Every finding on record at Calvert County Nursing CTR.

Based on medical observations and staff interviews, it was determined the facility staff failed to provide nursing care within the standards of practice. This was evident for 4 (Residents #78, # 43, #83, and #15) out of 6 residents reviewed during the recertification and complaint survey process.The findings include: The administration of supplemental oxygen and prescribed nebulizer treatments to a resident, as ordered by a physician, to maintain adequate oxygen saturation and support respiratory function. Equipment, including oxygen tubing and humidifier bottles, is expected to be clean, dated, and labeled. Nebulizer masks and tubing are expected to be clean, dated, labeled, and stored in a clean plastic bag when not in use.On 03/22/2026, during Southern Shore unit rounds, surveyor observations revealed multiple unlabeled respiratory supplies as follows: at 7:50 AM, Resident #78 in bed with oxygen tubing in place; humidifier bottle empty and unlabeled; at 7:55 AM, oxygen tubing and nebulizer tubing on Resident #43's nightstand, unlabeled; at 8:10 AM, Resident #83 in bed with oxygen tubing in place; humidifier bottle present and unlabeled; and at 8:27 AM, Resident #15 with nebulizer mask and tubing on floor at bedside, unlabeled. On 03/22/2026 at 8:40 AM interview with Licensed Practical Nurse (LPN) #8 revealed oxygen tubing should be changed weekly and dated, masks should be dated and stored in a plastic bag when not in use. On 03/23/2026, during unit rounds on the Southern Unit, surveyor observations revealed the following: at 7:02 AM, Resident #83's nebulizer mask and tubing were observed on the nightstand without a label. At 7:05 AM, Resident #78 had oxygen tubing and a humidifier bottle at bedside; the bottle contained no water and was unlabeled. At 7:32 AM, Resident #43 had a nebulizer mask hanging on a gallon water bottle on the nightstand; no oxygen sign was observed at the resident's door. On 03/23/2026 at 7:40 AM interview with LPN #8, confirmed oxygen tubing should be changed weekly and dated; masks should be dated and stored in a plastic bag when not in use. The LPN further stated an oxygen sign should be present at the resident's door. Following surveyor intervention, LPN #8 placed an oxygen sign on the resident's door. On 03/23/2026 at 8:00 AM during unit rounds on the Southern Unit with Registered Nurse (RN)#9, surveyor observation revealed Resident #83 in bed receiving oxygen; oxygen tubing and humidifier bottle were unlabeled. Nebulizer tubing and mask were observed on the nightstand, unlabeled and not stored in a plastic bag. On 03/23/2026 at 8:06 AM, interview with RN #9 revealed that oxygen tubing and humidifier bottles should be labeled, and nebulizer masks and tubing should be stored in a plastic bag when not in use. He further confirmed that no labels were present for Resident #83. With the surveyor's intervention, RN #9 replaced and labeled the oxygen tubing, nebulizer tubing, and mask.

Based on record reviews and interviews, it was determined that the facility failed to ensure 1) Residents' immunization status was verified and 2) current vaccinations were offered. This was found to be evident for 4 (Resident #30, #45, #2, and #49) out of 5 Residents reviewed for infection control during the recertification and complaint survey. The findings include: Tuberculosis (TB) is a contagious, airborne bacterial infection primarily caused by Mycobacterium tuberculosis, which usually attacks the lungs but can affect other body parts like the brain or spine. It is preventable and curable yet remains a leading cause of death worldwide.According to Centers for Disease and Prevention (CDC) nursing home residents must undergo tuberculosis (TB) screening upon admission to identify latent or active infection, typically using a two-step tuberculin skin test (TST/Mantoux) or a single IGRA blood test. A two-step test is generally required, with the second step performed 1-3 weeks after the first. Influenza (the flu) is a contagious viral respiratory infection causing sudden fever, muscle aches, sore throat, and severe fatigue, lasting from a few days to two weeks. It spreads primarily via droplets from coughs/sneezes, often treated with rest, fluids, and antiviral drugs. Complications can include pneumonia and, in severe cases, death.Pneumococcal disease is a serious bacterial infection caused by Streptococcus pneumoniae, leading to illnesses like pneumonia, meningitis, and sepsis. It is highly contagious, spreading through respiratory droplets. Vaccination is the best prevention, particularly for young children, adults 65+, and those with high-risk health conditions.Severe acute respiratory syndrome (SARS) is a contagious illness caused by a coronavirus disease (COVID). It's a disease that affects the lungs and airways, also called a respiratory illness.Nursing homes must offer Influenza, Pneumococcal, and SARS/COVID vaccinations to all residents, reinforcing their importance for infection control. Facilities are required to conduct active surveillance, including daily symptom checks, and implement measures like masking, testing, and antiviral treatments during outbreaks to manage respiratory virus transmission.During a review of Resident immunization records conducted on 03/26/26 at 9:21 AM, it was determined that Residents #30, #45, #2 medical records did not show their immunization status for TB, Influenza, SARS/COVID, and Pneumococcal. During a review of Resident #49's medical records conducted on 03/26/2026 at 9:38 AM, it was determined that the Resident received TB testing on 2/05/25 and 2/12/25 with education. However, there was no record of the immunization status for SARS/COVID, Pneumococcal, and Influenza. During an interview conducted on 03/26/2026 at 10:43 AM, the Infection Control Preventionist reported that she did not obtain the immunization status of Residents nor did she offer vaccines. She stated that the MDS Coordinator did that because she did not have time to commit to her Infection Control Preventionist role due to her fulltime role as the unit manager on the Western [NAME] Nursing Unit. ImmuNet is Maryland's secure, confidential, and HIPAA-compliant Immunization Information System (IIS). It is a web-based database used by healthcare providers, schools, and public health programs to store, track, and manage vaccination records for both children and adults across the state. It helps prevent over- or under-vaccination. During an interview conducted on 03/26/2026 at 10:53 AM, the MDS Coordinator advised that she viewed the immunization status of a resident on ImmuNet when she completed her assessment. However, she did not input the immunization status in the Resident's medical records. During an interview conducted on 03/26/26 at 11:00 AM, the Director of Nursing (DON) acknowledged that the Infection Control Preventionist did not have time to dedicate to Infection Control and as a result certain requirements for Infection Control were not currently getting done. He further explained that his goal was to put someone in the role of the Infection Control Preventionist that would be dedicated to Infection Control.

Based on record reviews and interviews it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) received at least 12 hours of in-service training annually. This was found to be evident for 5 (GNA #18. #19, #20, #21 & #22) out of 5 GNA's reviewed for training. The findings include:During an interview with the Nursing Home Administrator (NHA) on 03/25/2026 at 9:13 AM she reported the Director of Nursing (DON) handles training for staff.During an interview with the Director of Nursing on 3/25/2026 at 9:46 AM he reported education is completed throughout the year for GNA's via in-services and educational sheets. He reported the GNA's should be receiving 12 hours of mandatory training yearly. During a review of the training records for GNA's #18, #19, #20, #21 and #22 on 3/25/2026 at 11:45 AM it was discovered the records provided by the staffing manager were competency checkoff sheets and tests that had been completed by the GNA's. There was no documentation confirming the GNA's had 12-hours of annual training.During an interview with the DON on 3/26/2026 at 10:12 AM he advised he had just started employment with the facility three weeks ago and reported they have been unable to locate any documentation confirming the GNA's had completed their required 12-hour training so he was unable to confirm that the training requirement had been met for GNA #18, #19, #20, #21 and #22.

Based on interview and record review, it was determined that the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee consisted of the minimum required members. This deficient practice had the potential to affect all residents. This was identified during the QAPI/QAA facility task during the annual/complaint survey.The findings include:On 03/26/2026 at 10:11 AM, the Administrator provided the QAPI (Quality Assurance and Performance Improvement) binder for review. The Administrator reported that there were impacts to QAPI meetings due to unfilled clinical staff positions. On 03/26/2026 at approximately 11:00 AM, this surveyor conducted a record review of the QAPI binder, including QAA committee meeting attendance and signatures. Record review revealed that for the QAPI meeting dated 10/23/2025, there was no documented attendance or signature for the Administrator or Infection Preventionist. For the meeting dated 11/17/2025, there was no documented attendance or signature for the Infection Preventionist. For the meeting dated 12/19/2025, there was no documented attendance or signature for the Infection Preventionist.On 03/26/2026 at 11:36 AM, this surveyor conducted an interview with the Administrator regarding QAPI meeting attendance. The Administrator confirmed that there was no documented attendance or signature for the Administrator or Infection Preventionist on 10/23/2025, and no documented attendance or signature for the Infection Preventionist on 11/17/2025 and 12/19/2025.On 03/26/2026 at 11:52 AM, during continued interview, the Administrator reported that there were issues with attendance and confirmed that the facility did not ensure the minimum required members were present at each QAPI meeting. The Administrator acknowledged the concern.

Based on observations and interviews, it was determined that the facility failed to provide a safe and sanitary environment. This was found to be evident for 2 (Resident #2 & #130) out of 20 Residents observed for Infection Control during the recertification and complaint survey. The findings include: 1) A Foley catheter bag collects urine from a flexible tube (catheter) inserted into the bladder, typically holding 600–900 mL (leg bags) or up to 2000 mL (bedside bags). Always keep the bag below waist level to use gravity for draining and prevent infection. Empty the bag every 3-4 hours or when it is 1/2 to 2/3 full. During an interview conducted on 03/22/2026 at 8:42 AM, the Surveyor observed Resident #2's bed in the lowest position with the foley catheter bag attached to the right side of the bed and lying on the floor. On 03/22/26 at 9:17 AM the Surveyor reported the observation to the assigned License Practical Nurse (LPN) #3. The Surveyor observed the LPN raise the resident's bed from the lowest position to a position that allowed the foley bag to no longer touch the floor. During an interview conducted on 03/22/26 at 9:19 AM, LPN #3 acknowledged that the foley bag should never touch the floor because of Infection Control concerns that could cause the resident to contract a urinary tract infection. She stated that she would speak with the unit manager for directions on deciding if the foley catheter bag should be replaced. 2) During an observation of Licensed Practical Nurse (LPN) #3 on 3/24/2026 at 8:46 AM it was observed that she used a portable blood pressure cuff and a pulse ox on Resident #2. When she was finished using the equipment she left the Resident's room and placed the cuff and pulse ox on top of her medication cart without being cleaned. During an observation of Licensed Practical Nurse (LPN) #3 on 3/24/2026 at 9:12 AM it was observed that she took the portable blood pressure cuff and pulse ox from the top of her medication cart and used the devices on Resident #130. When she finished using the cuff and pulse ox she left the Resident's room and placed the cuff on her medication cart without cleaning the equipment. During an interview with LPN #3 on 3/24/2026 at 9:26 AM she reported that she should have cleaned the equipment after using them on Resident #2 and #130. During an interview with the Director of Nursing on 3/24/2026 at 3:10 PM he confirmed that the blood pressure and pulse ox should have been cleaned after each use and before using on another Resident.

Based on interviews and record reviews it was determined that the facility failed to maintain an antibiotic stewardship program. This was found to be evident for 5 out of 5 Antibiotic stewardship line listings during the recertification and complaint survey. This deficient practice has the potential to affect all residents.The findings include:Antibiotic Stewardship Program (ASP) requires a facility to develop and implement policies, procedures and/or protocols to optimize the selection, dosage, route and duration of antibiotic therapy. This is to improve Resident outcomes, reduce the risk of residents having adverse reactions to antibiotics, receiving them unnecessarily and/or developing antibiotic-resistant organisms.An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.Based on a review of a certificate of completion from the Centers for Disease Control and Prevention on 3/24/2026 at 1:27 PM it reported the Unit Manager for the Western [NAME] Unit had completed the Nursing Home Infection Preventionist Training Course on 3/06/2026.During an interview with the Unit Manager of the Western [NAME] Unit on 3/25/2026 at 12:33 PM she reported she was the full time Unit Manager of the Western [NAME] Unit and was assigned the role of Infection Preventionist (IP). She confirmed the monitoring of the antibiotic usage is the role of the facility IP.Line listing is a detailed list used by a team of clinicians to identify, track, and monitor suspected infections to ensure appropriate treatments. It is a table where each row represents a single case of disease (a person) and each column represents a specific variable, such as demographic information, clinical symptoms, or exposure history. During an additional interview with the Unit Manager of the Western [NAME] Unit on 3/26/2026 at 10:37 AM she provided documentation of the Line listings for the Antibiotic Stewardship for October through March. She reported that the Line Listings for October and November 2025 was incomplete.During a review of the Line Listings provided by the Unit Manager on 3/26/2026 at 12:25 PM it was discovered that the months October through February was incomplete for several residents. The site of infection was missing for some Residents, it was not identified if some Residents diagnosed with pneumonia had a chest x-ray which was a column to be completed, for Residents that had a chest x-ray completed there was no date of when it was completed. In addition, the column for Healthcare Acquired or Community Acquired infections was not documented on most residents.

Based on record review and interviews of the facility records, it was determined that the facility failed to designate an Infection Preventionist at least part time to be responsible for managing its Infection Prevention and Control Program. This was evident during the recertification survey. This deficient practice has the potential to impact all residents in the building. The findings include:An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.Based on a review of a certificate from the Centers for Disease Control and Prevention on 3/24/2026 at 1:27 PM it reported the Unit Manager for the Western [NAME] Unit had completed the Nursing Home Infection Preventionist Training Course on 3/06/2026.During an interview with the Unit Manager of the Western [NAME] Unit on 3/25/2026 at 12:33 PM she reported she was the full time Unit Manager of the Western [NAME] Unit and was assigned the role of Infection Preventionist (IP). When asked about her role as an IP with the facility she reported, she doesn't have a lot of time to dedicate to the position due to her Unit Manager position. During an additional review with the Unit Manager of the Western [NAME] Unit on 3/26/2026 at 10:37 AM she reported that she was in the position as IP last year from March through April, then in April the Director of Nursing (DON) at that time took over the IP position, the Assistant Director of Nursing later took it over from the DON and now the IP position was given back to the Unit Manager of the Western [NAME] about three months ago and she reported she didn't have the time to complete the required duties of an IP due to being full time in the Unit Manager PositionDuring an interview with the Administrator on 3/26/2026 at 11:56 AM she confirmed that the Unit Manager was full-time in that position and had the IP role added to that duty.

Based on observations and interviews it was determined that the facility failed to ensure food was prepared and served on sanitary pans, dishes and utensils. This was found to be evident for 1 out of 1 commercial dishwasher observed during the recertification and complaint survey. The deficient practice has the potential to affect all residents who consume liquids and food. The findings include: 3-bay Compartment Sinks maintains proper sanitization. Each sink bowl (bay) serves a different role, one for rinsing, washing, and sanitizing. During an observation conducted on 03/22/26 at 8:49 AM, the Surveyor observed Dietary Aide #13 rinsing silver metal pans in the 3-bay compartment sink. The Surveyor observed one bay with water, the bay for washing and sanitizing was empty. The Surveyor asked why the other 2 bays weren't filled, the Dietary Aide replied that he was rinsing the pans before placing them in the dishwasher so there was no need to fill the other 2 bays. Center of Medicaid and Medicare Services (CMS) requirements for hot water dishwashers in facilities like nursing homes mandate that high-temperature machines must achieve a wash temperature of at least 150 degrees Fahrenheit (F) and a final sanitizing rinse of 180 degrees (F) to effectively kill bacteria. For stationary rack, single-temperature machines, the requirement is a minimum of 165 degrees (F). During an observation conducted on 03/26/2026 at 8:48 AM in the kitchen, the Surveyor and Certified Dietary Manager (CDM) observed the hot water dishwasher not meet the required final rinse of 180 degrees (F). The CDM ran 5 trays through the dishwasher with the final rinse ranging between 138- 140 degrees (F). The CDM reported that she would notify the Maintenance Director. The Surveyor and CDM reviewed the dishwasher temperature log for the month of March. Each day from 3/1/26-03/26/26 showed the wash temp was 150 degrees (F) and the final rinse was 180 degrees (F). The CDM reported that she realized that the temperatures were the same for each day since 3/1/26 were unlikely since the final rinse was failing to meet 180 degrees (F). She further reported that she would immediately conduct education for the dietary staff.

Based on observations, record reviews and interviews it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%.The findings include:1. During an observation of Certified Medication Aide (CMA) #10 on 3/23/2026 at 8:49 AM she completed her medication administration to Resident #83.During a review of the Medication Administration Record (MAR) for Resident #83 on 3/23/2026 at 8:56 AM it was discovered that the Resident also had an order to receive eye drops that had not been given. The order was for Carboxymethylcellulose Sodium Ophthalmic Liquid (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes four times a day for dry eyes on drop in each eye four times a day.During an interview with CMA #10 on 3/23/2026 at 8:58 AM she reported that she had given all the medications due to Resident #83 at that time and advised that she didn't see an order for eye drops for Resident #83.During an observation of CMA on 3/23/2026 at 9:01 AM she confirmed the Resident had an active order and Resident #83 was due to get the eye drops listed in the order. She returned to administer the medication to Resident #83.2. Oxycodone is an immediate-release, short-acting opioid medication used for acute pain, while OxyContin is a brand-name, extended-release version of oxycodone designed for long-term, around-the-clock pain management. Oxycodone acts in 4-6 hours, whereas OxyContin works over 12 hours.During an observation of Licensed Practical Nurse (LPN) #3 on 3/24/2026 at 8:46 AM she was gathering medication to administer to Resident #2. While collecting the medication for Resident #2 she came to an order for OxyContin Oral Tablet ER 12 Hour and instead of OxyContin 10 mg she added Oxycodone 10 mg to the medication cup to be given to Resident #2.During an interview with LPN #3 on 3/24/2026 at 8:48 AM she reported that Resident #2 had run out of Oxycontin yesterday, so she was giving him/her Oxycodone in place. She reported that she did not notify the doctor to advise Resident #2 was out of Oxycontin and did not obtain an order to administer Oxycodone in place of the Oxycontin. She administered Oxycodone 10 mg to Resident #2 in place of Oxycontin 10 mg.During a review of the MAR for Resident #2 on 3/24/2026 at 9:52 AM it was discovered that he/she was receiving Oxycodone 10 mg until 3/07/2026 when it was discontinued and replaced with Oxycontin 10 mg. The Resident had no active order for Oxycodone 10mg. Additional review of the MAR showed that the Oxycontin 10 mg was signed off as given by LPN #3 although it was Oxycodone that was administered.During an interview with the Director of Nursing (DON) on 3/24/2026 at 10:12 AM he advised the nurse should have notified the doctor to make aware of the unavailability of the Oxycontin and requested an order for the Oxycodone 10 mg as a replacement.

Based on observations, interviews and record reviews it was determined that the facility failed to store medications to ensure medications remained safe and effective. This was evident for 1 (Western [NAME] Unit) out of 3 Refrigerators used for medication storage.The findings include:During an observation of the medication storage refrigerator on the Western [NAME] Unit on 3/23/2026 at 10:09 AM with Licensed Practical Nurse (LPN) #11 it was observed that the medication storage refrigerator was at 64 degrees Fahrenheit. The refrigerator had several medications stored inside that included insulin: Mounjaro autopens, Lispro autopens, Humulin 70/30 autopens, Lantus; suppositories: Acetaminophen and Bisacodyl; and Tuberculosis Purified Protein Derivatives (PPD).During an interview with Licensed Practical Nurse (LPN) #11 on 03/23/2026 at 10:09 AM she reported night shift checks the refrigerator temperatures and records them in a log nightly.During a review of the Refrigeration Monitoring Quality Assurance Record log for the Western [NAME] Unit medication refrigerator on March on 03/23/2026 at 10:10 AM it revealed there was no documentation for the medication refrigerator being checked on the night shift of 3/22/2026.During an observation with the Western [NAME] Unit Manager on 3/23/2026 at 10:16 AM she confirmed the temperature in the refrigerator was too high. She reported that the medication refrigerator should be checked nightly and documented in the Refrigeration Monitoring log. She confirmed it was not signed off as being checked on 3/22/2026 and advised it should have been signed off by the night nurse.During a review of the facility Storage and Expiration Dating of Medications and Biologicals medication storage policy on 03/23/2026 at 1:41 PM it revealed that Facility should ensure medications and biologicals are stored at their appropriate temperatures and identified the refrigeration storage temperature should be 36 - 46 degrees Fahrenheit.

Based on observations and interviews it was determined that the facility failed to maintain a safe, functional and sanitary environment. This was evident in the Laundry Washer Room and the Laundry Folding Room during the recertification survey. This practice has the potential to affect all Residents.The findings include:1. During an observation of the Laundry Washer Room on 3/23/2026 at 1:56 PM a leak was discovered dripping from a pipe in the ceiling and running down the wall in the corner near the dryer room. Additional observation revealed a large area of black staining along the wall and on top of the Ecolab dispensing system box where the water was leaking. Further observation showed a red bucket below the pipe that collected the dripping water.During an interview with Laundry Aide #14 on 3/23/2026 at 1:58 PM she reported the leak from the ceiling had been leaking off and on for a couple of months. She advised maintenance was aware and had worked on the leak.During an interview with the Maintenance Director on 3/23/2026 at 2:09 PM he reported he didn't know the Laundry Washer Room had a leak and began cleaning the wall while other maintenance staff worked on the leak reported to be coming from the kitchen. During a repeat observation of the Laundry Washer Room on 3/24/2026 at 8:08 AM it was revealed that the wall had been cleaned and the black staining was removed. There was no active leak present.During an interview with Maintenance Technician #15 on 3/24/2026 at 8:40 AM he reported that the leak was coming from the kitchen and looks like it's been going on for a while, but I didn't know about it. He advised the maintenance staff would be verbally notified by Laundry if there was an issue and he was not aware if this was done. During an interview with Laundry Aide #17 on 3/24/2026 at 9:57 AM she reported the leak in the corner of the laundry room near the dryer room was coming from the kitchen and it's been going on for a while. She advised she had reported the leak and maintenance was looking at it last week.During an interview with the Maintenance Director on 3/25/2026 at 10:50 AM he reported that each wing in the building had a book labeled maintenance requests to report any concerns, but the kitchen and Laundry relied on verbal notification to notify maintenance. He was unable to confirm if any of his maintenance personnel were aware of the leak from the ceiling since there was no documentation and he was not made aware of the concern. He reported that the leak into the laundry room was from a kitchen drain, the drain wasn't sealed, the seal wasn't good, it was old.During a repeat observation of the Laundry Washer Room on 3/26/2026 at 9:26 AM a leak was noted coming from the ceiling in the same area as the previous leak. The floor was wet and the red bucket under the leak from the ceiling had water inside.During an interview with the Nursing Home Administrator (NHA) on 3/26/2026 at 10:08 AM she reported that after discussing the concern of the leak from the ceiling with the Maintenance Director they concluded the current maintenance reporting system for the Laundry area was not working so they would add a binder for staff to report maintenance concerns, and it would be kept at the front desk.2. During an observation of the Laundry Washer Room on 3/23/2026 at 1:56 PM it was observed that the ceiling had large areas of peeling paint hanging from the ceiling and heating ducts. Additional observation revealed an overhead pipe that had an outer insulation casing which was torn with insulation exposed and hanging out.During an interview with the Maintenance Director on 3/25/2026 at 11:36 AM he reported the ceiling needed to be repainted and the pipe needed to be rewrapped.3. During an observation of the Laundry Washer Room on 3/23/2026 at 1:56 PM the vent ducts were noted to have large particles of visible dust, dust was also observed on the top of the washing machines and the hoses behind the washing machines.During an interview with the Director of Environmental on 3/24/2026 at 9:50 AM she reported that the laundry room should be cleaned daily and agreed the visible dust should not be on the vents, washing machines or the washing machine hoses.4. During an observation of the Laundry Washer Room on 3/24/2026 at 9:40 AM the UniMac washer on the left side of room was noted to be leaking with a large puddle behind the machine and a blanket had been laid under the leak at the back of the machine.During an interview with the Maintenance Director on 3/24/2026 at 9:46 AM he reported the Laundry staff was to notify maintenance verbally if there were any issues that needed to be repaired. He advised he was not notified of the leak and was not aware of the leak coming from behind the washer.During an interview with Laundry Aide #17 on 3/24/2026 at 9:59 AM she advised the washer had been leaking every now and again but could not advise how long it had been leaking.During an interview with the Maintenance Director on 3/25/2026 at 10:50 AM he reported two leaks were discovered that needed to be repaired on the washing machine. He reported that each wing in the building had a book labeled maintenance requests to report any concerns, but the kitchen and Laundry relied on verbal notification to notify maintenance. He was unable to confirm if any of his maintenance personnel were aware of the leak from the ceiling since there was no documentation and he was not made aware of the concern.

Based on interviews and record review it was determined that the facility failed to ensure a Resident was free of accidents. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for accidents during the recertification and complaint survey. The findings include: During an interview conducted on 03/22/2026 at 8:46 AM, Resident #2 reported that during incontinent care Geriatric Nursing Assistant (GNA) #7 raised the bed to a high position and rolled the Resident on their right side. The GNA told the Resident that she needed to get a washcloth and that she would be right back. The GNA left the Resident on his/her right side and the bed in a high position. The Resident reported that he/she rolled off the bed onto the floor and hit his/her head. The Resident reported that he/she was not injured. The Minimum Data Set (MDS) 3.0 is a standardized, federally mandated assessment tool for nursing home residents, implemented by CMS to improve care quality. It collects comprehensive data on functional, cognitive, and health status (e.g., mobility, pain, medications) at scheduled intervals to guide care planning, quality monitoring, and reimbursement.During a review of Resident #2's MDS assessment conducted on 03/25/2026 at 8:59 AM, it was discovered that the Resident was assessed as dependent for incontinent care requiring 2 staff assistance. According to MDS a dependent resident relies on the helper to make all the effort. The Resident does none of the effort to complete the activity. The dependent Resident requires assistance from 2 or more helpers to complete the activity. During an interview conducted on 03/25/26 at approximately 9:15 AM, the Nursing Home Administrator (NHA) confirmed that GNA #7 left Resident #2 unattended, on his/her right side with the bed raised to a high position. As a result, Resident #2 fell off the bed to the floor. During an interview conducted on 03/25/26 at approximately 10:30 AM, the Director of Nursing (DON) confirmed that Resident#2's MDS assessment identified the Resident as being dependent and required 2 staff assistance when care was provided. The DON reported that he had started an in-service education on providing appropriate care for dependent residents.

Based on interview and record review, it was determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 1 of 1 resident (Resident #118) reviewed for ADL care.The findings include:Activities of Daily Living (ADLs) are defined as basic self-care tasks, including bathing, dressing, toileting, transferring, eating, and personal hygiene, that are necessary to maintain a resident's health and well-being.On 03/23/2026 at 12:34 PM, this surveyor conducted an interview with Resident #118's family member, who reported concerns that the resident's ADL care was not being carried out on 11/09/2025.On 03/23/2026 at approximately 1:00 PM, this surveyor conducted a record review of Resident #118's electronic health record. Review of the Minimum Data Set (MDS), completed on 10/03/2025, revealed the resident was assessed as dependent for oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, personal hygiene, and tub/shower transfer. The MDS defines dependent as staff performing all of the effort, with the resident completing none of the activity, or the assistance of two or more staff members required for the resident to complete the activity.On 03/25/2026 at approximately 3:00 PM, this surveyor conducted a record review of ADL documentation for 11/09/2025. Record review revealed no documented evidence of ADL care provided during the 1500-2300 and 2300-0700 shifts. There was no documentation for bathing, bed mobility, bowel care, dressing, oral hygiene, personal hygiene, toileting, toileting hygiene, or transfers.On 03/26/2026 at 10:44 AM, this surveyor conducted an interview with the Director of Nursing (DON) regarding the lack of documented ADL care for the identified shifts. The DON acknowledged the concern.

Based on interviews and record review it was determined that the facility failed to ensure a Resident was free from abuse. This was found to be evident for 1 (Resident #6) out of 4 Residents reviewed for abuse during the recertification and complaint survey. The findings include: During an interview conducted on 03/22/26 at 9:35 AM, Resident #6 reported that Agency Geriatric Nursing Assistant (GNA) #16 provided rough care. The Resident reported that the GNA roughly pulled the Resident by the neck and arm and was very rude while repositioning the Resident in bed. During a review of Facility Reported Incident (FRI) #2736958 investigation conducted on 03/24/26 at 7:00 AM it was discovered that the Nursing Home Administrator (NHA) determined that Agency GNA #16 abused Resident #6. The NHA suspended the GNA at the onset of the investigation. At the conclusion of the investigation the NHA notified the staffing agency of the abuse and placed the GNA on the do not return list. During an interview conducted on 03/24/26 at approximately 9:30 AM the NHA reported that during the investigation 2 other residents reported that Agency GNA #16 was rude and provided rough care. As a result, the NHA reported that she verified the abuse and terminated the Agency GNA and placed her on the do not return list.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were offered written information regarding advance directives. This was evident for 4 (Resident#6, # 10, 89, and #90) out of 6 residents reviewed for advance directives during the recertification and complaint survey process. The findings include:An advance directive is a written instruction, such as a living will or durable power of attorney for healthcare, that is completed by a resident to outline their preferences for medical care in the event they are unable to make decisions for themselves.In a long-term care facility, an advance directive guides staff and providers in honoring the resident's choices regarding treatment, life-sustaining measures, and designation of a representative to make healthcare decisions on their behalf, in accordance with the resident's rights.On 03/23/2026 at 9:05 AM medical record review revealed no documentation to indicate that the facility provided information or education regarding advance directives to Residents #6, #10, #89, and #90 and/or their resident representatives. On 03/23/2026 at 8:01 AM interview conducted with the Social Worker (MSW) revealed that residents or their responsible party are asked upon admission whether an advance directive is in place. The MSW stated that if an advance directive is not in place, the facility provides the Maryland Attorney General's Office Advance Directive packet. When asked how the offering of advance directives to the resident or Responsible Party (RP) is documented, the MSW stated documentation is inconsistent, stating, sometimes I document, sometimes I don't. On 03/24/2026 at 8:19 AM, the surveyor and the Social Worker (MSW) conducted a record review of Residents #6, #10, #89, and #90's charts and electronic health records (EHR). The MSW confirmed that there was no documentation to indicate that information or education regarding advance directives had been provided to the residents and/or their Responsible Parties (RPs).

Based on a review of a complaint, staff interviews, and record reviews, it was determined that the facility failed to ensure the provision and use of a motorized wheelchair to promote and maintain the resident's independence and freedom of movement. This was evident for 1 (Resident #65) out of 1 resident reviewed during the recertification and complaint survey process. The findings include:A motorized wheelchair (power wheelchair) is a battery-operated mobility device used to assist residents with limited strength, endurance, or mobility. It is typically operated by the resident using a hand control and is intended to promote independence, safe mobility, and the resident's ability to move about the facility.On 03/26/2026 at 7:45 AM record review during the complaint investigation was conducted, Resident #65 reported that the motorized wheelchair has been nonfunctional since 2025. The resident stated that a vendor completed measurements for repair or replacement; however, no follow-up has been received regarding the status of the equipment. The resident further reported that the lack of a functioning motorized wheelchair has limited mobility within the facility and has impacted independence.On 03/26/2026 at 8:30 AM interview conducted with the Physical Therapy Director (PTD). She explained that the process involves taking the resident's measurements, obtaining a vendor estimate, and submitting it to the Business Office Manager (BOM) for processing, and stated she was unsure of the timeframe. The PTD confirmed that the initial motorized wheelchair assessment was completed on 08/18/2025 by Freedom Mobility (vendor), and the estimate was forwarded to the Administrator due to the absence of a Business Office Manager.On 03/26/2026 at 9:09 AM, an interview was conducted with the Business Office Manager (BOM), who stated she has been in her position since December 2025.The BOM stated she became aware of the resident's wheelchair issue on 01/16/2026. She further reported that she contacted Freedom Mobility on 01/16/2026 and was informed that authorization/approval had been received from Telligen on 10/10/2025.On 03/26/2026 at 9:34 AM during an interview with the Administrator she confirmed that the facility did not have a Business Office Manager (BOM) from July 2025 through December 2025. She stated that during this period, she assumed responsibility for Business Office functions, which resulted in a breakdown in follow-up and tracking of the authorization process.The Administrator acknowledged that the facility failed to follow up on the approved request, resulting in a delay in providing the resident with the necessary equipment to support mobility, as well as a failure to update the resident regarding the status. The Administrator further stated, I am going to talk to Resident #65 right now.

Based on medical record review and interview, the facility failed to provide psychiatric evaluation for a resident (resident #1) who had a history of trauma from physical abuse. This is evident in 1 of 4 residents reviewed during a complaint survey. Findings includes: On 3/18/25 at 2:10pm, surveyor review of resident #1's medical records revealed that the resident reported an allegation of abuse from LPN # 4 on 1/17/25 at approximately 8:30am. Resident #1 reported that LPN #4 threw a cup filled with the resident's medication at the resident. Review of the facility investigation on 3/18/25 at 2:20pm revealed that the facility was unable to substantiate the abuse but recommended that the resident receive psychiatric assessment after the alleged abuse incident. Continued review of resident #1's medical record on 3/18/25 at 2:40pm revealed that the resident received a trauma informed care assessment that revealed that the resident had a history of physical abuse and required psychiatric assessment. Further review of resident #1's medical records on 3/18/25 at 2:50pm found no evidence that Resident #1 received the recommended psychiatric assessment during his/her stay. An interview with the Administrator on 3/18/25 at 3:15pm confirmed that the facility failed to provide Resident #1's recommended psychiatric assessment during his/her stay.

Based on medical record review, observation and interview, it was determined the facility staff failed to transfer Resident #417 using a sit to stand transfer device that resulted in the resident sustaining a fracture to their right arm. This was identified a G of past non-compliance for facility reported incident MD00210322 for F689. This was true for 1 out of the 29 residents reviewed during this survey. The findings include: 1) Based on reviews of medical records, administrative records, and staff interviews, it was determined the facility staff failed to provide a resident with a safe environment, during a transfer from the bed to the wheelchair. Review of Resident #417's fall prevention care plan initiated on 8/11/2024 revealed Resident #417 was at high risk for falls. A review of Resident #417's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 4/20/24 Quarterly, was conducted. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provides the appropriate care and services to the resident and to modify the care plan based on the resident's status. MDS Section GG: Functional Abilities is coded to reflect that Resident #417 depends on staff for transfers (how the resident moved between surfaces including to or from the bed, chair and wheelchair and required the support of two or more individuals to transfer. Review of the facility reported incident MD00210322 on 8/23/24 at 9:59 AM, the date of the incident, revealed that the resident reported to the Director of Nursing that the Aide did not transfer her correctly. The resident explained that the GNA2 bear hugged her/him, and the arms were around the GNA2 neck when he/she lifted her. On 1/15/25 at 9:30AM, an interview with the resident revealed that the resident was getting ready to attend an activity and her Geriatric Nursing Assistant (GNA) was helping another resident. GNA 2 and GNA 3 came into the room to help her transfer from the side of the bed to the wheelchair. GNA 2 said they could lift the resident to the wheelchair, the resident and GNA 3 said that the resident was to be transferred via a sit to stand. A sit-to-stand device is meant to replace the manual stand-and-pivot transfer that's performed frequently by caregivers when transferring a weight-bearing resident/patient from a seated posture to a standing posture or different seated surface. The resident stated that's she felt the pain in her arm and heard the snap when she lifted her arms around the GNA's neck. On 1/15/25 at 11AM, GNA 3 revealed the resident was a sit-to-stand transfer and offered to get the resident the sit-to-stand device but, GNA 2 was in a hurry and lifted the resident. They said that they did hear the snap of the resident's arm. I immediately got the RN and then stayed with the resident to comfort them On 1/15/25 at 12 PM, an interview with the Director of Nursing revealed that resident had a sit-to-stand lift transfer initiated on 2/4/22 and it was continued to this day. GNA 2 did not follow the GNA transferring Kardex. The resident was sent to the emergency room for treatment of the right fractured arm. Education to staff on the protocol for safe lifting and movement of resident requiring a sit-to stand lift transferwas completed on 9/27/24. On 1/15/25 at 2:30PM, an interview with the Director of Nursing stated the delay in education was that the resident failed to inform staff at the time of the incident that the sit-to-stand device was not used in the transfer. On 1/16/25 at 8:55 AM, an interview with the Administrator revealed a Quality Assurance Performance Improvement (QAPI) action plan, completed 9/27/24, that identified what occurred i.e. full house education including agency staff and the suspension of GNA2. GNA2 was not allowed to return to the facility. There have been no new agency staff since this occurred. If new agency staff are to start work in the facility, they are educated on the transfer procedures for the residents. The plan of correction to address the facility's failure to be in compliance was completed by 9/27/24 and training is ongoing as needed for agency staff

Based upon observation and interview, the facility failed to ensure the ice machine in the kitchen and on the Southern Shore unit remained clean. This failure has the potential for food-borne illness affecting 97 of 98 residents in the facility. Findings include: During an observation on 01/13/25 at 9:40 AM, the kitchen ice machine, located in the food service area inside the double doors leading to the dining room, clear and brownish colored smears with debris on the top, sides, and front of the ice machine. The interior front portion of the ice machine had an orangish film on the surface. During an observation on 01/13/25 at 10:30 AM, in the Southern Shore unit nourishment room, the ice machine had clear and brownish colored smears with debris. During an interview on 01/14/25 at 8:40 AM, the Assistant Dietary Manager (ADM) verified both ice machines had brown colored smears and debris, and the kitchen ice machine had an orangish film on the surface. During an interview on 01/16/25 at 2:45 PM, the Maintenance Director (MTD) stated the maintenance department cleaned the inside of the ice machines and the kitchen cleaned the front and sides. Review of Ice Machine Log dated 2024 provided by the MTD shows quarterly clean-out and filter change [as needed]. The form does not indicate if the entire ice machine is cleaned inside and out. During an interview on 01/17/25 at 12:20 PM, the Director of Nursing (DON) stated she was unsure who the responsibility for keeping the ice machines in the facility clean fell upon. We discussed the interview with the MTD and the interview with the ADM. The DON stated it has been a group effort and housekeeping is also to clean the outside of the ice machines on the units. Policies were requested but were not provided prior to the end of the survey.

Based on record review, interview, and policy review, the facility failed to report an allegation of staff to resident abuse and injuries of an unknown origin for four residents (Resident (R) 342, R295, R296 and R13) reviewed for abuse out of 29 sample residents. This had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: Review of the facility's policy titled Abuse and Neglect-Clinical Protocol revised July 2017 revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin shall be promptly reported to local, state, and federal agencies. 1. Review of R295's undated Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including cellulitis, chronic pain, chronic obstructive pulmonary disease, and hypertension. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25, Brief Interview of Mental Status (BIMS) score was a 15 out of 15, indicating R295 is cognitively intact. R295 was assessed as not exhibiting any behavior during the seven-day look back period. Review of R295's Care Plan located in the EMR under the Care Plan revealed there was no indication resident has been identified as making false allegations of abuse. During an interview with R295 on 01/17/25 at 11:21AM, R295 was questioned concerning R296's incident with the night nurse. R295 stated the Licensed Practical Nurse (LPN)10 was rude and had told R296 to choose what you want to take and tossed the pill cup on R296's bed between the resident's legs. R295 proceeded to state that she had a similar incident with a Geriatric Nursing Assistant (GNA)3, the night before last (01/15/25), being rude to her. R295 stated she had called for help to move in her bed. When the GNA3 responded she told R295 that you can do it yourself. R295 reported the incident to Unit Manager (UM)2. On 01/17/25 at 12:00PM, UM2 was questioned if she had reported the incident with R295 to DON, and she stated maybe in passing as a verbal, telling the Director of Nursing (DON), we have another incident but not officially. When questioned if it should be reported, she stated yes it should have been. 2. Review of R296's undated Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses of psychoactive substance abuse, bipolar disorder, and fracture of lumbar vertebra. Review of R296's admission MDS with a ARD of 01/18/25, located in the EMR under the MDS tab, revealed R296's BIMS score is a 13 out of 15, indicating the resident was cognitively intact. R296 was assessed as not exhibiting any behaviors related to refusing care or making false accusations. During the observed medication pass on 01/17/25 at 8:45AM, R296, reported to the Unit Manager (UM)2, that LPN10 from the nightshift threw R296's pills at her, the pills landed on the residents' bed between R296's legs. LPN10 told R296 take what you want and walked out of the room. According to R296, there was valium (benzodiazepine for anxiety) and Dilaudid (opioid used for pain) in the medication cup. This incident was confirmed during an interview with R295, the resident's roommate, that is also cognitively intact. During an interview with R295 on 01/17/25 at 11:21AM, R295's Brief Interview of Mental Status BIMS score is a 13, indicating she is cognitively intact, was questioned concerning R296's incident with the night nurse. R296 stated the LPN9 was rude and had told R295 to choose what you want to take and tossed the pill cup on R296's bed between the resident's legs. During an interview with R296 on 01/17/25 at 11:29AM, R296 stated she had pressed the call button for medication, LPN10 came in her room about 8:30PM, and said this is your valium and suboxone (used to treat opiate addiction). LPN10 proceeded to throw the pill cup at R296, and stated take what you want. R296 stated there were other medications in the cup at the time also. At 7:30AM, LPN10 returned and stated she had tried to give R296's Dilaudid at 6:00 AM, but the resident was asleep. R296 stated LPN10 was disrespectful, rude, and treated her like a child. She felt intimidated and now hesitates to ask for her medications because she doesn't want to deal with the attitude. When questioned if she had informed anyone during the night of LPN10's actions, R296 stated no she had not, not until the UM2 came in this morning. During an interview on 01/17/25 at 11:08AM, the DON was questioned regarding the incident involving R296 and the DON stated, No she had not reported it, because she hadn't realized it rose to that level of investigation. 3. Review of R342's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated R342 was severely cognitively impaired. Review of R342's Progress Notes located in the EMR under the Notes tab dated 06/20/24 at 9:30 AM revealed, During routine care staff observed a bruise to the residents' left flank. The area is slightly red and warm to touch. Resident showed signs of facial grimacing during the assessment. Tylenol given for discomfort. Review of R342's Physician Progress Note located in the EMR under the Notes tab dated 06/20/24 at 3:06 PM revealed, resident is a .resident with dementia associated with aggressive behavior, cognitive impairment being seen today due to nursing concern. Initially notified by nursing regarding newly found large bruise. Second call received regarding unwitnessed fall which occurred after discovering of ecchymosis. Patient not able to give account of bruising or fall due to cognitive impairment. Nursing unable to account for possible source of left large left flank ecchymosis. During an interview on 01/15/25 at 2:47 PM Licensed Practical Nurse (LPN)Geriatric Nursing Assistant (GNA) reported the bruise to her, and she reported it to her unit manager. They were never able to determine how the bruise occurred. Review of R432's Progress Note located in the EMR under the Notes tab dated 12/16/2024 at 10:46: am revealed, Change in condition, bruise to right eye socket started on 12/16/2024. The bruise is located where her helmet sits on her head. During an interview on 01/17/25 at 10:16 AM, LPN8 stated she reported the bruise to her Unit Manager. During an interview on 01/17/25 10:35 AM, the Unit Manager (UM)2 stated the bruise to the residents left flank area was reported to her, and she reported it to the prior DON, and it was discussed during their clinical at-risk meetings. She said she did not report the bruised eye socket immediately because she didn't think it was so severe that it needed to be reported immediately. But they did discuss it during the clinical at-risk meetings. Review of Customer at Risk document, provided by the facility, dated 06/27/24 revealed discoloration to flank. Further review of this document revealed a note dated 12/19/24 bruise (yellow) right eyebrow-wears soft helmet-remove at bedtime. During an interview on 01/17/25 at 10:51 AM, the DON stated she was not the DON at the time the bruise was found on R342 on 06/20/24. She did say the bruise to R342 right eye was reported but she could not remember if she reported it to the Administrator. The DON stated any suspicious bruise, or mark should be reported to the DON or Administrator as soon as staff become aware. During an interview on 01/17/25 at 11:24 AM, the Administrator said injuries of unknown origin must be reported to a supervisor immediately if the nurse does not know how the injury occurred. The Administrator said they determined that the bruise to R342's right eye was the result sleeping with the helmet on. The Administrator confirmed this was not reported to the state and she was not sure if she had documentation of how and when they determined it was the result of sleeping with the helmet on, but she would provide that if she was able to do it. The Administrator did not provide the documentation prior to survey exit. 4. Review of R13's undated Face Sheet located under the Profile tab in the EMR revealed R13 was admitted to the facility on [DATE]. Review of R13's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/13/24 revealed the facility assessed R13 to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R13's Nursing Progress Note located under the Progress Note tab in the EMR revealed a note dated 11/30/24 at 6:53 PM which stated, While giving resident scheduled medications, Resident kicked blanket down and exposed right thigh. Swelling and bruising noted to the right inner thigh. Resident 6 out of 10 on non-verbal pain scale. On call [name of APN (advanced practice nurse)], informed of situation at 1710 [5:10 PM] .Daughter [name of daughter] informed of situation at 1730 [5:30 PM]. Supervisor notified of situation. Review of R13's Skin Assessment, dated 11/30/24 and located under the Assessment tab in the EMR revealed R13 had bruising to the Right thigh (front). Review of the list of Self-Reports 2024, provided by the facility, revealed no documented evidence R13's injuries to her inner thigh was reported to the State Survey Agency (SSA) as possible abuse. During an interview on 01/15/25 at 2:30 PM, the Director of Nursing (DON) stated, I saw her [R13], and it was discolored and hard to touch but not like a knot and it went down her leg. It did not look like a bruise from you hitting something. I saw her [R13] on the day she went to the hospital (12/02/24) because a supervisor or I have to assess anyone that the doctor is wanting to send to the hospital to see if we could take care of this issue here instead of going to the hospital. When the DON was asked if there was a documented assessment on R13, the DON stated, I don't know if I actually did a note. I don't remember. When the [NAME] was asked if she had knowledge of the bruise on R13's inner thigh before 12/02/24, the DON stated, I really don't remember. During an interview on 01/16/25 at 6:00 PM, Licensed Practical Nurse (LPN) 11 stated, I don't remember the specifics on this, but I remember she [R13] had a bruise on her inner thigh. I reported this to the Supervisor . During an interview on 01/17/25 at 8:49 AM, Registered Nurse (RN) 1 stated, The nurse [LPN 11] reported this to me. I told her to fill out a Change in Condition, call the MD [medical doctor] and call the [resident's] family. She [LPN 11] also put in a progress note. There were no reports of this from the off-going shift. I put this in the Supervisor's report and then at the end of my shift, I faxed it to the DON. I think this was an injury of unknown origin because no one knows how it got there. When RN 1 was asked what the time frame was to report an injury of unknown origin to the state agency, RN1 replied I have 24 hours to report this. During an interview on 01/17/25 at 9:04 AM, the DON was asked what the Supervisor's reports were used for. The DON stated, It is used so the Supervisors can let us know what is going on in there shift. For example, call outs and any issues out of the ordinary. When asked what the time frame was to report an injury of unknown origin to the SSA after it was identified, the DON stated, From the time you see it, or it is reported, that person is supposed to notify the Administrator and myself, and this has to be reported to the state agency within two hours. When asked if R13's bruising/injury of unknown origin was reported to the state agency, the DON stated, I don't know. During an interview on 01/17/25 at 11:24 AM, the Administrator stated, If we are not here, the Supervisors are to call me and the DON to report suspicious bruising. The nurses will attempt to find out how. For example, how the bruising occurred and if they cannot find the etiology of the bruise, then I will do a Self-Report. When the Administrator was asked what the time frame was for reporting this to the SSA, the Administrator stated, They have to investigate this immediately so I can report this within two hours. The Administrator was notified of the nursing note dated 11/30/24 and the Administrator stated, Should have been the same thing. I should have been notified so that it could have been reported within two hours if they did not know the cause of the bruise. When the Administrator was asked if the bruise was reported to the SSA, the Administrator stated, I don't believe so.

Based on observation, staff interview, and review of medical record and complainant documentation, it was determined that prior to the installation of bed rails, the facility: 1) failed to assess resident risks for entrapment 2) failed to obtain consent for bed rail use for cognitively impaired residents, and 3) failed to attempt to use appropriate alternatives prior to installing or using bed rails. After Resident #1 was observed hanging out of the bed on 2/3/23 with his/her head on the floor and feet at or in the bed rails, staff returned him/her into the bed without addressing the bed rails and did not notify facility management of the incident. This concern was evident for 3 (#1, #8, #9) of 3 residents reviewed during a complaint survey. As a result of these interrelated failures, an immediate jeopardy was declared on 2/10/23 at 7:20 PM. The facility submitted a written plan of removal of the immediacy on 2/10/23 at 10:56 PM and it was accepted by the State Agency on 2/10/23 at 11:20 PM. After removal of the immediacy, the deficiency remained at a potential for more than minimal harm and at a scope and severity of E. The findings include: 1) On 2/8/23 at 2:00 PM, a review of complaint #MD00188646 was conducted. In the complaint, the complainant reported that on 2/3/23 at 9:30 AM, when he/she walked in a resident ' s room, the complainant witnessed Resident #1 falling out of bed with his/her head not fully on the fall mat and the resident ' s legs were in a stressed and dangerous position. The complainant indicated he/she immediately left the room and reported this to the nurse, then returned to the room. The complainant reported that upon returning to the room, he/she took 3 photos of Resident #1 in the falling position, which were submitted to OHCQ (Office of Health Care Quality) for reference. The complainant wrote that the nurse and another staff member came into the room and returned the resident to his/her bed, then left the room. The complainant reported that when he/she was leaving the room, Resident #1 was observed attempting to get out of bed which the complainant again reported to the nurse and another staff member who indicated Resident #1 was care planned for bed sliding. In the pictures submitted by the complainant, Resident #1 was observed hanging inverted (upside down) off the bed, with the resident ' s right leg wedged in the top opening of the bed rail (adjustable metal or rigid plastic bars that attach to the bed) located at the top of the left side of the bed, and Resident #1 ' s head appeared to be touching the floor in front of a floor mat. On 2/9/23 at 10:00 AM, a review of Resident #1 ' s medical record revealed Resident #1 was admitted to the facility in June 2022 with diagnoses that included spastic quadriplegic cerebral palsy, epilepsy and muscle weakness. Resident #1 ' s most recent assessment with an Assessment Reference Date (ARD) 2/3/23 documented Resident #1 did not speak, his/her BIMS (brief interview for mental status) score was 00, indicating severe cognitive impairment, the resident required extensive assistance with 1 person physical assistance for bed mobility, extensive, 2 person physical assistance for transfers, and Resident #1 was non-ambulatory. The assessment documented Resident #1 had functional limitations in ROM (range of motion) with impairment of both upper and lower extremities. Further review of the medical record revealed an order for Bilateral bed rails to support mobility for functional tasks every shift, with a start date 8/6/22 was discontinued on 2/7/23, and an order for a perimeter mattress (special type of mattress with raised sides which may be employed as a fall prevention measure when in bed) to bed for safety was ordered on 2/7/23. In the EMR (electronic medical record), Resident #1 had 6 Safety/Assistive Device Evaluations, completed on 2/17//22, 5/17/22, 8/17/22, 10/16/22, 1/16/23 and 2/7/23, which documented no safety/assistive device, including bed rails, was recommended for Resident #1. Continued review of the medical record failed to reveal evidence Resident #1 was assessed for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) from bed rails prior to installation of the rails. In addition, no documentation was found to indicate (1) that the risks and benefits of bed rails were reviewed with the resident or resident representative, (2) that informed consent was obtained prior to installation of the bed rails, and (3) that appropriate alternatives were attempted prior to installing and using bed rails for Resident #1. On 2/9/23 at 12:13 PM, during a phone interview, the complainant reported that he/she was visiting another resident when she saw Resident #1 with his/her foot and ankle entwined in the half side rail on the bed, the resident was inverted on the bed with his/her head on the floor. The complainant stated that when he/she told the nurse, the nurse indicated that the resident did this all the time. The nurse with another staff member put the resident back to bed, and as the complainant was leaving the room, he/she observed Resident #1 scooting out of bed, which he/she again reported to the nurse. On 2/9/23 at 12:55 PM, an observation of Resident #1 ' s bed revealed a perimeter mattress was on the bed frame, and no side rails were observed to be attached to Resident #1 ' s bed. On 2/10/23 at 12:30 PM, during an interview, the NHA (Nursing Home Administrator) stated he/she became aware of Resident #1 ' s fall from bed from an email from the complainant that included photographs in which Resident #1 ' s leg appeared to be in the side rails. The NHA indicated the email, sent on the evening of 2/3/23, was not read until the night of 2/6/23, and, after viewing the pictures with Resident #1 ' s leg in the side rail, maintenance staff was contacted immediately to remove the side rail. The NHA stated he/she became aware that the side rail assessments noted that Resident #1 was not a good candidate for rails and began auditing all residents with bed rails. Staff had not immediately notified the Administrator of the 2/3/23 incident when Resident #1 was first reported to have fallen out of bed with his/her leg entrapped in the bed rails. The NHA indicated that on 2/6/23, he/she acted as fast as possible, put a plan in place, and did a house wide sweep of every side rail in the building. The NHA stated he/she interviewed the nurse and GNA who provided care to the resident, and, during the interview with the nurse, became aware the resident had 2 falls. At that time the NHA was made aware of the above concerns related to failing to assess Resident #1 for risk of entrapment prior to the implementation of the side rails, failing to obtain consent for a cognitively impaired resident prior to implementing side rails and failing to attempt to use appropriate alternatives prior to installing or using bed rails. 2) On 2/10/23 at 5:10 PM an observation was made of Resident #8 lying in bed. At that time bilateral bed rails were observed on the resident ' s bed. A review of Resident #8 ' s medical record revealed an order for bilateral bed rails to support mobility for functional tasks, initiated on 8/31/2022. Review of Resident #8 ' s Minimum Data Set (MDS) quarterly MDS with ARD 12/2/22 documented that Resident #8 ' s BIMS was 00, indicating he was severely cognitively impaired, and that the resident was dependent for all activities of daily living (ADLs). Review of Resident #8 ' s care plans revealed a fall care plan which included the intervention, Bilateral bed rails to support mobility for functional tasks, initiated on 8/6/22, and an ADL care plan with the intervention Resident to have 1/4 side rails for functional bed mobility, initiated on 2/6/23. The medical record revealed a Safety/Assistive Device Evaluation on 2/7/23 recommended bilateral quarter side rails. Continued review of the medical record failed to reveal evidence that Resident #8 was assessed for risk of entrapment from bed rails prior to installation. In addition, no documentation was found to indicate the risks and benefits of bed rails had been reviewed with the resident or with Resident #8 ' s representative and no documentation was found to indicate that informed consent was obtained prior to installation of the bed rails. 3) On 2/10/23 at 5:20 PM an observation was made of Resident #9 lying in bed. At that time bilateral bed rails were observed on Resident #9 ' s bed. On 2/10/22 at 5:45 PM, a review of Resident #9 ' s medical record revealed an order for bilateral bed rails to support mobility for functional tasks, initiated on 8/31/2022. Review of Resident #9 ' s quarterly MDS with an ARD of 12/30/22 documented that Resident #9 ' s BIMS was 00, indicating the resident was severely cognitively impaired and was dependent for all ADLs. Review of Resident #9 ' s care plans revealed an ADL care plan which included the intervention Bilateral bed rails to support mobility for functional tasks, initiated on 8/6/22. The medical record review revealed a Safety/Assistive Device Evaluation on 1/22/23 recommended bilateral quarter side rails. Continued review of the medical record failed to reveal evidence that Resident #9 was assessed for risk of entrapment from bed rails prior to installation. In addition, no documentation was found to indicate the risks and benefits of bed rails was reviewed with the resident or Resident #9 ' s representative and no documentation was found to indicate that informed consent was obtained prior to installation of the bed rails. On 2/10/23 at 6:00 PM, the surveyor requested the NHA provide evidence that prior to implementing the bed rails, the facility assessed Resident #8 and Resident #9 for risk of entrapment with bed rails, and evidence informed consent for the use of the bed rails had been obtained prior to installation of the bed rails. On 2/10/23 at 6:10 PM, the NHA and Corporate Clinical Nurse confirmed residents had not been assessed for risk of injury or entrapment from the use of bed rails and confirmed that informed consent from the resident/representative for the use of the bed rails had not been obtained prior to the installation of bedrails. As a result of the facility's failure to assess a resident for risk of entrapment prior to the installation of bed rails, an immediate jeopardy was called on 2/10/23 at 7:20 PM. The facility submitted a written plan of removal of the immediacy on 2/10/23 10:56 PM and it was accepted by the State Agency on 2/10/23 at 11:20 PM. The provisions of the plan to remove the immediacy included the following: 1. The Regional Director of Nursing updated the Safety/Assistive device evaluation form to include attempted alternatives to bed rails and risks of entrapment. The updated Safety/Assistive device evaluation form includes reviewing the risk and benefits of bed rails with the resident and or representative and obtaining informed consent prior to the installation of the bed rail. Completion date 2/10/23. 2. Resident #1, #8 and #9 suffered no adverse outcomes as a result of this alleged, deficient practice. Resident #1, #8 and #9 was reassessed using the updated Safety/Assistive device evaluation form that includes risk of entrapment. Removed Resident #9 bed rails. Completion date 2/10/23. 3. Risk and benefits of bed rails reviewed with the resident representative and informed consent obtained. Completion date 2/12/23. 4. The unit managers reassessed all current residents using the updated Safety/Assistive device evaluation form that includes risk of entrapment. Completion date 2/12/23. 5. The Unit Managers reviewed Risk and benefits of bed rails with the resident and or representative and obtain informed consent. Completion date 2/13/23. 6. The Unit Managers and or designee will assess all new admissions using the updated Safety/Assistive device evaluation form that includes attempted alternatives to bed rails, risk of entrapment, risk and benefits of bed rails reviewed with the resident and or representative. Informed consent will be obtained prior the installation of the bed rail. Completion date 2/11/23. 7. The Director of Nursing and or designee will educate Licensed Nurses on the use of the updated Safety/Assistive device evaluation from that includes attempted alternatives to bed rails, risk of entrapment, risk and benefits of bed rails will be reviewed with the resident and or representative. Informed consent will be obtained prior the installation of the bed rail. Completion date 2/13/23. 8. 100% of new admissions will be audited 5 x week for 12 weeks. 10% current residents will be audited weekly x 4 weeks then monthly time for 2 months. Audit results will be reported to the QAPI committee monthly for further recommendations. The immediate jeopardy was removed on 2/17/23 at 8:25 PM, after validation of the implementation of the plan, which included staff interview, observation of all resident beds for side rails, and medical record review for 79 residents with side rails by the surveyor during an onsite visit at the facility. The extended survey was completed on February 24, 2023.

Based on medical record review and staff interview, it was determined that: the facility failed to accurately assess nutritional needs of Resident #4, failed to effective plan for his/her nutritional needs; failed to obtain ordered weights during his/her first month of admission, failed to plan, order and implement recommendations for an added supplement after known unexplained weight loss in his/her first month of admission; and failed to assess and evaluate additional documented weight loss in his/her second month of admission. Throughout his/her entire two-month admission, the facility failed to take necessary steps to protect Resident #4 from unexplained weight loss which was an indicator of clinical decline and therefore substantiated resident harm. This was evident for one of four residents reviewed for nutrition. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. On 2/14/23 at 8:30 AM, a review of Resident #4's medical record was conducted and revealed documentation that Resident #4 was admitted to the facility in the beginning of June 2022 following an acute hospitalization for surgical repair of a hip fracture. In an Admission Summary progress note, on 6/2/22 at 12:24 AM, the nurse documented that Resident #4 was admitted to the facility following hospitalization with multiple diagnoses and comorbidities. The nurse reported that Resident #4 was alert to his/herself, his/her speech was garbled, and the resident had a DTI (deep tissue injury) on each heel. In a Baseline Care Plan on 6/1/22, the nurse documented that Resident #4 required one-person physical assist for eating, the resident was alert and cognitively impaired, and Resident #4 had no teeth or dentures. In a Nutritional Risk Assessment, on 6/2/22 at 7:30 AM, the Dietician failed to assess the resident ' s nutritional risk factors and then inaccurately concluded that Resident #4 was at low risk for nutritional concerns. In the section, Relevant conditions and diagnosis check all that apply no conditions or diagnosis were checked. The possible conditions and diagnosis listed that applied to Resident #4, but were not identified or checked were heart disease, fracture, recent surgery, dementia, and dysphagia. In the section Physical and mental functioning check all that apply, no physical or mental functioning items were checked. The possible physical or mental functioning listed that applied to Resident #4 but were not identified or checked included, edentulous (no teeth) unable to communicate and extensive or total assistance while eating. In the section, Skin Conditions, the Dietician inaccurately selected skin intact, failed to identify Resident #4 ' s suspected DTIs (left and right heel) and did not identify that the resident also had a surgical wound. (Nutrition is essential to promote wound healing and to prevent skin wound deterioration.) Review of Resident #4 ' s admission, 5-day assessment with an ARD (assessment reference date) of 6/8/22 documented that Resident #4 ' s BIMS (brief interview of mental status) was 3. Also, the information reviewed indicated that the resident had severe cognitive impairment, and documented that Resident #4 was dependent on staff for all activities of daily living and required extensive, one person physical assistance when eating during the assessment period. Review of Resident #4 ' s medical record failed to reveal evidence that a comprehensive, resident centered nutrition care plan was developed and implemented to address Resident #4 ' s nutritional needs. Review of Resident #4 ' s physician orders revealed a 6/1/22 order for staff to obtain resident weights (weekly for 4 weeks from admission and then monthly). On 6/1/22 Resident #4's obtained weight was documented at 157.8 lbs. On 6/5/22 Resident #4's obtained weight was documented at 158.1 lbs. The weekly weight order was transcribed into the June 2022 Resident #4 ' s June 2022 TAR (Treatment Administration Record) with weights expected to be obtained 6/8/22, 6/15/22, 6/22/22 and 6/29/22. However, none of these ordered weights were obtained and documented. On 6/8/22 no weight was obtained and documented in the TAR. On 6/15/22 no weight was obtained and documented in the TAR. On 6/22/22, staff documented the ordered weight was held (not obtained) with no reason documented. Also on 6/22/22 at 5:57 PM, in a Care Conference note, the Social Service Director wrote that the Speech Therapist reported that Resident #4 had poor memory, poor recall, problem solving with poor attention span. The resident had been inconsistent with his/her meals, there were days he/she would eat on his/her own, other days he/she would allow the staff to assist with feeding and on other days he/she refused to eat. The Speech Therapist reported that nutrition was important especially for wound healing. Although noted as important the refusal to eat at times was not further assessed and did not appear in any planned interventions. On 6/29/22 the ordered weight was again held with no documented reason. On 7/5/22 at 1:53 PM, Resident #4 ' s weight was documented as 147.2 lbs, which was a 6.9% weight loss in one month meeting the regulatory definition for significant weight loss. On 7/6/22 at 8:06 AM, in a weight change note, Dietician #1 (Staff #8) documented that Resident #4 had a 6.9 % weight change over 30 days. The dietitian documented nutrition intervention recommendations for provide Ensure (dietary supplement) twice a day, to follow weights, meal and supplement intakes; and minimize potential for significant weight changes through the review period. However, review of Resident #4 ' s physician orders failed to reveal that any orders for Ensure were implemented in July 2022. No staff on any shift for the rest of July ever followed up to obtain an order for the recommended supplement related to the known weight loss. Further review of the medical record failed to reveal evidence that the physician had been notified of Resident #4 ' s weight loss. There was also no documentation that the resident or resident representative had been notified of the resident's weight loss. Consistent with the weight loss noted in early June, on 7/27/22 at 8:49 PM, Resident #4 ' s weight was documented as 149 Lbs. However, additional weight loss was documented in the record in August. On 8/4/22 Resident #4 ' s weight was documented as 127.2 lbs and on 8/6/22 Resident #4 ' s weight was documented at 128.2 lbs. This documentation indicated that Resident #4 had experience weight loss of 30 lbs. or approximately 19% since his/her admission two months prior. A weight documented on 7/27/22 contradicted the two weights in early August so it could not be determined if that July weight or the two August weights may have been inaccurate. Nonetheless, review of the medical record failed to reveal documentation that the resident was evaluated for his/her significant weight loss by the Dietician or the physician after the August weights were obtained and documented. Review of the resident ' s physician orders revealed on 8/4/22 the CRNP (certified registered nurse practitioner) ordered Resident #4 to have Ensure 2 times a day for supplement but this was a full month after the supplement had first been recommended by the dietitian. On 8/10/22, Resident #4 was transferred to an acute care hospital and did not return to the nursing home. On 2/14/23 at approximately 12:00 PM, the NHA (Nursing Home Administrator) was made aware of the concerns related to Resident #4's significant weight loss. At that time, the NHA indicated that in July 2022, the facility recognized a concern with the staff obtaining resident weights as ordered, the concern was brought to the facility ' s QAPI (Quality Assurance and Performance Improvement) meeting and the staff were educated. The NHA provided the facility ' s QAPI report to the surveyor for review. As reviewed, the plan included a monthly weight report for 7/15/22 which included that Resident #4 was identified for not having weekly weights done. Review of the facility ' s action plan for weight protocol was initiated on 7/18/22, with the goal, all weekly and monthly weights will have orders and be obtained and entered into Point Click Care (PCC) per protocol, with a target completion date of 8/15/22, and an audit for weights was conducted in July 2022. The facility's QAPI Report for August (July 2022 data) indicated that residents were identified with significant weight loss which was attributed to staff not obtaining resident weights timely and resident reweights not being conducted consistently. However, the QAPI effort in July was not effective as there was no evidence provided that Resident #4's significant weight loss had been identified and/or investigated even after the additional weight loss was documented into the record in August. On 2/14/23 at 12:55 PM, during an interview, Staff #7, Speech Therapist, stated that Resident #4 was seen by speech therapy for cognitive communication dysfunction and swallow dysfunction which impacted his/her ability to eat so a mechanically altered diet was recommended for safety. Staff #7 indicated that at the time of his/her discharge from speech therapy, Resident #4 continued to require 50% verbal cueing to manage texture at 60% accuracy. On 2/14/23 at 1:14 PM, during an interview, Staff #11, Dietician #2 stated that he/she had been employed by the facility since 8/8/22, following the departure of the previous Dietician (Staff #8). The Dietician, Staff #11, stated that he/she recalled reviewing Resident #4 ' s weights on 8/10/22, which was after the resident had been sent to the hospital and remembered thinking that a 20 lbs. weight loss in one week was odd. Although this was stated in the survey interview, no actions were taken to reevaluate or address the concern at the time the August weights were recorded. For Resident #4, the facility failed to ensure an accurate assessment of nutritional risk was conducted, failed to ensure an effective care plan was developed and maintained for nutritional services, failed to obtain ordered weekly weights during the first month of admission, failed to ensure recommendations for an added supplement were planned, ordered and implemented after an approximate 7% weight loss in 30 days, and failed to assess and evaluate the cause of additional weight loss when weights were obtained on two dates in August showing 19% weight loss over two months. In sum, the facility failed to meet the minimum requirements for planning and delivering care and failed to take necessary steps to protect Resident #4 from unnecessary and unexplained weight loss, constituting resident harm.

Based on observation, interviews, and medical record review, it was determined that the facility failed to ensure that 2 staff members were present to assist in the safe transfer of a resident. This finding resulted in harm to the resident and was evident in 1 resident (#3) of 37 residents reviewed in the Stage 2 sample. The findings include: A record review conducted on 01/06/2017 at 9:00 AM revealed that Resident #3's [DIAGNOSES REDACTED]. According to the Incident Report completed by the facility, on 12/31/2016 at approximately 5:35 PM an injury was sustained when Resident #3 fell and hit his/her head on the roommate's bed when a Geriatric Nursing Assistant (staff #17) attempted to transfer the resident from his/her bed into a wheelchair. The resident sustained [REDACTED]. A review of the facility documentation, including the Minimum Data Set, or MDS (a tool for nursing home resident assessment and care screening), and care plan (a guide that addresses the unique needs of each resident) revealed that before the fall occurred the facility had determined that Resident #3 required 2 staff for transfers. An interview conducted on 01/06/2017 at 11:00 AM with the Director of Nursing (DON) and Assistant Director of Nursing (staff #16) corroborated that the GNA had attempted the transfer alone when the resident had been designated as a 2 person assist with transfers. In a subsequent interview at 11:30 AM, the DON stated that it is facility protocol when the GNA's come on they go to the kiosk and pull up the Activities of Daily Living (ADL) statuses which is the first thing they see. They use this in lieu of a team sheet. The GNA's all have been educated on that. Activities of daily living (ADLs) are basic self-care tasks and includes a description on how a resident transfers. At 11:45 AM, per surveyor request, staff #13 accessed Resident #3 ' s information from a kiosk on the unit. It was observed that the resident's transfer status, 2 person assist, was clearly displayed on the first screen. At 11:55 AM the observation of the accessibility of Resident #3's transfer status in the kiosk was brought to the attention of the DON who stated that it was not the GNA's (staff #17) normal unit to work, she got pulled, but she should have known to look at the kiosk. Between 11:30 AM to 12:00 PM additional members of the survey team were sent to all of the units to conduct supplementary interviews. Staff #4, #5, #6, #7, #8, #9, #10, #11, #12, #18, #19, and #20 were able to either verbalize or demonstrate where and how to access a resident's transfer status. This finding revealed that the practice of how to obtain transfer status was consistent throughout the facility.

Based on medical record review and interview of facility staff it was determined the facility staff failed to honor a resident's advance directive regarding the right to refuse life sustaining treatments and failed to follow up with a resident's physician regarding medical orders for life sustaining treatments (also referred to as a MOLST). This was evident for 2 of 5 sampled residents selected for review. Resident #1 and Resident #2 were affected by the deficient practice. The findings include: 1. Resident #1 is an [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on [DATE]. Medical record review revealed the resident was admitted to the facility from another skilled nursing facility on [DATE]. The resident was admitted to the facility with a gastrostomy tube which had been placed on [DATE], prior to admission to the facility. A gastrostomy tube is placed through a surgically created artificial opening into the stomach through the abdominal wall, and is used to administer nutrition, hydration and medications for a patient that is not able to take anything by mouth. Medical record review of the resident's advance directive dated [DATE], which included the appointment of a health care agent and health care instructions, revealed the following health care instructions: "If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." Medical record review revealed on [DATE], the day that the resident was admitted to the facility, the resident's attending physician certified that the resident is not competent to understand and make medical decisions or sign documents due to dementia. The resident's attending physician further certified on [DATE] that the resident is in an end-stage condition, which is an advanced, progressive, irreversible condition that has resulted in severe and permanent deterioration indicated by incompetency and complete physical dependency. Medical record review of the Minimum Data Set (MDS), an assessment tool, dated [DATE] revealed that the resident is dependent for all activities of daily living and has severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 01. A score of 00 - 07 represents severe cognitive impairment. Between [DATE] through [DATE], the resident had Medical Orders for Life Sustaining Treatment including cardiopulmonary resuscitation (CPR) if arrest occurred as well as orders for artificially administered fluids and nutrition. Medical record review of the social worker's assessment revealed that as early as [DATE], the facility staff were aware that the resident had an advance directive. Medical record review revealed on [DATE], the physician completed a MOLST based on discussion with the resident's health care agent as named in the resident's advance directive. At that time, the physician gave an order for [REDACTED]. Since the resident's admission to the facility on [DATE], the facility staff has continued to give artificially administered fluids and nutrition in violation of the resident's right to refuse life sustaining treatments as made known in the resident's advance directive dated [DATE]. 2. Resident #2 has a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on [DATE]. review of the resident's medical record revealed [REDACTED]. physician via facsimile for the attending physician's signature. Further medical record review and interview of the Director of Nursing revealed that the completed MOLST was not on the resident's medical record. After surveyor intervention, the resident's attending physician completed the resident's MOLST on [DATE]. The social worker provided this information to the surveyor via facsimile on [DATE].

Based on medical record review and interview of facility staff it was determined the facility staff failed to provide appropriate care and services to a resident assessed with [REDACTED]. The findings include. Review of the Resident #1's medical record on 12/27/13 revealed that on 8/15/13 the nurse documented a change in resident status. The resident was assessed with [REDACTED]. The nurse further documented that Triple Antibiotic Ointment and a dry dressing were applied to the site after cleansing with normal saline solution. The resident's physician was notified and ordered a portable x-ray of the right lower leg to rule out a fracture. The physician failed to order a treatment to the site. On 8/17/13 the nurse documented that the resident's right shin had an open area surrounded by bruising and was tender to the touch. The nurse further documented that the area was cleaned, TAO (Triple Antibiotic Ointment) applied and a dry dressing. On 8/18/13 the nurse documented in the nursing progress note that the resident's right shin was bruised with an open area which was tender to the touch. The nurse further documented that the area was cleaned per the physician's orders [REDACTED]. On 8/18/13 the resident's physician examined the resident. The resident's physician documented that the resident had a swollen right ankle and that x-ray of the right ankle was negative for a fracture. The physician further documented that the resident's right ankle range of motion was normal and there was no [MEDICAL CONDITION]. There is no documented evidence that the physician assessed the resident's right shin wound. On 8/28/13 the nurse documented a change in resident status. The resident was assessed with [REDACTED]. The nurse documented that a mild amount of serosanguineous drainage was observed. The nurse documented that the tissue tear was cleansed with normal saline solution, TAO applied and a dry dressing. The physician was notified and gave no new orders. Further review of the resident's medical record and interview of the Director of Nursing on 12/27/13 revealed that there was no further assessment or treatment provided to the resident's right or left lower extremity wounds. On 9/5/13 the nurse documented a change in resident status. The resident was assessed with [REDACTED]. The nurse notified the resident's physician and an order was given to send the resident to the hospital emergency room for a stat Doppler study of the right lower extremity. The resident's hospital medical record was reviewed on 1/16/14 and 1/27/14. Review of the emergency department documentation revealed that the resident was sent to the emergency room for evaluation of worsening [MEDICAL CONDITION] and swelling of the right lower extremity. The emergency department documentation further noted that the wound on the resident's right shin had gotten progressively larger, redder and more swollen. Review of the hospital history and physical dated 9/5/13 revealed that the resident presented to the hospital with a chief complaint of increasing pain and swelling of the right lower extremity, ulceration of the right lower extremity and [MEDICAL CONDITION] of the right lower extremity. The resident was subsequently admitted to the hospital for treatment of [REDACTED].

Based on medical record review, review of the facility's investigation and interviews with facility staff, it was determined the facility failed to protect a resident from injury when being transferred in a wheelchair from the facility's van. The findings include: Resident #1 is a [AGE] year old with multiple [DIAGNOSES REDACTED]. The resident is alert and oriented. Interview with the Director of Nursing and the Transportation Aid/Geriatric Nursing Assistant (GNA) revealed that the resident is able to lock her own wheelchair. Review of the resident's medical record and review of the facility's investigation revealed that on 11/9/10, the resident was transported to a medical appointment via the facility's handicap access van. The resident was in her wheelchair when she was transported. Upon return to the facility, the Transportation Aid/GNA placed the resident on the wheelchair lift platform of the van and told the resident to lock her brakes. The lift platform was raised above the ground. When the Transportation Aid/GNA exited the van, she noted the resident was lying on the ground. Per statements obtained from the resident's daughter and granddaughter, who were present when the fall occurred, it was determined that neither the resident's daughter nor granddaughter witnessed the Transportation Aid/GNA check the resident's wheelchair breaks. In a statement obtained from the resident, the resident reported that she pushed the brake level forward to lock the wheelchair brakes but started to roll forward and was unable to stop her wheelchair from rolling off of the wheelchair lift platform of the van. The family confirmed the resident's statement. As a result of the fall from the van, the resident sustained [REDACTED]. The Transportation Aid/GNA failed to ensure that the resident's wheelchair brakes were locked prior to exiting the van. It was further determined that the van has a safety belt that is to be utilized when a resident is on the wheelchair lift platform. The safety belt was not utilized by the Transportation Aid/GNA because the safety belt was damaged. There is no documented evidence that the damaged safety belt had been reported to the maintenance staff. As a result of the accident which injured the resident, the Transportation Aid/GNA's employment with the facility was terminated. The maintenance staff evaluated the resident's wheelchair brakes and determined that the right brake had a drag and needed to be adjusted. The safety belt on the wheelchair lift of the van was repaired.