Every finding on record at Caroline Nursing and Rehab

Based on review of employee files and interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was evident for 5 (GNA #23, #24, #25, #26, #27) out of 5 GNAs' employee files reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 3/10/26 at 2:01 PM review of GNA #23's employee file revealed she was hired on 12/1/23; however, failed to reveal a performance review from 2025.On 3/10/26 at 4:29 PM review of GNA #24's employee file revealed she was hired on 12/27/17; however, failed to reveal a performance review from 2025.On 3/11/26 at 3:03 PM review of GNA #25's employee file revealed she was hired on 1/28/13; however, failed to reveal a performance review from 2025.On 3/11/26 at 4:17 PM review of GNA #26's employee file revealed she was hired on 10/17/22; however, failed to reveal a performance review from 2025.On 3/11/26 at 5:01 PM review of GNA #27's employee file revealed she was hired on 8/1/22; however, failed to reveal a performance review from 2025.On 3/12/26 at 8:36 AM in an interview with the Director of Nursing (DON) when asked about GNA performance reviews, he stated, Viventium (the facility's Human Resources (HR) platform) alerts when an employee's hiring anniversary is coming up. The HR Manager (HRM #17) prints off the evaluation and gives it to the Manager for that department. For example, she'll give nursing staffs to me or dietary staff to the kitchen manager.On 3/11/26 at 8:46 AM in an interview with the DON the surveyor shared the concern that there were no 2025 performance reviews observed in the 5 GNA employee files reviewed. When asked about the GNA performance reviews, he stated, I conduct them annually. HR forwards them to me and I do it, but it slipped through the cracks. None of the GNAs have had a performance review in the past 6 months. On 3/11/26 at 8:51 AM in an interview with HRM #17 when asked about GNA performance reviews, she stated, I let the managers know when it's time to complete an annual review. When asked how she gets the alert that an employee's hiring anniversary is coming, she stated, It's only if I log in [to Viventium] do I get an alert. There is no email sent. When asked what she was supposed to do once she received notification of an employee's upcoming hiring anniversary, she stated, I am to notify the department heads when the employees' anniversary is coming up. When asked if she had been alerted and seen employees' date of hire anniversaries, she stated, Yes, I have seen in my daily logging in [to Viventium] that an employee's anniversary is coming up. When asked if she communicated that information to the appropriate Manager or Department Head such as the DON for the nursing staff, she stated, No, I have not communicated to the DON that nursing staffs' date of hire anniversary was coming up. When asked why she stated, I don't know, there's been a lot of changes going on. When asked about the GNAs performance reviews, she stated, There is nothing to print off Viventium. Once I alert the manager, there is a paper form called Employer Evaluation that they do with the employee and then they give it to me to be filed in their employee file. The surveyor stated upon review there were no Employer Evaluation reviews observed in any of the 5 GNA files reviewed. HRM #17 verified and confirmed that if they were not in the employee's file, they had not been completed. On 3/12/26 9:14 AM in an interview with the Nursing Home Administrator, the surveyor shared the concerns that none of the 5 GNA employee files reviewed included a 2025 performance evaluation. Furthermore, the performance reviews are used to identify specific, in-service education and how could in-service trainings be determined if the performance reviews were not completed. The NHA acknowledged understanding of the concerns. Additionally, he verified and confirmed that none of the 5 GNAs had had a performance review completed. Cross reference F947

Based on review of employee files and interviews with facility staff, it was determined that the facility failed to develop, implement, and maintain an in-service training program for nurse aides to ensure all nurses' aides received 12 hours of training that included abuse prevention and dementia management annually and addressed areas of weakness as determined in nurse aides' performance reviews. This was evident for 5 (GNA #23, #24, #25, #26, #27) out of 5 GNAs' (Geriatric Nursing Assistants) employee files reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 3/10/26 at 2:01 PM review of GNA #23's employee file revealed she was hired on 12/1/23; however, failed to reveal evidence of the annual 12 hours of in-service training for 2025.On 3/10/26 at 4:29 PM review of GNA #24's employee file revealed she was hired on 12/27/17; however, failed to reveal evidence of the annual 12 hours of in-service training for 2025.On 3/11/26 at 3:03 PM review of GNA #25's employee file revealed she was hired on 1/28/13; however, failed to reveal evidence of the annual 12 hours of in-service training for 2025.On 3/11/26 at 4:17 PM review of GNA #26's employee file revealed she was hired on 10/17/22; however, failed to reveal evidence of the annual 12 hours of in-service training for 2025.On 3/11/26 at 5:01 PM review of GNA #27's employee file revealed she was hired on 8/1/22; however, failed to reveal evidence of the annual 12 hours of in-service training for 2025.On 3/12/26 at 9:44 AM the surveyor requested evidence of the 12 hours of in-service training for the 5 GNAs.On 3/12/26 at 11:05 AM in an interview with the Nursing Home Administrator (NHA) he verified and confirmed there was no evidence of the required 12 hours of in-service training for the GNA's requested. He stated the Director of Nursing had 12 binders up and ready to go moving forward. The surveyor shared this was a concern. Additionally, the surveyor shared the concern that none of the GNAs had had performance reviews, which is in part what determines what the GNA will receive training on. The NHA acknowledged and verbalized understanding of the concerns. Cross reference F730

Based on observations, staff interviews, and record review, it was determined that the facility failed to provide respiratory services consistent with professional standards of practice. This was found to be evident in 3 (Resident #13, Resident #34, and Resident #69) of 5 residents reviewed for respiratory care during the annual survey. The findings include: Oxygen therapy delivers extra oxygen to help users breathe, while a nebulizer converts liquid medicine into an inhalable mist. A nasal cannula consists of a flexible tube that is placed under the nose to deliver oxgyen. The tube includes two prongs that go inside the nostrils to deliver oxygen. 1) On 3/9/2026 at 8:11 AM, Resident #13's nebulizer was observed sitting on their bedside table. An aerosol mask with tubing was observed attached to the nebulizer. The mask was observed sitting on the bedside table, uncovered. The nebulizer tubing was not dated or labeled. Resident #13 stated they were unaware when the nebulizer tubing was last changed. On 3/9/2026 at 8:15 AM, Resident #69's nebulizer was observed sitting on their bedside table. An aerosol mask with tubing was observed attached to the nebulizer. The mask was observed sitting on the bedside table, uncovered. The nebulizer tubing was not dated or labeled. Resident #69 was also observed to be receiving humidified oxygen at 2 liters per minute (LPM) through a nasal cannula (NC) attached to an oxygen concentrator. Neither the nasal cannula nor the humidifier bottle was observed to be dated and labeled. Resident #69 stated they were unaware when the nebulizer tubing or NC were last changed. On 3/9/2026 at 8:25 AM, Licensed Practical Nurse (LPN) #5 observed the nebulizer and oxygen tubing with the surveyor. LPN #5 stated that it is the facility's expectation that oxygen and nebulizer tubing are changed weekly or more frequently if necessary and dated/labeled when changed. On 3/9/2026 at 8:30 AM, the Nursing Home Administrator (NHA) was made aware of surveyor concerns. On 3/10/2026 at 9:15 AM, Resident 69's medical orders were reviewed. There was no order in Resident 69's medical chart stating to change humidifier bottle, nebulizer mask/tubing, and NC tubing. On 3/10/2026 at 9:20 AM, Resident #13's medical orders were reviewed. There was no order in Resident #13's medical chart stating to change nebulizer mask/tubing. The facility's oxygen administration policy was reviewed on 3/10/2026 at 3:12 PM. The policy stated to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. It further stated to, change nebulizer tubing delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated, and to, keep delivery devices covered in plastic bag when not in use. 2) On 3/9/2026 at 9:15 AM, the surveyor observed Resident #34 lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the right side of the resident's bed. The oxygen concentrator did not have the humidifier bottle and the tubing and nasal cannula were on the floor under the residents clothes. The surveyor made the nurse, staff #12 aware of it and was told they would look into it. During a review of Resident #34's medical record conducted on 3/11/2026 at 12:31 PM, surveyor noted active physician orders dated 3/5/2026 for: Oxygen at 2 L/min via Nasal cannula. Change tubing night shift every Thursday. Date tubing and Change humidifier bottle night shift every Thursday. Date Humidifier bottle.: On 3/11/2026 at 1:45 PM, during a follow up observation tour, Resident #34's humidifier bottle was still missing and the tubing was on the floor and not dated. The surveyor made the DON aware of the situation an was told he would take care of it.

Based on medical record review and interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and/or documented that the information regarding Advanced Directives had been provided. This was found to be evident for 3 (Resident #1, #2,and #34) out of 3 residents reviewed for advance directives. The findings include: Review of Residents' (#1, #2, and #34) medical records revealed that the residents did not have either an Advanced Directive, a progress note stating that the Advance Directives had been explained and offered to the resident and/or their responsible representative or a Physician's Certificate stating the resident were incompetent to make a decision. On 3/12/2026 at 1:30 PM, a request was made with the DON for copies of the Advanced Directives for Residents #1, #2 and #34. The DON brought the surveyor copies of the Maryland Order for Life Sustaining Treatment (MOLST). He was informed that the MOLST forms were not Advanced Directives and he went to the Medical Directive who brought a copy of the Advanced Directives and stated that he and the Attending Physician gave every resident admitted a copy. He was asked if they documented that they did provide the residents a copy of the Advanced Directives and explained it to them. He said no and was reminded about the necessity of documentation to prove the Advanced Directives information had been provided.

Based on review of the medical record and interview with facility staff, it was determined the facility failed to ensure the local Ombudsman was notified prior to the resident's discharge or transfer. This was evident for 1 (Resident #95) out of 1 discharges reviewed during the investigative portion of the facility's recertification survey. The findings are:On 3/10/26 at 2:00 PM review of Resident #95's medical record revealed he/she was discharged from the facility on 1/12/26. Further review failed to reveal evidence that the Ombudsman was notified of the discharge. On 3/10/26 at 2:28 PM in an interview with the Nursing Home Administrator (NHA) when asked if the facility notified the Ombudsman prior to a resident's discharge or transfer, he stated, I'm not sure, I'll find out. On 3/11/26 at 7:44 AM the NHA provided a copy of the facility's January 2026 discharges and transfers and stated, It was sent late, but they told me to give it to you. When asked how the discharges and transfers were communicated to the Ombudsman, he stated, I think email, but I'll confirm. On 3/11/26 at 8:05 AM in an interview with the NHA he said the facility's process was for the Social Worker to email the discharges to the Ombudsman. The surveyor requested a copy of the email sent to the Ombudsman notifying him/her of the facility's January 2026 discharges.On 3/11/26 at 8:18 AM the NHA provided a copy of the email of the facility's January 2026 discharges that was sent to the Ombudsman. Review of the email revealed the resident list, including Resident #95, was sent to the Ombudsman on 3/10/26 at 4:02 PM. The surveyor shared this was a concern. The NHA acknowledged understanding of the concern.

Based on observations, medical record review, and staff interview, it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 2 (Resident #69, Resident #34) of 45 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Oxygen therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. 1) On 3/9/2026 at 8:15 AM, Resident #69 was observed receiving oxygen therapy via nasal cannula in their room. On 3/11/2026 at 10:24 AM, Resident #69's electronic health record was reviewed. Record review showed that Resident #69 was admitted to the nursing facility on 3/13/2024 for short term rehabilitation. The resident was later discharged and then readmitted to the facility in Fall 2024 and was transitioned to long term care and remained a resident of the facility ever since. Record reviews also revealed Resident #69 also had an active medical order for continuous oxygen at 2 liters per minute. Review of Resident #69's current care plan failed to reveal that a respiratory care plan was developed for oxygen therapy with measurable goals and nursing interventions/evaluations. On 3/11/2026 at 4:07 PM, the Director of Nursing (DON) was made aware of surveyor concern of the lack of oxygen therapy of Resident #69's care plan. The DON stated that it was an oversight of the facility and their expectation is that it should have been included in the resident's care plan and would update to reflect the resident's oxygen therapy. 2) On 3/9/2026 at 9:15 AM, the surveyor observed Resident #34 lying in bed. An oxygen concentrator (a machine that concentrates oxygen from the air) was on the right side of the resident's bed. During a review of Resident #34's medical record conducted on 3/10/2026 at 12:31 PM, surveyor noted active physician orders dated 12/14/2023 for: Oxygen at 2 L/min via Nasal cannula. Change tubing every week every night shift every Thursday. Date tubing and Change humidifier bottle every Thursday. Date Humidifier bottle. A nasal cannula consists of a flexible tube that is placed under the nose. The tube includes two prongs that go inside the nostrils to deliver oxygen. On 3/11/2026 at 8:33 AM, a review of Resident #34's care plan failed to reveal that a respiratory care plan was developed for oxygen therapy with measurable goals and nursing interventions/evaluations. The surveyor reviewed Resident #34's care plan with the DON during an interview on 3/11/2026 at 1:50 PM. DON confirmed that there was no focus, goal, or interventions on the care plan for the use of supplemental oxygen. DON stated that she was going to investigate.

Based on interview and record review, it was determined that the facility failed to provide activities of daily living (ADL) care by ensuring timely assistance with toileting. This is evident for 1 (Resident #96) of 7 residents reviewed for ADL care.The findings include: On 03/11/2026 at 9:49 AM, during investigation of Complaint 2656323, the surveyor interviewed the complainant and they stated that Resident #96 had contacted the local health department with concerns about care provided on 10/30/25. Review of the complaint showed that the resident reported s/he was left on the bedside commode for 2.5 hours this morning before staff responded to move him/her back. The Hoyer lifts are never charged. At 10:15 AM, review of the electronic medical record revealed that Staff #20 provided care to Resident #96 on the morning of the alleged incident; however, there were no entries in the treatment record or progress notes indicating that the resident had been left on the commode or required assistance. On 03/12/2026 at 9:30 AM, during interview, Staff #20 stated that Resident #96 had been left on the toilet by the previous shift. Staff #20 further stated that staff were unable to transfer the resident off the toilet because the bariatric Hoyer lift required for the resident was not charged. Staff #20 explained that the bariatric Hoyer lift used a different battery than other lifts in the facility and staff often failed to plug it in. Additionally, because it was the only lift of that type, staff could not obtain a charged battery from the charger due to incompatibility. At 2:08 PM, during interview, the Director of Nursing (DON) stated they were unsure about the incident and would need to verify the weight limits and usage of the facility's Hoyer lifts. At 2:25 PM, during interview, the Nursing Home Administrator (NHA) stated that the Hoyer lifts in the building had a weight limit of up to 600 pounds and was unable to explain why Resident #96 required a specific bariatric Hoyer lift. The surveyor confirmed at this time that the resident did not exceed the weight limit of the other Hoyer lifts in the building. The NHA stated they would attempt to obtain additional information regarding why other lifts were not used. By the end of the survey, the facility had no additional information clarifying why alternative equipment could not be used to assist Resident #96 off the toilet.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure staff followed physician orders for a resident. This was evident for 1 (Resident #3) out of 45 residents reviewed during the facility's recertification survey.The findings include:On 3/11/26 at 10:28 AM review of Resident #3's medical record revealed a physician order for Alert Charting: Complete a progress note every day and evening shift for ABX (antibiotic) use for UTI (urinary tract infection) until 03/13/2026 23:59 with an order date of 3/2/26 2:33 PM. The order specified a frequency of every day (7 AM-3 PM) and evening (3 PM-11 PM) shift.Further review revealed progress notes were completed on:3/4/26 day shift3/5/26 day shift3/6/26 day shift3/8/26 day shift3/11/26 day shiftHowever, continued review failed to reveal a progress note observed for any evening shift for 3/2/26 to 3/10/26. Additionally, there were no progress notes observed for day shift on 3/3/26, 3/7/26, 3/9/26 or 3/10/26.On 3/11/2026 at 11:23 AM in an interview with the Director of Nursing (DON) when asked if he observed a progress note for any evening shifts starting from 3/2/26 or on 3/3, 3/7, 3/9 or 3/10 day shift, he stated, no. When asked about the facility's expectations regarding orders for residents, he stated that the expectation was that the staff followed the physician orders. The surveyor shared this was a concern. The DON acknowledged understanding of the concerns.

Based on observation and staff interview it was determined that the facility failed to maintain an environment free of accident hazards. This was evident for 1 (Resident #81) of 1 residents reviewed during the recertification process. The findings include: During the initial observation on 3/9/3036 at 8:45 AM, the surveyor reached for a chair in Resident #81's room and found that it was very wobbly. It was discovered that the back left leg of the chair was broken and about 2.5 inches shorter than all of the rest of the legs. The DON was made aware of the broken chair and stated he would tell the maintenance director to remove it. On 3/10/2026 at 12:15 PM on a follow-up observation tour, it was discovered that the chair was still in the room, and still broken. On 3/10/2026 at 1:45 PM, the Maintenance Director was shown the chair and immediately removed it and promised to check all the other chairs in the building for disrepair.

Based on observation, record review and staff interview, it was determined that the facility failed to ensure a side-rail use assessment was fully completed prior to installation of assist rails, including documentation of interventions attempted prior to use and resident consent. This deficient practice was evident for 1 (Resident #4) of 1 residents reviewed for bedrails.The findings include: On 3/09/2026 at 9:56 AM, Resident #4 was observed to have a side rail in place on their bed. On 3/11/26 at 10:42 AM, review of the electronic medication administration record (eMAR) and the side-rail use assessment form for Resident #4 revealed the assessment appeared incomplete. The section documenting interventions attempted prior to the use of side rails was not completed, and the document did not contain the resident's signature indicating consent. On 3/11/26 at 12:15 PM, during interview, the Director of Nursing (DON) explained the facility's process for side-rail installation. The DON stated that an evaluation is completed first, the side-rail use assessment form is then filled out, and maintenance installs the rails afterward. When asked why the form was not signed by the resident, the DON stated that Resident #4 had difficulty using their hands. When asked why the form lacked a date or documentation of verbal consent, the DON did not provide additional documentation at that time. On 3/11/26 at 12:35 PM, Staff #13 stated that maintenance installs bed rails and that they are checked monthly by maintenance staff. On 3/11/26 at 2:41 PM, during interview, Staff #19 stated that Resident #4 had contractures of the lower body, and that Occupational Therapy (OT) recommended an assist rail to support the resident's mobility. Staff #19 stated OT completes their portion of the assessment form and nursing then completes the remainder of the assessment. The Nursing Home Administrator (NHA) confirmed during the interview that the nursing portion of the assessment form for Resident #4 was incomplete, indicating that it may not have been completed. The surveyor requested any additional documentation if discovered. No further documentation was provided prior to the end of the survey on 3/12/26.

Based on observation, staff interview and medical record review, it was determined that the facility failed to provide residents' medications in a timely manner. This was evident for 2 (#14, #54) of 4 residents observed during medication administration. The findings include: Observation was made, on 3/10/2026 9:15 AM, of Staff #11 preparing medications for Resident #14. Staff #11 dispensed 4 pills in a medication cup. They stated there were 2 medications that were not in the medication cart; Abilify and a Lidocaine Patch. Staff #11 told the nurse Staff #12 stated he/she would have to re-order them from the pharmacy. The Abilify had been ordered on 3/6/2026 but had not come in yet. Staff #11 was asked why the medications were not available and the response was the pharmacy hadn't delivered them yet. Staff #11 stated he hadn't received the Abilify in 2 days. Staff #11 said she would need to go to the other hall to get the Lidocaine patch. The surveyor accompanied Staff #11 to Resident #54's room to observe medication administration on 3/10/2026 at 10:16 AM. Staff #11 poured 5 medications and said that the residents Tizanidine was missing. They checked the computer that said it had been ordered the previous day and they hoped it would get there today. The surveyor asked if medications were missing often and they said yes, at least once or twice a week. I let the nurse know and they call to try and get it. On 3/12/2026, at 2:30 PM, the surveyor spoke with the Medical Director who stated that missing medications is a constant problem that he is working on.

Based on observations and staff interviews, it was determined that the facility staff failed to properly label multi-dose medications and properly secure medications in blister packs. This was evident in 2 of 2 medication carts reviewed during the annual survey.The findings include: During the Medication Administration observation on 3/10/2026 at 9:52 AM, with the E wing medication cart it was observed that a large number of pills and capsules had come out of the blister packs and were lying on the bottom of the medication cart drawers. (A blister pack is a type of medication packaging in which pills and capsules are sealed in plastic with a cardboard backing. The medication is pushed through small foil windows in the cardboard.) In 2 sections of the medication cart drawer there were 62 pills and capsules. Staff #11 observed the retrieval of the medication from the drawer bottom and the DON was given the cupful of pills for disposal. Also, during this observation, it was noted that none of the over the counter bulk stock medication were marked with the date they were opened. Staff #11 was made aware and began marking them immediately after finishing administering morning medication. On 3/22/2026, at 9:20 AM, the surveyor did a Medication Storage observation on the Nurse's medication cart on D/E wing. It was also noted on this cart that none of the bulk over the counter stock had the date it was opened marked on it. Staff #12 was made aware. After the medication cart observations, Employees #11, #12 and the DON acknowledged the loose pills and capsules and unmarked stock medication as being a deficit practice and stated that they would work immediately to remedy it.

Based on observations and staff interviews, it was determined that the facility failed to use appropriate infection control practice during urinary catheter maintenance. This was found to be evident in 1 (Resident #31) of 44 residents reviewed during the annual survey. The findings include: A urinary catheter (also known as a foley) is a thin, flexible, rubber or plastic tube that drains urine from the bladder into an external drainage bag. It is used when a person is unable to urinate naturally due to medical conditions, surgery, or physical blockages. Keeping the external bag off the floor is a critical step in preventing Catheter-Associated Urinary Tract Infections (CAUTIs). On 3/9/2026 at 7:14 AM, Resident #31's urinary catheter external bag was observed to be laying on the floor, next to the resident's bed. On 3/9/2026 at 7:18 AM, the facility's infection preventionist (IP) observed the catheter bag lying on the floor with the surveyor. IP stated that it's the facility's expectation that the catheter bag is not on the floor and should be securely hanging from the resident's bed. On 3/10/2026 at 3:00 PM, the nursing home administrator was made aware of surveyor concern.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure the required staffing information was complete, accurate, and current and posted in a prominent place readily accessible to residents, staff, and visitors on a daily basis at the beginning of each shift. This was evident for all 4 units observed during the Staffing investigation portion of the recertification survey. The findings include: An observation of the facility's 4 nursing units took place on 3/9/26 at 7:03 AM. During the observation, a dry erase board was found on each unit that contained some staffing information for the unit. The D wing board noted the date, the shift, the nurse, and the 2 GNAs (Geriatric Nursing Assistants); however, it did not display the facility name, the resident census, nor the total number of staff or the actual hours worked by the following categories of licensed and unlicensed nursing staff per shift: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Certified Nurse Aides (CNAs). Additionally, the board did not contain information regarding the other shifts (3 PM- 11PM or 11 PM- 7AM). The C wing board only had displayed a portion of the date, March , 2026. There was a Unit Census of 19 written; however, the date was not displayed, so it was unclear which date and/or shift this number represented. Furthermore, the C wing board did not display the facility name, the resident census, nor the names or total number of staff and/or the actual hours worked by the following categories of licensed and unlicensed nursing staff per shift: RNs, LPNs, or CNAs. The B wing board had no information displayed on it.On 3/9/26 at 7:27 AM in an interview with Unit Manager (UM #4) the surveyor shared the concerns about the boards not including all required staffing information. UM #4 acknowledged understanding of the concerns. When asked who was responsible for completing the boards with the required staffing information, she stated, I usually do the boards when I come in. For day and evening shifts, it's done. I'm not sure about night shift to be honest. When asked if the staffing information was posted anywhere else, UM #4 stated in the break room and walked the surveyor over to it. The surveyor requested a copy. On 3/9/26 at 8:13 AM review of the staffing information provided by UM #4 revealed the schedule for the day. Further review revealed the facility name, date, and the licensed and unlicensed nursing staff per shift; however, it did not include the total number of licensed and unlicensed nursing staff per shift, or the actual hours worked by licensed and unlicensed nursing staff per shift, or the resident census. Furthermore, this was not posted in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift, as it was in the staff's break room.On 3/10/26 at 2:57 PM in an interview with the Director of Nursing (DON), when asked if staffing information was posted anywhere else aside from the 4 nursing unit boards and in the break room, he stated, No. A dual observation of the 4 nursing units staffing boards was conducted. When asked if the posted daily staffing included the facility name, resident census, and the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff per shift: RNs, LPNs, or CNAs, he stated no, the facility name was not on any of the 4 nursing unit boards nor was the total number of staff by the following categories of licensed and unlicensed nursing staff per shift: RNs, LPNs, and CNAs, nor the actual hours worked by licensed and unlicensed nursing staff per shift. During the interview, he stated that there was the resident census posted on B, C, and E wing; however, it was not displayed on the D wing board. The DON said, They don't post that on here [the nursing unit boards]. That information is out front. The surveyor and DON walked to the front reception desk and the DON handed the surveyor the [NAME] Staffing Posting. The surveyor stated that when asked earlier in the interview if the facility staffing information was posted anywhere else, he had stated no. He said, I forgot because I come in the employee entrance. When asked if the staffing information being posted at the reception desk was accessible to residents and staff he said, I believe so. It's better than if it was at the time clock near the schedule. A dual observation was conducted of the [NAME] Staffing Posting sheet. When asked if it included the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff: RNs, LPNs, or CNAs for each shift, he stated, No, maybe we can change the template. I'll have to talk with the team. The surveyor shared the concern that the posted sheet at the receptionist's desk did not specify the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff: RNs, LPNs, or CNAs for each shift and was not accessible to all residents and staff. The DON acknowledged understanding of the concerns and confirmed that the facility did not post a document or board that contained the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff: RNs, LPNs, or CNAs for each shift.

Based on the investigation of complaints, reviews of medical records, and interviews with staff, it was determined that the facility failed to 1) appropriately manage narcotic medications, and 2) give medications as ordered by a Physician. This was evident for 4 (Resident #4, #8, #9, and #12) of 14 residents reviewed during the complaint survey. The findings include: Controlled substances must be dispensed and administered exactly as prescribed by an authorized practitioner. Any alteration (e.g., changing dose form, splitting, compounding, or storing unused portions) must comply with federal law and institutional policy. [U.S Drug Enforcement Administration (DEA) Diversion Control Division-21 CFR part 1301 and 1304 ] Controlled substances shall not be pre-drawn, pre-split, or pre-prepared for later administration. Any partial tablet prepared for a single dose and not administered must be immediately and properly wasted. [State Nursing and Pharmacy Boards] 1) A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 had a prescribed medication for pain, Oxycodone 15mg every 8 hours, from 7/18/25 to 7/28/25. The order was changed on 7/29/25 at 11:59 PM to Oxycodone 15mg, give 7.5mg by mouth every 8 hours for pain. On 10/27/25 around 10:30 AM, a review of the Medication Administration Record (MAR) for July 2025 revealed that Oxycodone 7.5mg was administered on 7/30/25 at 1:37 PM and 10:03 PM, and on 7/31/25 at 8 AM and 2 PM. The surveyor reviewed Resident #4's controlled drug sheet for Oxycodone 15mg on 10/27/25 at 11 AM. The review revealed a handwritten statement on the top left side that read: Dosage is 7.5mg cut in half and waste other half if needed per NP 7/30/25. It also recorded medication administration on 7/30/25 at 1:37 PM and 10:03 PM, and on 7/31/25 at 8 AM and 2 PM, all with a half dose of the tablet. However, there was no documentation for wasted doses on 7/30/25 and 7/31/25. In an interview with Staff #1 (Licensed Practical Nurse) on 10/27/25 at 1:03 PM, she stated, If a narcotic medication has a score line, we can split it. But it must be discarded with two nurses. We can't keep the remaining dose. On 10/29/25 at 11:06 AM, the surveyor reviewed the policy and procedure named Controlled Substance Administration & Accountability. The policy stated that when the dosage form dispensed is larger than the dose, the total dose administered and that portion destroyed is documented to show the total disposition of the drug. Also, on 10/29/25 at 11:08 AM, in an interview with Staff #8 (Vice President of Clinical Services), she confirmed that nurses should not be splitting narcotics. She said, If they needed to, the remaining half of it should be destroyed with two nurses' signatures. During the exit conference with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 10/29/25 at 11:15 AM, the surveyor shared the above concern. The DON and NHA validated the concern. 2a) On 10/27/2025 at 9:45 AM, review of Resident #8's medical record revealed the following: A Physician's order dated 09/03/2025 on the medication administration record for Calcium Citrate Oral (Calcium Citrate is a mineral that plays an important role in building strong bones and maintaining heart health.) tablet to give one tablet by mouth 2 times a day. However, further review of the Medication Administration record, Calcium Citrate was documented as 9 (see nurses notes) 16 times throughout the month of September. On 10/27/2025 at 9:45 AM, continued review of the nurse's progress notes for the month of September indicated Nurses notes documented for the Calcium Citrate as medication not here. There was no evidence that indicated that the Pharmacy, or a Physician was notified about the unavailable medication. On 10/27/2025 at 9:45 AM, the surveyor reviewed a Physician order dated 09/03/2025 on the medication administration record for Listerine Mouth/Throat Liquid (Mouthwashes) to give 15 milliliters (ml) by mouth three times a day for Dry Mouth. However, further review of the Medication administration records the Listerine Mouthwash was documented as, 9 (see nurses note) 26 times for the month of September. On 10/27/2025 at 9:45 AM, continued review of the nurse's progress notes for the month of September indicated Nurses notes documented for the Listerine as medication unavailable. There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication. On 10/27/2025 at 9:45 AM, the surveyor reviewed a Physician's order dated 09/18/2025 on the medication administration record for Potassium Chloride Tablet Extended Release to give 1 tablet orally two times a day for Low potassium. However, further review of the Medication Administration record revealed the Potassium was documented as 9 (see nurses Notes) 2 times for the month of September. On 10/27/2025 at 9:45 AM, Continued review of the nurse's progress notes for the month of September indicated Nurses notes documented for the Potassium as medication unavailable. There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication. 2b) On 10/27/2025 at 10:45 AM, a review of Resident #9's medical record revealed the following: A Physician's order dated 09/08/2025 on the medication administration record for Trelegy Ellipta Inhalation Aerosol Powder (a medication used to improve lung function and breathing) to take 1 puff inhaled orally one time a day for Chronic Obstructive Pulmonary Disease (COPD) which is a lung disease that cause airflow obstruction and breathing difficulties. However further review of the medication administration record revealed from 09/08/2025 through 09/13/2025 was documented as 9 (see Nurses note) for those 6 days. On 10/27/2025 at 10:45 AM, continued review of the nurse's progress notes for the month of September indicated that nurse's notes were documented for the Trelegy as medication unavailable. There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication. 2c) On 10/27/2025 at 12:30 PM a review of Resident #12's medical record revealed the following: A Physician's order dated 11/15/2023 on the medication administration record for Fish Oil Oral Capsule 1000 MG (Omega-3 Fatty Acids) Give 1 tablet by mouth one time a day related to Cerebrovascular disease (a health condition that affect the blood vessels in the brain) documented 9 (see nurse notes) from September 15, 2025 through September 23rd, 2025 a total of 8 days. On 10/27/2025 at 12:30 PM, continued review of the nurse's progress notes for the month of September indicated that nurse's notes were documented for the Fish Oil as medication unavailable. There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication. On 10/27/2025 at 1:20 PM during an interview, Staff #3 Certified Medication Aide (CMA) stated that if a medication is unavailable, she documents in the electronic medical record the medication is unavailable and informs the nurse. On 10/27/2025 at 1:25 PM during an interview, Staff # 4 Registered Nurse (RN) stated if a medication is unavailable, the Pharmacy must be contacted to ascertain the medication's delivery status. The Physician should be notified for an alternative medication, and the Omnicell (a backup system for nurses to retrieve medication) should be checked. Notification to both the Physician and Pharmacy is required on the first day of the medication's unavailability. On 10/28/2025 at 8:35 AM, during an interview with the Director of Nursing (DON) stated that if a medication is unavailable, the pharmacy would be contacted for a refill, or the backup system would be used to obtain the medication. Nurses would contact the Physician if a medication were on backorder. The Director of Nursing (DON) was informed of concerns at this time.

Based on medical record review and staff interview it was determined that the facility failed to ensure the discharge of a resident was documented in the medical record that included the resident's status at the time of discharge and the reason for the discharge. This was identified for 1 (Resident #12) of 3 residents reviewed for discharge during the complaint survey.The findings include:On 10/27/2025 at 12:30 PM a review of Resident #12's medical record revealed: A Transfer/Discharge Report that include Resident #12's information of an admission date of 11/11/2023 and a discharge date of 09/23/2025 for transfer/discharge to an acute care hospital. However, further review of Resident #12's medical record revealed no indication of Resident's status or the reason for the transfer/discharge to the hospital. On 10/27/2025 at 1:25 PM during an interview, Staff #4 Registered Nurse (RN) stated if a resident had a change in condition, an assessment would be completed. An EInteract Change in Condition form is completed, the physician is notified, and all actions are documented in the progress notes of the Electronic medical record.On 10/28/2025 at 8:35 AM during an interview, the Director of Nursing (DON) stated that when a resident is transferred to the hospital, the nurse completes an EInteract form, and a physician order would be obtained.On 10/28/2025 at 12:26 PM the DON verified there was no documentation or Physician order for Resident #12's change in condition that resulted in him/her being transferred to the hospital on [DATE]. At this time the DON was made aware of the concern.

Based on review of Intakes, medical record review, and staff interview it was determined that the facility failed to 1) properly monitor a resident's status after a significant medication error, 2) Notify the physician before withholding a medication used to regulate blood sugar, and 3) ensure that a resident's medications were administered as ordered. This was evident for 2 (Resident #13 and #4) of 2 residents reviewed for medication administration during this complaint survey. The findings include: Insulin is used to regulate blood sugar levels. According to the American Diabetes Association, fast acting insulin begins to work about 15 minutes after injection, peaks in about one or two hours after injection, and lasts between two to four hours. Long-acting insulin takes 6 hours to reach the bloodstream, has no peak, and is effective for 36 hours or more. 1) On 10/27/2025 at 9:00 AM in review of Intake # 2634348, an anonymous source, expressed concerns related to medication errors. On 10/27/2025 at 11:20 AM, a review of the facility incident log provided by the Director of Nursing (DON) revealed a medication error dated 08/19/2025 at 7:40 AM. On 10/27/2025 at 11:40 AM, a review of the medication error investigation provided by the DON revealed, during breakfast, the training nurse administered 10 units of fast-acting insulin that was not needed instead of the scheduled long-acting insulin. On 10/27/2025 at 2:50 PM, a review of Resident #13's medical record revealed the following: on 08/19/2025 at 07:52 AM a progress note that indicated new orders were received to continue to monitor blood sugars every 15 minutes until Resident #13 was transferred out for an office visit. However, there was no evidence of a Physician order in Resident #13's medical record for the monitoring of blood sugar. On 10/27/2025 at 2:50 PM, further review of Resident #13's medical record revealed blood sugar levels were documented on 08/19/2025, at the following intervals: -8:16 AM (24 minutes after the previous reading) -8:45 AM (29 minutes after the previous reading) -9:20 AM (35 minutes after the previous reading) -10:09 AM (49 minutes after the previous reading) On 08/19/2025 at 11:51 AM a progress note for Insulin Lispro (fast acting insulin) sliding scale with a notation Patient out of facility for provider appointment. On 10/28/2025 at 8:30 AM during an interview, the Assistant Director of Nursing stated that he had made the medication error on 08/19/2025 with Resident #13. He informed the Nurse Practitioner and initiated blood sugar monitoring. He couldn't recall if the ordered 15-minute blood sugar monitoring period was 2 or 3 hours but acknowledged he should have placed the order in the Electronic medical record. He documented the blood sugar monitoring in the vital signs section of the electronic medical record. He confirmed that blood sugars were not being monitored every 15 minutes following the insulin medication error. On 10/28/2025 at 8:45 AM during an interview, the Director of Nursing stated that if a physician ordered blood sugar monitoring every 15 minutes, such an order should be documented in the medical record 2) On 08/26/2025 at 11:56 AM a progress note for Resident #13 indicated that Insulin Glargine (a long-acting insulin), 10 units once daily, was held due to low morning glucose. However, a review of Resident #13's medical records showed no evidence of physician notification or Physician order to hold the Insulin Glargine for low blood sugar. On 10/28/2025 at 8:45 AM during an interview, the Director of Nursing indicated that if a nurse were to withhold scheduled insulin, he would expect a physician's order and notification to the physician. 3) A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 had a prescribed medication for pain, Oxycodone 15mg every 8 hours, from 7/18/25 to 7/28/25. The order was changed to Oxycodone 5mg every 6 hours as needed, starting on 7/29/25. On 10/27/25 around 10:30 AM, a review of the Medication Administration Record (MAR) for Resident #4 for July 2025 revealed that Oxycodone 5mg was administered on 7/29/25 at 00:37 AM and 07:15 AM. However, a further review of Resident #4's controlled drug record for Oxycodone 15mg showed that the resident was dispensed the Oxycodone 15mg tablet on 7/29/25 at 00:37 AM and 7:15 AM. There was no additional controlled drug sheet for the Oxycodone 5mg dose that was ordered. During an interview with the Director of Nursing (DON) on 10/27/25 at 12:21 PM, the surveyor reviewed Resident #4's medical record with the DON. The DON verified that Resident #4 did not have medical records supporting the administration of Oxycodone 5mg. He confirmed that, per the medical records, Resident #4 received Oxycodone 15mg on 7/29/25 instead of the ordered 5mg of Oxycodone. The surveyor shared concern with the DON that Resident #4 received the wrong dose of Oxycodone on 7/29/25.

Based on the investigation of complaints, record review, and staff interviews, it was determined that the facility staff failed to document the administration of medication in a resident's Medication Administration Record (MAR). This was evident for one (Resident #4) of the four residents reviewed for medication administration during the complaint survey.The findings include:A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 received Narcan (naloxone), a life-saving drug that can reverse an opioid overdose, on 7/29/25 due to a lethargic condition.A further review of Resident #4's progress note revealed that Staff #19 (Registered Nurse) documented on 7/29/25 at 1 PM: This nurse has made the clinical decision to Narcan resident once. However, there was no documentation for the medication in the MAR.During an interview with Staff #1 (Registered Nurse) on 10/27/25 at 1:03 PM, she stated that a resident who received Narcan should be documented in both the MAR and the progress note.In an interview with the Director of Nursing (DON) on 10/29/25 around 1 PM, the surveyor shared the concern that the facility staff did not document Resident #4's Narcan administration. The DON validated the concern.

Based on closed medical record review and interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #1). This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of Resident #1's closed medical record on 06/27/25 revealed that Resident #1 was admitted to the facility on [DATE] and suffers from Major Depression. On 12/05/24, Resident #1's physician instructed the nursing staff to administer the antidepressant, Lexapro, 5 mg, orally, to be given daily and to also administer Lexapro, 10 mg, orally, daily along with the 5 mg tablet to equal 15 mg daily. This was 2 different physician orders. Review of Resident #1's January, February, and March 2025 medication administration records revealed the nursing staff administer 15 mg of Lexapro daily. On 03/15/25, Resident #1's physician changed Resident #1's Lexapro order instructing the nursing staff to administer Lexapro, 20 mg, orally, every day for major depression. Further reviews of Resident #1's March, April, May, and June 2025 medication administration records revealed the nursing staff was administering Lexapro 20 mg daily to Resident #1 but also administering an additional 5 mg tablet of Lexapro (25 mg total) between 03/15/25 and 06/24/25. The 5 mg Lexapro physician order and the 20 mg Lexapro physician order were 2 separate physician orders. Review of Resident #1's psychiatric consultations for 2025 revealed the psychiatric consultant assessed Resident #1 on 04/10/25, 04/25/25, and 05/16/25 and indicated Resident #1 was receiving 15 mg of Lexapro daily. A review of Resident #1's monthly Pharmacist medication review between March 15 and June 24, 2025, revealed Resident 1's medication regimen was reviewed on 04/11/25, 05/12/25, and 06/10/25. Reviews of these individual assessments did not reveal any recommendations from the reviewing Pharmacist regarding the amount of Lexapro being administered to Resident #1. In an interview with the vice president of clinical services on 06/27/25 at 2:05 PM, the vice president of clinical services was unable to explain if Resident #1 was to receive an addition 5 mg of Lexapro after the dose was changed on 03/15/2025 from 15 mg to 20 mg daily.

Based on record review and interviews, it was determined that the facility failed to ensure that all nursing staff had competency evaluations. This was evident for six (Licensed Practical Nurses #19, #40, #41, Geriatric Nursing Aides #42, #43, and #44) of the six randomly selected nursing staff reviewed for competencies. The findings include: The American Nurses Association defines nursing competence as an expected level of performance that integrates knowledge, skills, abilities, and judgment. A review of the employee training files on 11/19/2024 at 9:39 AM revealed the following: 1. Licensed Practical Nurse (LPN) #19 was hired in May 2023. No competency evaluation was found for LPN #19 for 2023. 2. LPN #40 was hired on 10/09/2023. No competency evaluation was found for LPN #40. 3. LPN #41 was hired on 8/11/2022. No competency evaluation was found for LPN #41 in 2023. 4. Geriatric Nursing Assistant (GNA) #42 was hired on 12/27/2017. There were documented competencies for 4/2021 and 3/2022, but no competencies evaluation for 2023 for GNA #42. 5. GNA #43 was hired on 1/28/2013. Competency evaluation was found for 1/2020, 3/2021, 3/2022, but no competency evaluation was documented for 2023 for GNA #43. 6. GNA #44 was hired on 1/02/2023. No competency evaluation was found for GNA #44. On 11/19/2024 at 11:48 AM, the Staffing Coordinator (staff #24) was asked about staff training and competencies. She stated that during onboarding, the staff was given a packet of training to be conducted by the Assistant Director of Nursing (ADON) or Director of Nursing (DON), who was also responsible for competencies. An interview was conducted on 11/19/2024 at 4:08 PM with the ADON, who stated that competency training was not being done. On 11/22/2024 at 08:36 AM, the DON was made aware of staff competency training concerns.