observation, record review, and staff interview, it was determined that the facility failed to label oxygen tubing and humidifier bottle with date of change to indicate maintenance of respiratory equipment for proper hygiene and safety. This was evident of 5 (Resident #11, #49, #65, #90, and #134) of 7 residents observed for respiratory care during this recertification/complaint survey.The findings include:During the screening phase of the survey process on 12/03/2025 at 8:42 AM, surveyor observed Resident #49 and Resident #90 receiving oxygen through an unlabeled Nasal Cannula (N/C) tubing hooked to an unlabeled humidifier.A second observation was made on 12/4/2025 at 10:15 AM that prompted surveyor to observe other residents receiving oxygen. The surveyor observed the following residents: Resident #11- N/C tubing not labeled and humidifier not labeled Resident #65 - N/C tubing not labeled, and humidifier not labeled Resident #90 - N/C tubing not labeled Resident #134- N/C tubing not labeled, no humidifier in placeOn 12/4/2025 at approximately 11:30, an interview was conducted with the ADON (Staff # 4) who stated that oxygen tubing are changed every 7 days and as needed, and humidifiers are changed when emptied and both should be labeled with the change out dates. The ADON accompanied surveyor to verify that the tubing and humidifiers were not labeled for Resident #49 and Resident #90 who were on the same unit.On 12/4/2025 at 12:15 PM, record review of resident #49 noted an order for oxygen (O2) at 2L via NC continuous every shift for Shortness of Breath (SOB). The care plan documented that resident is on oxygen therapy as ordered and to change oxygen tubing per facility policy. On 12/9/2025 at 10:12 PM, the Nursing Home Administrator (NHA) provided the surveyor with the Supplemental Oxygen using Nasal Cannula procedure and standard policy, which indicated that oxygen is considered a medication and will be treated similarly and that nasal cannula tubing should be labeled when opened. On 12/09/2025 at 10:21 AM an interview was conducted with the Director of Nursing (DON) who stated that oxygen tubing should be changed out and labeled. Oxygen tubing is changed every 7 days, and the facility had provided education to the nursing staff that tubing and humidifier bottle should be labeled. The surveyor informed the DON that the findings were a concern, and the DON agreed that the N/C tubing and humidifiers should have been labeled.

Based on observation and staff interviews, it was determined that the facility failed to ensure that all areas were in good repair. This was evident on all the units in the facility during the recertification/complaint survey.The findings include.On 12/4/25 and 12/10/25 at 8:40 AM and 9 :00 AM respectively, an environmental round was conducted on all the facility units. Observation of the residents' rooms revealed environmental issues to include but not limited to:room [ROOM NUMBER] A/B- The wall paint was scraped off behind each resident's bed measuring about 6x3 feet. The paint on the door edges leading to the bathroom were peeled off and the door in the bathroom connecting to the next room had paint scrapes on the lower edges measuring about 3x1 foot long.In room [ROOM NUMBER], the door handle/Knob was almost off the hinges, and the curtain rods on the window frame were broken and taken down. The bathroom sink was partially pulled off the wall leaving a see-through gaping hole. The wall adjacent to the lateral side of the bed had paint scraping coming off the wall and measuring about 6x2 feet long.In room [ROOM NUMBER] B, the wall paint was scrapped off behind the head of the bed measuring about 4x3 feet.Behind the head of the 2 beds in room [ROOM NUMBER] were observed paint scrapes on the walls measuring 3x4 feet and 10x2 feet respectively while room [ROOM NUMBER]A had the wall paint scratched up behind the head of bed and measuring about 5x3 feet. The same was observed in rooms [ROOM NUMBERS]. In an interview with the maintenance person on 12/4/25 at 11:35 AM, the surveyor asked how staff let maintenance know when a piece of equipment needed to be fixed or that residents area needed to be fixed. The maintenance person stated that staff put information in TELS - a system that provide information to the maintenance department. He checks the system daily, makes walk rounds to look for things that need repair, or staff can call him on the phone or the walkie-talkie.On 12/10/2025 at 9:20 AM the Nursing Home administrator (NHA) and the director of Nursing (DON) were asked in an interview if they were aware of the above findings. The NHA said they've had issues with hiring a maintenance director but have support from their regional director of operations, the maintenance director from a sister facility and their maintenance associate. She said they are fully aware that these rooms are damaged and would need more help to get the building fixed up. They were made aware that this was a concern, they agreed that it was.

Based on record review and staff interviews it was determined that the facility failed to send a copy of the notice of discharge to the representative of the Office of the Long-Term Care Ombudsman. This was evident during the recertification/complaint survey. The findings include:On 12/03/25 at 11:21 AM review of resident #3's medical records revealed that resident was sent out to the hospital for a medical condition on 10/28/25 and came back to the facility on [DATE].On 12/08/25 at 2:30 PM the ombudsman revealed in an interview that she has not been receiving discharge notification from the facility since April/May of 2025 till date.In an interview with the nursing Home Administrator (NHA) on 12/08/25 at 3:37 PM, the NHA acknowledged that the facility has not been notifying their Ombudsman of discharges. She was made aware that it was a concern.On 12/09/25 at 10:16 AM The Director of Nursing (DON) was also asked if the facility notifies their ombudsman when residents are discharged and she confirmed that they do not. On 12/09/25 at 11:54 AM The NHA brought a document Blue Point HC November transfers and discharges, stating that it's a letter sent to the ombudsman regarding discharges which they have not been doing. She said it covers discharges from July through November which they just sent to the ombudsman. She explained that the social worker was supposed to be responsible for sending it to the ombudsman but there was a gap in their social work team and that's how it fell through the cracks. She confirmed that March 2025 was the last time the ombudsman received a copy of the discharges. She was made aware that this was a concern.

Based on observation, interview and record review it was determine that the facility staff failed to 1) follow the facility infection prevention policy to operate on a systematic and organized date-driven method track and trend for in-house infections effective and timely, and 2) maintain/use laundry dryers according to the manufacture's instructions for use. The second one was found to be evident of 3 out of 3 dryers observed during the recertification/complaint survey.The findings include-1) On 12/04/2025 at 08:50 AM, observation and interview of Residents' 2nd floor revealed that Infection isolation signs were up in some of the resident's doors. However, the staff was not sure the reasons why.On 12/04/2025 at 9:49 AM during an interview, The Infection preventionist Staff #19 stated she using infectious diagnosis daily information to format her worksheet. However, she did not follow the facility policy to run a systematic and organized data-driven method to track/ trend the rough data. She could not provide any back-up reports from Regional office in McGeer Criteria either.During Record Review, on 12/04/2025 at 10:59 AM, the Infection Prevention binder was examined and revealed that it only had about one year's worth of worksheets and Resident print-outs in chronological order but no data analysis or trending data records.In an Interview, on 12/08/2025 at 02:12 PM, The Director of Nursing reported that she was aware that the Infection Preventionist did not have a method to track/trend the in house infections.2) Laundry observation, on 12/04/2025 at 11:59 AM, revealed that 3 dryers were in poor condition, and full of debris caught in the drum's wall i.e. melted diapers, gloves, food and unknown items. The Administrator was present at the time and agreed it was not acceptable.In an Interview, On 12/04/2025 at 12:05PM, the Laundry manager Staff #20 stated that it was her mistake to check if her staff screen the dirty laundry and take out all objects. Further interview was conducted with the maintenance staff #21 who stated they did not keep a washer/dryer manufacture's instruction book on hand.On 12/04/2025 at 13:05PM, Record review of the laundry service record revealed that only the dryer exhausted air duct had a recent service. No other record including the dryer manufacture's instructions was revealed.On 12/08/2025 at 10:22 AM an observation was conducted, after surveyor's intervention, all 3 dryers' inside drum metal walls were cleaned, temperature was tested within functional range by the service company this AM. On 12/08/2025 at 2:12 PM, a further interview was conducted with the Administrator and the above findings were reviewed. She agreed that her staff did not follow the policy and procedure and both were concerns of deficient practices.

Based on observation, resident interview, record review, and staff interviews, it was determined that the facility failed to provide appropriate pain management. This was evident for 1 (Resident #75) out of 2 residents reviewed for pain during the recertification/complaint survey.The findings include: A pain scale is a numerical scale, usually 0-10, used to determine the severity of a person's pain. Parameters (Instructions in order on when a medication can be given) for a pain scale are used to determine which pain medication would be given according to a person's severity of pain. On 12/02/2025 at 9:30 AM, Resident #75 was observed in the hallway, sitting in a wheelchair and moaning in pain. On 12/02/2025 at 12:20 PM, Resident #75 was observed moaning and reported experiencing inadequate back pain relief despite receiving medication. On 12/03/2025 at 2:49 PM, in review of Resident #75's medical record revealed a Physician order dated 11/24/2025 for oxycodone HCl Oral Solution 5 MG/5ML (Oxycodone HCl) give 5 ml by mouth every 8 hours as needed for severe pain 7-10. On 12/03/2025 at approximately 2:53 PM, in review of Resident #75's medical record revealed a Physician order dated 10/31/2025 for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for Mild Pain 1-3. On 12/04/2025 at 8:05 AM, in review of Resident #75's November medication administration record (MAR) showed Oxycodone was administered 11 times for pain scores below 7, and Tylenol was given once for a pain score of 5 on 11/5/2025. On 12/04/2025 at 8:37 AM, Staff #5 (Unit Manager RN) outlined the pain protocol as a nurse would assess for pain, attempt a non-pharmacological interventions first; if those are ineffective, establish the pain scale, administer appropriate medication based on the scale, and then reassess for effectiveness. Staff #5 confirmed that Resident #75's pain medication was not administered according to the established appropriate pain parameters. On 12/04/2025 at 9:31AM, in an interview with the Director of Nursing (DON) clarified that nurses are expected to adhere to the pain management parameters detailed in the physician's order. The DON was informed of the concern at this time.

Based on observation, staff interviews and record reviews, it was determined that the facility failed to ensure that it was free of medication error rates of five percent or greater. This was evident during observation of med pass on 2 of the 2 units in the facility during a recertification/complaint survey.The findings includeOn 12/08/25 at 8:20 AM an observation of med pass was conducted on the basement floor with Staff #15, a Registered Nurse (RN). Resident #90's two eye drops Cosopt ophthalmic solution and artificial eye drop were not given, Staff #15 stated that she could not find them and will call pharmacy to bring it stat. On 12/8/25 at 9:52 AM during another med pass observation for Resident #36 with staff #16 a certified medicine aide (CMA), the resident was ordered Visine ophthalmic and Systane ophthalmic eye drops for dry eyes, the CMA could not find the eye drops, she said the facility allows them to use the artificial tear drops as substitutes.Review of the physician's order for Resident #36 did not reveal an order to substitute any of the eye drops with the artificial tear drops. Staff #18 a registered nurse (RN) was standing by, she stated that both eye drops will be reordered and confirmed that both medications cannot be substituted with the artificial tear drops.On 12/8/25 at 12:15 PM the surveyor asked Staff #15 again about the eye drops for Resident #90, she stated that pharmacy would deliver it that day. That the eye drops were supposed to be reordered when it was noted to be running low. She confirmed that Resident #90 did not get their morning doses of eye medication.In an Interview on 12/8/25 at 9:30 AM, the director of nursing (DON) was asked the process for reordering medications. She stated that it was the responsibility of the assigned nurses to reorder medications when they observe them running low or call pharmacy to send it Stat.The DON and the administrator were made aware that both residents missed their morning eye drops and that staff were substituting medications without orders and that their med error rate was 13.33%. The DON stated that she will follow up.

Based on observation, staff interview and record reviews, it was determined that the facility failed to 1) appropriately store drugs for Resident #121 and, 2) label drugs and biologicals in accordance with currently accepted professional standards. This was evident for 2 of 2 nursing units observed during the recertification/complaint survey.The findings include1) On 12/02/25 at 1:08 PM Observation of a medicine cup in Resident #121's room with 4 pills were made including an inhaler labelled Symbicort 160 mcg/4.5 mcg, 2 puffs twice a day and an icy hot max pain relief lidocaine cream 2.7 oz bottle. The resident stated it was his Gabapentin and Tylenol and that the inhaler was from the hospital.On 12/02/25 at 1:16 PM Staff #3 a Certified medicine Aide (CMA) was asked about the medication at the bedside. She said the medications should not be left at the bedside and verified the surveyors' findings. In an Interview with the Director of Nursing (DON)/Administrator on 12/03/25 at 9:03 AM. They stated that there is a protocol for medications at the bedside and that Resident #121 can keep his icy hot pain medication, but no other medication. They were made aware that this was a concern at this time. 2) On 12/8/25 at 8:55AM review of the med cart on the basement floor with Staff #15 a Registered Nurse (RN) revealed a medication for Resident #54- Vit D3 25 mcg (1000 U) take one tab daily, it was not dated with an open date. Also Observed on the med cart on the A/B wing with Staff #3 a certified medicine Aide (CMA) was a medication for heartburn relief in a white medicine container labelled Famotidine 20mg tablet an inhouse stock, it was not dated with an open date.On the A/B wing med. room, was observed in the refrigeration on 12/8/25 at 10:18 AM a liquid medication in a dark brown bottle for Resident #60. It was labelled-Gabapentin 250mg/5ml, it was 1/3 full and was not dated with an open date.On 12/8/25 at 10:21 AM this medication was shown to Staff #17 a Licensed Practical Nurse (LPN) who confirmed that it was not dated. He was asked about the process for labelling multi-dose medications, and he said medications should be dated with an open date to indicate when they were opened.Review of resident #54's physician's order on 12/8/25 at 10:23 AM revealed an order written as Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth, one time a day for supplement. Further review of Resident #60's physician's order revealed an order written as Gabapentin Oral Solution 250 MG/5ML (Gabapentin) Give 6 ml by mouth three times a day for Neuropathy. This confirmed that both residents were actively taking these medications.On 12/8/25 at 10:30AM the Director of Nursing (DON) and the Nursing Home administrator (NHA) were made aware of the findings, they stated they will follow up.

Based on medical record review and interviews, it was determined that the facility failed to provide Dental services. This was evident for 3 (Resident #4, #12, and #8) of 4 residents reviewed for dental services during the recertification/complaint survey. The findings include: 1) During the investigative interview on 12/03/2025 at 9:17 AM with Resident #4, the resident stated my teeth are falling out, and I need dentures. Surveyors observed missing teeth on the top and bottom areas of the resident's mouth. A record review on 12/04/2025 at 8:25 AM noted that Resident #4 had a consult ordered on 10/3/2025 for: Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed. 2) During the investigative interview on 12/3/2025 at 8:54 AM, Resident #12 stated, I have been at this facility for a couple years, and I have not seen a dental hygienist or dentist. I am losing my teeth and would like dentures. A record review on 12/04/2025 at 8:35 AM noted that Resident #12 had a consult ordered on 11/29/2023 for: Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed. On 12/04/2025 at 8:57 AM, an interview was conducted with ADON who stated that when a resident complained of dental pain or discomfort the information is given to the Social Worker (SW) to place them on a list. The new admissions are also seen on the upcoming appointment list for Health Drive, who come to the facility quarterly, annually and as needed. An interview was conducted on 12/04/2025 at 10:45 AM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) regarding dental services at the facility. The NHA stated that residents are seen by Health Drive, a service provider that came to the facility to provide dental service to the residents. The NHA also stated that the list of residents to be seen are sent to Health Drive by the Social Worker and Health Drive will send a list of the residents back to the facility of the residents they will treat when they come to the facility. Surveyor requested a copy of the list of residents seen for the past 6 months. On 12/04/205 at 2:32 PM, The NHA provided a list of residents who were seen for dental care from 01/01/2025 to 12/04/2025 and Resident #4 and Resident #12 were not listed. On 12/5/2025 at 8:17 AM, the NHA provided the surveyor with a list of a Facility Census Audit for dental, eye, and audiology services provided for each resident in the facility from last visits to upcoming visits; Resident #4 and Resident #12 were not on the list. The NHA was made aware this was a concern, and the NHA acknowledged the concern and stated that the residents will be enrolled in the Health Drive program so that they can be put on the list to be consulted for dental services. 3) On 12/04/2025 at 3:14 PM, Resident #8's medical record revealed a Physician order dated 10/29/2025 for a Dental consultation for a broken tooth. On 12/04/2025 at 3:16 PM, in review of Health drive (Dental services used by the facility) list provided by the Administrator Resident #8 was not on the list as being seen or scheduled to be seen. On 12/05/2025 at 9:15 AM, during an interview with the Director of Nursing (DON) described the Dental consult process: Social Worker (SW) faxes a list to Health drive, which visits monthly for routine and as-needed consults. Nurses notify SW of new physician orders for Health drive. She verified Resident #8 was not on the health drive list and had not been seen, though the DON would have expected Resident #8 to have been seen if a dental consult physician order was placed for a broken tooth. On 12/05/2025 at 9:22 AM, during an interview with the Administrator explained that Residents must be enrolled to be seen by Health Drive. Resident #8 has not received services and requires an enrollment form (request for services form). The Administrator was notified of this concern at this time.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and/or a copy of an advance directive was in the medical record. This was evident for 2 (Resident #75 and Resident # 6) out of 3 residents reviewed for advanced directives during the recertification/complaint survey. The findings include: 1) On 12/03/2025 at 9:42 AM, a review of Resident #75's admission record revealed the resident was documented as his/her own representative. However, the medical record lacked evidence of an Advance Directive. On 12/04/2025 at 10:14 AM during an interview, the Social Worker stated she only informs Residents of their right to an advance directive, which is noted in their care plan. She clarified that the admission director is responsible for handling advance directives. On 12/04/2025 at 11:14 AM, review of the 11/03/2025 Social History assessment, Section C (Advance Directives) question 1, showed that none of the four options (Living Will, Durable Power of Attorney for Health Care, Behavior Health Advance Directive, and MOLST) were checked. Furthermore, there was no documentation of a discussion with Resident #75 regarding their right to formulate an advance directive. On 12/04/2025 at approximately 11:20 AM, further review of Resident #75's medical record revealed no evidence of a care plan for an advance directive. On 12/04/2025 at 12:29 PM, during an interview with the Admission's Director she claimed she only handles PASARR (Preadmission Screening and Resident Review) and the MOLST (Maryland Orders for Life-Sustaining Treatment) forms, not advance directives. On 12/04/2025 at 12:36 PM, the Administrator confirmed that there was no record of an advance directive for Resident #75 or evidence of documentation that a discussion occurred with Resident #75 regarding their right to formulate one. The Administrator was informed of the concern at this time. 2) During the record review for advance directive for Resident #6 on 12/3/2025 at 12:00, the Social Worker (SW) assessment note dated 11/17/2025 stated in Section C question 6- Advance Directive was uploaded under document tab. On 12/03/2025 at 12:15 PM, during the review of Resident #6's medical record, the surveyor could not locate a copy of an advance directive. During an interview with SW on 12/04/2025 at 10:14 AM, she/he stated that residents are informed of their right to an advance directive, which is noted in their care plan and that the admission Director handled the advance directives. On 12/04/2025 at 12:29 PM, an interview was conducted with the Admission's Director, who stated that she/he only handles PASARR (Preadmission Screening and Resident Review) and the MOLST (Maryland Orders for Life-Sustaining Treatment) forms, not advance directives, however, advance directive is discussed within the admissions process. The surveyor requested a copy of the advance directive that was documented as being uploaded in the document section of Resident #6's medical record. On 12/04/2025 at 12:36 PM, the Nursing Home Administrator (NHA) confirmed that there was no record of an advance directive for Resident #6. The NHA acknowledged that this was a concern.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to notify the Physician that ordered labs were not obtained. This was evident for 1 (Resident #75) of 41 residents reviewed during the recertification/complaint survey.The findings include: On 12/04/2025 at 8:24 AM, in review of Resident #75's medical record revealed a physician order dated 12/01/2025 for labs to be obtained of a CBC (Complete blood count) and a CMP (Comprehensive Metabolic Panel) in am for the date of 12/02/2025. On 12/04/2025 at 8:26 AM, in review of Resident #75's progress note, dated 12/2/2025 at 07:14 AM, revealed: Unable to obtain blood specimen after two trials. Lab work rescheduled for AM on 12/3/25. On 12/04/2025 at 8:28 AM, in review of the medical record for Resident #75 showed that lab orders for CBC and CMP, dated 12/03/2025, were cancelled. Documentation noted the labs were unable to be obtained, facility aware. However, there was no documented evidence that a Physician was notified of the inability to obtain the ordered labs on either 12/02/2025 or 12/03/2025. On 12/4/2025 at 09:12 in further review of Resident #75's medical record revealed a late entry progress note, dated 12/03/2025, the note stated: resident labs were unable to obtain obtained, Nurse Practitioner (NP) made aware, orders given to repeat labs. This entry, however, was made following surveyor intervention. On 12/04/2025 8:37 AM, in an interview with Staff #5 (Unit Manager) explained that labs are drawn routinely or when a patient's condition changes. If a lab cannot be obtained, the nurse is required to notify the physician and document this in the medical record. However, Staff #5 stated she failed to document any notification to the physician in this instance. On 12/04/2025 at 9:31 AM, in an interview with the Director of Nursing (DON) stated that if resident labs could not be obtained, the nurse was expected to notify the Physician and document this in the medical record. The DON was informed of the concern regarding the notification process for labs at this time.

Based on medical record review and staff interviews it was determined the facility failed to implement recommended wound care treatments based on wound consults. This was evident for 1 (Resident #8) of 1 resident reviewed for pressure ulcer/injury during the recertification/complaint survey. The findings include:On 12/05/2025 at approximately 1:05 PM, review of Resident #8's November Treatment administration record (TAR) revealed physician orders dated 9/23/2025. Treatments included daily, as needed changes for sacral, right/left hip, and right ischium wounds. The sacral wound required cleansing with Dakin's solution, patting dry, applying Medihoney and calcium alginate, and covering with ABD pads then bordered gauze. Right/Left Hip wounds needed cleansing with Dakin's solution, patting dry, applying calcium alginate, and covering with ABD pads then bordered gauze. The right ischium wound required cleansing with Dakin's solution 0.125%, applying Medihoney and calcium alginate, and covering with ABD pads then bordered gauze.On 12/05/2025 at approximately 1:15 PM, review of Resident #8's November Treatment Administration record (TAR) revealed a Physician order dated 9/25/2025 for the Left Lateral ankle wound with Dakins Solution and apply Calcium Alginate with Medihoney cover with bordered gauze dressing every day and as needed.On 12/05/2025 at approximately 1:20 PM, continued review of Resident #8's medical record revealed wound assessment reports for the following dates of 09/24/2025, 10/01/2025, 10/09/2025, 10/15/2025, 10/22/2025, 10/29/2025, 11/05/2025, and 11/12/2025. These reports, signed by a wound Nurse Practitioner, consistently documented a Stage 4 pressure injury on the right hip and recommended the following treatment: daily cleansing, application of Dakins moistened fluffed gauze and Santyl, secured with bordered gauze and an ABD pad. However, the treatment administration records for September, October, and November indicated that Resident #8 continued to receive the original order from 09/23/2025, which included: Right/Left Hip wounds needed cleansing with Dakin's solution, patting dry, applying calcium alginate, and covering with ABD pads then bordered gauze.During an interview on 12/05/2025 at 1:48 PM, the Director of Nursing (DON) described the facility's wound care process. A Nurse Practitioner assesses residents with wounds and makes recommendations for treatment changes, which the wound nurse is then responsible for implementing and updating treatment orders. The DON confirmed that the recommended change in wound treatment for Resident #8's right hip wound was never implemented between 09/24/2025 and 11/12/2025.On 12/05/2025 at 1:55 PM, further review of Resident #8 medical records revealed a physician order dated 11/13/2025 to schedule the next appointment with MedStar Wound Healing.On 12/05/2025 at approximately 2:05 PM, further review of Resident #8's November Treatment Administration Record (TAR) showed an active physician's order from 11/14/2025 to 11/18/2025. This order was to be completed daily, and as needed wound cleansing with Dakin's solution, application of Aquacel Silver (including gentle packing for all wounds), and covering with gauze and foam border dressings or ABD pads secured with tape. The TAR also contained September wound treatment orders, indicating the resident was receiving two different wound treatments during that five-day period. On 12/08/2025 at 8:56 AM, the DON provided the surveyor with Medstar Wound Clinic documents from 11/13/2025 and 11/25/2025. These recommended daily wound care for all wounds: cleansing with Dakin's, applying Aquacel Silver, gently packing into sacral wounds, and covering with gauze/foam/ABD pads. The DON stated that if a Resident has two different wound providers, the facility should follow the outside clinic's recommendations. The facility's Director of Nursing (DON) confirmed a failure to implement the recommended wound care for Resident #8. The resident received the proper treatment for only five days in November, which resulted in the continuation of treatments that had been ongoing since September. The DON was notified of this concern.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident was provided with splints based on the recommendations of the rehabilitation staff. This was evident for 1 (Resident #10) of 3 Residents reviewed for position and mobility during the recertification/complaint survey.The findings include:According to the Cleveland Clinic contractures affect one's skin, muscle, joints, tendons or other soft tissue. It happens when scarring or fibrosis makes the tissues tighten and stiffen. Without intervention, contractures can permanently reduce range of motion.According to the Cleveland Clinic, a splint, is a medical device that stabilizes a part of your body and holds it in place. On 12/08/2025 at 8:34 AM, during an observation and interview, Resident #10 reported being unable to use or straighten their contracted left hand.On 12/08/2025 at 10:02 AM, the Rehab Director confirmed Resident #10 received therapy from 08/25/2025 to 09/23/2025 for a left-hand contracture, with a recommendation for a resting hand splint and left elbow extension splint. He stated Therapy is responsible for training the Geriatric Nursing Assistants on application and reviewing with Unit Managers. The Therapy Manager verified Resident #10 had no splints available and they would need to be ordered. On 12/08/2025 at approximately 10:30 AM in review of and Occupational Therapy note provided to surveyor by the Rehab Director with a certification period from 08/25/2025 through 09/23/2025 revealed a goal of Resident #10 would wear a resting hand splint on the left hand and left wrist, and a left elbow extension splint for up to 2 hours with minimal signs or symptoms of redness, swelling, discomfort, or pain. On 12/08/2025 at 10:58 AM, an interview with the Director of Nursing (DON) explained the process for a Resident for splints would come from a recommendation from therapy that is communicated in the morning clinical meeting. Therapy would train the Geriatric Nursing assistants (GNA) on how to apply the splints and when to apply. This would be documented in the task (a reference for GNA's to refer to for resident care) for the GNA to apply. On 12/08/2025 at 11:00 AM, in review of Resident #10's medical record specifically the task section, no instructions for splint application by the GNAs for Resident #10 were found. On 12/08/2025 at 11:24 AM, the Director of Rehab returned and stated the Splint for Resident #10 was ordered and received on 12/05/2025. Therapy re-evaluated Resident #10 and provided the Surveyor with an evaluation dated 12/08/2025 that indicated a focus on proper application, wearing schedule (left hand splint up to 4 hours, left elbow splint up to 2 hours), and caregiver education. The Rehab Director verified this was completed after surveyor intervention.On 12/10/2025 at approximately 9:00 AM, the Director of Nursing (DON) provided the surveyor with a Task list report for Resident #10, that indicated Resident #10 was to wear a resting left-hand splint and left elbow extension splint with instructions. The DON verified this was only done after surveyor intervention. The DON was notified of the concern at this time.

Based on review of medical record and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #5) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include: On 12/4/2025 at 8:44 AM, The surveyor received copies of the Medication Regimen Review (MRR) for the past 6 months from the Director of Nursing for Resident #5. During the review of the MRR documents on 12/4/2025 at 08:45 AM, the MRR dated 10/8/2025 had the following recommendation: Please consider monitoring a TSH level on the next convenient lab day to monitor this change in therapy. The copy was not signed or dated. A review of Resident #5's medical record on 12/04/2025 at 08:48 AM, noted that there was no order documented for a TSH level from 10/8/2025 to current date of 12/4/2025. During an interview with the Director of Nursing (DON) that took place on 12/04/2025 at 9:04 AM, the DON stated that the process for processing pharmacy recommendations is that the recommendation is sent to the DON and the In - house Nurse Practitioner (NP) via email on the same day that the recommendation were made. The NP reviews it as soon as possible and then lets the unit manager or the nurse know of the recommendation; and that is why the copy provided to the surveyor is not dated or signed. Surveyor requested documentation that the recommendation from 10/8/2025 for Resident #5 was completed.On 12/04/2025 at 11:46 AM, the Nursing Home Administrator (NHA) stated that there was no documentation that the recommendation was completed and that the facility missed the order. The surveyor informed the NHA that this was a concern, and the NHA acknowledged the concern and stated that the facility will follow up on the recommendation.

Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze residents at risk for illicit drug use/overdoses. This was evident during review of the facility's QAPI process after 11 residents (#56, #8, #4, #45, #31, #11, #33, #32, #7, #36 and #37) were reported by the facility to the state agency for suspected drug overdoses in the past 13 months and has the potential to affect all residents with Substance Use Disorders. As a result of this deficient practice, an Immediate Jeopardy was identified on 7/2/2025 at 10:00 AM and an IJ summary tool was provided to the facility. The removal plan was accepted by OHCQ on 7/2/25 at 9:20 PM after 5 initial plans were submitted to the surveyors at 3:40 PM, 4:45 PM, 7:45 PM, 7:48 PM and 8:45 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of F.The Immediate Jeopardy was removed on 7/7/25 at 10:45 AM after on-site confirmation of the completion of the facility's plan of removal. The findings include:The Centers for Medicare and Medicaid Services (CMS), defines Quality Assurance (QA) and Performance Improvement (PI) as a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem-solving. Narcan is a medication that rapidly reverses an opioid overdose. A list of residents provided by the Director of Nursing (DON) and reviewed on 6/27/25 at 10:32 AM revealed that 94 out of 111 residents who resided in the facility had diagnoses which included but were not limited to Substance Use Disorder (SUD). Between 5/23/24 and 6/2/25 the facility reported 11 incidents to the state agency involving suspected resident drug overdoses: 1. Resident #56 overdosed on 5/23/24, passed away2. Resident #8 overdosed on 9/4/243. Resident #4 overdosed on 10/2/244. Resident #45 overdosed on 12/27/245. Resident #31 overdosed on 12/31/246. Resident #11 overdosed on 2/3/257. Resident #33 overdosed on 3/3/25 8. Resident #32 overdosed on 4/10/259. Resident #7 overdosed on 4/15/25, passed away10. Resident #36 overdosed on 5/23/2511. Resident #37 overdosed on 6/2/25, passed away Review of Resident #56's record on 6/30/25 at 8:00 AM revealed the resident had a prior overdose on 2/23/24. During an interview on 6/27/25 at 12:10 PM the Director of Nursing identified that the SUD program was overseen by an outside contracted service provider that provided psychiatric services in the facility. 1 Nurse Practitioner (NP), Staff #36, oversaw the SUD program and another NP provided other psychiatric services. The SUD program NP, Staff #36, was interviewed on 7/1/25. She indicated that she had worked in this facility since April 2025. She revealed that she did not develop SUD care plans nor attend the care plan meetings for the residents in the SUD program. She also indicated that a resident who has used and overdosed is at high risk, and she would expect a change in the plan of care to find out the reason, whether it's a personal event, pain or a need for medication changes. When asked how staff would know how to assist the residents if they voiced or expressed symptoms such as cravings, she indicated, that would be up to the nursing staff. When asked if she attended QAPI meetings she indicated she had in the past, in other facilities but not in this facility. Review of QAPI meeting records for the past year revealed the facility included Quality Measures for: Behavior Affecting Others - with the Action Plan: Continue to partner with [Contracted psychiatric services provider] and insert appropriate interventions as needed; and, Depressive Symptoms - with the Action Plan: Continue to partner with [Contracted psychiatric services provider] and insert appropriate interventions as needed. Facility has a high admission rate of residents admitted with depression diagnoses due to prior history and/or possible substance abuse. However, the QAPI process did not include measures to track and analyze illicit drug use and/or overdoses in the facility. In an interview on 7/1/25 11:02 AM the Administrator and DON were asked if the facility developed and conducted performance improvement activities for drug overdoses. The Administrator indicated, no, that they did not determine that there was a break in their system. She indicated that they investigated all the overdoses and determined during their investigations that processes were followed, that some overdoses were out of their control even though the facility's processes were followed. She indicated that the facility would QAPI if they determined the overdoses were a break in their system. However, there was no evidence that the overdose incidents were systemically tracked, reviewed or analyzed in the aggregate to identify trends or systemic issues. The provision of the plan to remove the Immediate Jeopardy immediacy had a completion date of 7/7/2025 and included the following:QAPI Governing body to be educated on monitoring and tracking/trending Narcan administration by Regional clinical team by 7/3/25.SUD NP to attend monthly QAPI meetings.DON to track Narcan administration and report findings during QAPI.Ad hoc QAPI meeting conducted to review processes for monitoring of: 1) Residents at risk for substance use disorder; 2) Review updated QAPI process in relation to reporting and tracking Narcan administration; 3) Staff Development Coordinator to educate all nursing staff on Substance Use Disorder policy and Behavior Management.Identification of Others: The DON to complete an audit of all residents that received Narcan within the last 12 months to determine the appropriateness of treatment plan.Education: Facility Governing Body to be educated by Regional clinical leadership on monitoring and tracking Narcan administration by 7/3/25. System Change: 1) The SUD NP to attend weekly RISK meeting to discuss substance use disorder residents, 2) SUD NP to attend the monthly QAPI meeting and present trends related to the Substance Use Disorder program. 3) DON to audit the chart of the resident who received Narcan to ensure the facility is following the SUD policy, program and appropriateness of the comprehensive care plan - Finding will be presented during the monthly QAPI meeting.Monitoring: The DON and Executive Director to validate tracking/monitoring of residents that received Narcan administration during QAPI meeting. 1) SUDs NP to attend monthly QAPI. 2) SUDs NP to present information regarding the SUDs program.Audits to be completed weekly x 4, the monthly x 3 Audits to be reviewed monthly at QAPI committee. Results of the audits will be submitted to the QAPI committee monthly for 3 months, the Committee will determine the need for further audits and/or action plans. Beginning 7/2/25 Ad Hoc then monthly for 3 months. Facility to be compliant by 7/7/25.

Based on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to effectively communicate with the Substance Abuse Disorder (SUD) team, the physician and direct care staff regarding residents in order to develop and maintain a comprehensive plan of care to address residents substance abuse disorders and treatment plans. This was evident for 1 of 11 residents (Resident #56) reviewed during the complaint survey.As a result of this deficient practice, an Immediate Jeopardy was identified on [DATE] at 12:15 PM and an IJ summary tool was provided to the facility. The removal plan was accepted by OHCQ on [DATE] at 9:20 PM after 5 initial plans were submitted to the surveyors at 3:40 PM, 4:45 PM, 7:45 PM, 7:48 PM and 8:45 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The Immediate Jeopardy was removed on [DATE] at 10:45 AM after on-site confirmation of the completion of the facility's plan of removal.The findings include:Substance Use Disorder is a treatable mental disorder that affects a person's brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications.Suboxone: is part of a family of medications used in Medication Assisted Treatment (MAT).Medication Assisted Treatment (MAT): is an addiction recovery treatment plan that includes medications designed to treat opioid use disorders.Narcan: A medication given to help reverse an opioid overdose.A list of residents provided by the Director of Nursing (DON) and reviewed on [DATE] at 10:32 AM revealed that 94 out of 111 residents who resided in the facility had diagnoses which included but were not limited to Substance Use Disorder (SUD). On [DATE] at 8 AM, the surveyor reviewed Resident #56's medical record which revealed a change in condition report on [DATE], that the resident was observed with decreased responsiveness with limp body, decreased respiration and decreased heart rate. The resident was given 2 doses of Narcan and transported to the hospital. The resident returned to the facility on [DATE]. Further, review of the medical record failed to identify the overdose. The resident was seen by the SUD staff on [DATE] and the assessment failed to identify the overdose on [DATE] and documented that the resident admitted to occasional craving and thoughts, however, denied desire to use at this time.A review of the SUD staff assessment dated [DATE] revealed that the resident disclosed an incident where he/she unknowingly ingested heroin given to him/her by someone else, leading to an overdose that required Narcan administration. The resident mentioned being on Suboxone and stated that no adjustments were needed. However, he/she reported experiencing cravings.Further, a review of the SUD assessments revealed:1. That on [DATE], Resident #56 reported experiencing cravings.2. On [DATE], the client disclosed having last used illicit drugs yesterday, stating he/she liked using drugs even if on Suboxone.3. On [DATE] progress notes revealed that Resident #56 last used 2 days ago.4. On [DATE] and [DATE] Resident # 56 admitted occasional craving and thoughts of using drugs.5. On [DATE] Resident #56 disclosed to SUD staff having used drugs a week ago. All of the above information on the SUD assessments was not communicated to the facility staff.A review of the electronic medical record revealed that that Resident #56 refused his/her suboxone from [DATE] - [DATE]. On [DATE] Resident #56 was observed slumping down in his wheelchair in the hallway. Prior to finding the resident slumped down, the resident was self-propelling in his wheelchair. The resident was assisted into the bed. The resident was assessed as follows: Slow shallow breathing and faint pulse. Narcan was given x 2, due to resident drug history without positive results. CPR was initiated, 911 called and one shock by AED was given. The Resident was pronounced dead on [DATE] at 0446 in the facility.On [DATE] @ 1:15 PM an interview with LPN #33 stated that he did not inform the physician or the SUD team of Resident #56's refusal of suboxone. LPN #33 also said that he does not communicate with the SUD team, only the physician.On [DATE] @ 9:17 AM an interview with the Unit Manager #6 revealed that if a resident refuses medications that the Physician is made aware and a note is written in the resident's medical record. The Unit Manager #6 stated that he/she did not communicate with the SUD team or physician. The Unit Manager confirmed that she/he attends the care plan meeting, but the SUD staff does not.The SUD program NP, Staff #36, was interviewed on [DATE]. She indicated that she had worked in the facility since [DATE]. She revealed that she does not develop SUD care plans nor attend the care plan meetings for the residents in the SUD program. She also indicated that a resident who has used and overdosed is at high risk and she would expect a change in the care plan to find out the reason, whether it's a personal event, pain or a need for medication changes.When asked how staff would know how to assist the residents if they are voicing or expressing symptoms of cravings, she indicated, that would be up to the nursing staff. On [DATE] at 9:43 AM an interview with SUD Program NP Staff #36 stated we are working on improving communication with nursing staff by placing a binder at the nurse's station to communicate the residents' SUD needs. The SUD team needs to be aware as with the physician when the resident is refusing SUD medications to find out the reason why and educate the resident of risk. The SUD does not go to the care plan meetings or create care plans for the residents. The provision of the plan to remove the Immediate Jeopardy immediacy had a completion date of [DATE] and included the following:Brighter Days Regional team will educate all facility nursing staff on their substance use disorder program. Brighter Days Regional team to educate nursing staff on notifying providers of medication refusal related to Medication Assisted Treatment (MAT), and providers to notify facility staff of changes with substance use disorder residents by [DATE].Brighter Days to educate license nurses on maintaining a comprehensive plan of care to address residents' substance abuse disorders and treatment plans by [DATE].Nursing staff to audit the care plans of all residents admitted in the last 30-days with substance use disorder to determine an appropriate treatment plan with substance use disorder.Nursing staff to audit the medication administration record of all residents with substance abuse disorder admitted in the last 30-days to ensure all MAT refusals are reported to the providers.Brighter Day's NP to attend care plan meetings for substance use disorder residents. Ad Hoc QAPI meeting conducted to review processes for monitoring of1. Residents at risk for substance use disorder.2. Review process for nursing staff on communicating changes to Brighter Days and facility providers for residents with substance use disorder.3. Review process for Brighter Days communicating changes to facility nursing staff.4. Staff Development Coordinator (SDC) to educate all nursing staff on Substance Use Disorder policy and Behavior Management by [DATE].5. SDC to educate licensed nurses on maintaining a comprehensive plan of care to address residents' substance abuse disorders and treatment plans by [DATE]. Identification of Others: All residents have the potential to be affected by this deficient practice1. An audit of the medication administration record of all current residents with substance use disorder will be reviewed to ensure medication compliance with MAT.2. An audit of all current residents' (admitted in the last 30 days) care plan with history of substance abuse reviewed for risk of overdose.3. An audit of the last 30 days of SUD NP's notes of current residents with substance use disorder regarding communication to facility staff and facility providers regarding resident changes. Education:1. Facility nursing staff and Brighter Days providers will be educated by the Regional clinical team on notifying providers of medication refusals related to MAT, and providers to notify facility staff of changes with the substance use disorder residents by [DATE].2. SDC to educate license nurses on maintaining a comprehensive plan of care to address residents' substance abuse disorders and treatment plans by [DATE].3. SDC to educate all nursing staff on Substance Use Disorder policy and Behavior Management by [DATE]. System Change:1. Brighter Days to attend weekly RISK meeting to discuss substance use disorder residents.2. ADON and/or Unit Manager to communicate changes and document communication to Brighter Days providers.3. Brighter Days providers to communicate changes to ADON and/or Unit Manager.4. Facility nursing staff to notify providers of residents' refusals of MAT.5. In the daily clinical meeting, ADON and/or Unit Manager will communicate changes to SUD NP. All residents discussed will be logged the concern list.6. SDC to educate license nurses on maintaining a comprehensive plan of care to address residents' substance abuse disorders and treatment plans by [DATE].7. SDC to educate all nursing staff on Substance Use Disorder policy and Behavior Management by [DATE]. Monitoring:Director of Nursing and Executive Director to audit residents' PCC documentation daily Monday - Friday during clinical risk meeting to assure:1. Providers and Brighter Days providers were notified of MAT refusals.2. DON to track and monitor residents who received Narcan.3. Facility staff to review treatment and appropriateness of the comprehensive care plan for residents with a substance use disorder. Audits to be completed weekly x 4, The monthly x 3 Audits to be reviewed monthly at Quality Assurance Performance Improvement CommitteeResults of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for 3 months, the Committee will determine the need for further audits and/or action plans. Beginning [DATE] ADHOC then monthly for 3 months. Facility to be compliant by [DATE].

Based on record review and staff interview; it was determined that the facility failed to protect a resident (Resident #43) from misappropriation of personal funds by failing to provide the resident with way to secure the resident's valuables from theft. This was evident for 1 of 67 residents reviewed during the complaint survey. The findings include: The surveyor reviewed a facility reported incident (MD00217424) sent to the State of Maryland ' s Office of Health Care Quality alleging that Resident #43's money was stolen from his/her room. Medical record review for Resident #43 on 6/24/25 at 1:28 pm revealed the facility documented a change on condition which reported that the resident alleged that his/her money ($110.00) was stolen from the resident's room. On 6/24/25 at 1:40pm, the surveyor reviewed the facility investigation of the reported incident. The investigation contained a concern form dated 4/28/25 which reported that the resident was given a lock box to secure his/her valuables. On 6/25/25 at 8:30am, the surveyor interviewed Resident #43 in his/her room. The resident stated that he/she did not have a lock box at the time of the interview. The resident stated that his/her valuables were in a drawer unsecured. The resident also stated that he/she was transferred to his/her present room on 6/20/25. Interview with the Director of Nursing (DON) on 9:40am confirmed that the resident was transferred from room [ROOM NUMBER]C to 305C on 6/20/25. The surveyor informed the DON that the facility failed to provide the resident with a locked box to secure his/her valuables. The DON confirmed that the locked box was not the new room.

Based on medical record review and interview, it was determined the facility staff 1) failed to provide written notice to the resident and resident representative of the transfer to a local hospital for evaluation on 12/17/24. (Resident # 38). This was evident in 1 of 67 residents reviewed during a complaint survey; and 2) failed to ensure that hospital transfers were documented in the residents' medical records and that appropriate information was communicated to the receiving health care institution. This was evident for 1 (Resident #14) of 67 residents reviewed. Findings include:1) On 6/25/25 at 12:00pm, the surveyor reviewed complaint MD00212839 that was sent to the State of Maryland's Department of Health Care Quality alleging that the facility failed to recognize Resident #38's change in status resulting in the resident's family calling for emergency assistance to have the resident transferred to the local hospital on [DATE]. Review of Resident #38's medical records on 6/25/25 at 12:29pm revealed that the resident was treated for abnormal laboratory results by his/her primary provider on 12/17/24. Further review of the resident's medical record revealed that nursing staff documented that the resident was hospitalized as of 12/18/24. There was no evidence that the facility documented the resident's change of condition nor transfer of the resident for treatment prior to the hospitalization documentation.During an interview with the Director of Nursing (DON) on 6/25/25 at 1:36pm confirmed that that nursing staff failed to create a transfer for treatment documentation prior to the resident being transferred to the local hospital. The DON also confirmed that the facility was unable to confirm that this transfer document was given to the resident or the resident representative prior to the resident being transferred to the local hospital. 2) Resident #14's medical record was reviewed on 6/30/25 at 8:24 AM. S/he was admitted to the facility on [DATE]. The census record indicated that the resident was discharged 2 days later on 1/30/24. A Nursing progress note dated 1/30/24 16:03 (4:03 PM) Stated Resident called 911. Upon request resident transported to emergency room. Further review of the record failed to reveal the location of the transfer, the reason for the transfer, that the required information was provided to the receiving health care institution including but not limited to advance directive information, diagnoses and allergies, medications, most relevant labs other diagnostic tests, all special instructions and/or precautions for ongoing care, and care plan goals; there was no evidence that the resident was provided with a written discharge notice nor the facility's bed hold and return notice. There was no documentation in the record regarding the resident's orientation or that the physician was notified. On 6/30/25 at 9:50 AM the DON (Director of Nursing) was made aware of the above concerns and asked to provide all additional documentation pertaining to the residents hospital transfer on 1/30/24 including but not limited to change in condition, assessment and hospital transfer. He returned at 10:21 AM on 6/30/25 and confirmed that the only documentation related to Resident #14's hospital transfer was the nurses note which indicated the resident called 911. He indicated he was unable to locate any additional documentation. These findings were reviewed with the Administrator and Director of Nursing on 7/2/25 at 1:15 PM.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to notify the attending physician when the resident was refusing their medications. This was evident during the review of 1 of 3 residents administered Narcan (Resident #11) The findings include: The medical record for Resident #11 was reviewed on 6/23/25 at 10:51 AM related to a facility reported incident where Resident #11 was administered Narcan secondary to a suspected overdose occurring on 2/3/25. Further review at this time of Resident #11's medical record revealed admission to the facility for a minimal 6-week course of intravenous antibiotics for septic wounds on the leg and abdomen from suspected drug use and related endocarditis (inflammation of the heart due to an infection). Resident #11 was ordered Suboxone as part of his/her substance use disorder treatment. According to his/her medication administration record (MAR), Resident #11 refused 9 doses for the month of January and 5 of 8 doses for February 2025. Surveyor interviewed physician staff #35 on 6/25/24 at 10:12 AM regarding a note from 1/31/25 that referred to Resident #11 appearing high. She was asked about interventions related to this and she stated that that is why [resident] is on suboxone and followed by mental health. This surveyor asked who would have been responsible for letting mental health know that there was a concern that Resident #11 had an incident where s/he could have relapsed and she stated that it would have been her or the nursing staff. Concurrent review of the record with Staff #35 revealed there was no report to mental health or a meeting with any other discipline than her after this occurrence prior to the overdose incident. She was also asked if she had been notified of the numerous refusals of the Suboxone in January and for February 2025 and she reported no. The concern about the notification was reviewed with the current DON and NHA throughout the survey and again on 6/27/25.

Based on observation, interviews and medical record review, it was determined that the facility failed to assess residents for the ability to self administer medication. This was evident during random observations when medications were found at the bedside of 2 residents (Resident #61 and #62). The findings include: During the tour of the 'C' unit of the facility on 6/25/25 at 8:15 AM, this surveyor and another surveyor completing tour observed a medication cup on a bedside table full of pills. There were no residents observed or staff from the doorway. This surveyor knocked and entered the multiple person room. There were 2 people, an individual in the 'b' bed was awake, 'c' bed asleep and the 'a' bed resident sounded to be in the bathroom. The medication cup of pills was at the 'a' bed. There were 7 pills in the cup, 5 white, 1 pink and 1 brown. This surveyor asked the other surveyor to please go get a nurse to assist. LPN #15 arrived at the room and was asked if she passed the medication or who did. She picked up the medication and stated it was not her. At this time Resident # 61 proceeded out of the bathroom and too was asked about the medications. S/he stated that s/he told the nurse s/he had to go to the bathroom, so the nurse left the medication there for him/her. Resident #61 then took the medication from LPN #15 and swallowed all the pills with the water that was also on the bedside table. This surveyor and the other surveyor proceeded up the hall when another resident with pills at the bedside were observed at 8:25 AM. This surveyor asked Resident #62 about the pills on his/her bedside. S/he stated that s/he got distracted working on the computer but will take it now, there were 6 pills in that medication cup. This surveyor then interviewed LPN #14. She was asked about her process for passing medications. She stated that she gives it to the residents and watches them and that there were no narcotics left with either of the identified residents whose pills were reportedly left at the bedside. The records of both individuals were reviewed on 6/25/25 at 8:30 AM. Both residents were recently assessed with a current brief interview of mental ( BIMS) status of 15, meaning that they were cognitively intact and were documented as making their own medical decisions. However, there was no current assessment or evaluation in the medical record that determined their ability to self administer medication without the supervision of medical nursing staff. This was reviewed with the current facility NHA and DON on 6/25/25 and again on 6/27/25.