Every finding on record at Carroll Park Healthcare

Based on reviews of a medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #1) of 3 residents reviewed during a complaint survey.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in conditions that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.During the review of Resident #1's electronic medical record on [DATE], it was discovered that Resident #1 had a physician's order, dated [DATE], to a Full Code. Further reviewe of Resident #1's paper clinical record revealed a MOLST form that indicated Resident #1 wanted to be a NO CPR, Option A-2, Do Not Intubate (DNI). Do not use any artificial ventilation. Do not give any blood products. Do not provide acute or chronic dialysis. In an interview with the facility administrator and the director of nurses on [DATE] at 4:30 pm, the facility administrative staff were made aware of the medical record issue.

Based on complaint, reviews of a clinical records, and resident and staff interviews, it was determined that the facility staff failed to provide treatment to maintain dental health for Resident #1. This is evident for 1 out of 3 residents reviewed during a complaint survey. The findings include: Review of complaint 3055728 on 06/29/26 at 11 am listed an allegation that Resident #1 was not given access to care. Review of Resident #1 clinical record on 06/29/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to a stroke with left hemiparesis, s/p craniotomy with swelling around the right ear, chronic pain, migraines, insomnia, trigeminal neuralgia and bruxism. Resident #1 is dependent upon the nursing staff for several aspects of their care. Further review of Resident #1's June 2026 physician's orders revealed the following dental orders:1) 12/17/25 - Have Resident #1 be evaluated and treated by the facility Dentist as needed.2) 03/18/26 - Have Resident #1 be evaluated and treated by the facility Dentist services.3) 03/28/26 - 7 am, Have Resident #1 be evaluated and treated by the facility Dentist for the diagnosis of Bruxism. (Bruxism - is the medical term for the involuntary grinding, clenching, or gnashing of teeth. It can occur while awake or asleep, and often results in jaw pain, headaches, tooth wear, and sleep disruption.) In an interview with Resident #1 on 06/30/26 at 12:35 pm, Resident #1 stated that they have not been seen by a dentist since being admitted to the facility. Resident #1 stated that they have a history of grinding teeth. In an interview with the facility Director of Medical Records and Scheduler on 06/302/6 at 2:22 pm, the Director of Medical Records and Scheduler stated that the facility has a dental service that comes to the facility to consult with residents. The Director of Medical Records and Scheduler confirmed that Resident #1 has not been seen by a Dentist.

Based on complaint, reviews of a clinical record, and staff interview, it was determined that the facility failed to notify Resident #2's representative in a timely manner after a fall in the shower room. This was evident for 1 (Resident #2) out of 3 residents reviewed during a complaint survey. The findings include: Review of complaint 3055512 on 06/29/26 revealed an allegation that Resident #2 had 2 falls (on 06/12/26 and 06/13/26) after being admitted and that Resident #2's responsible party was not immediately notified of the falls. Review of Resident #2's clinical record on 06/29/26 revealed that Resident #2 was admitted to the facility on [DATE] after suffering an ischemic stroke with thrombolysis and thrombectomy, aphasia, dysphagia, and being unsteady of their feet and in need of assistance with care. Resident #2 had a BIMS score of 11/15 as documented on 06/18/26. Further review of Resident #2 clinical record revealed that Resident #2 was found on their knees on 06/12/26 at approximately 8 pm. A review of the 06/12/26 post fall SBAR communication form signed on 06/12/26 by LPN#1 revealed that LPN#1 did not notify Resident #2's representative after this fall because no one was listed. LPN#1 also documented Resident #2 was not identified with any injuries and did not hit their head during the fall. Further review of Resident #2's clinical record revealed nursing documentation od a Near Miss - Fall on 06/13 26 at 12:15 pm. The Near Miss - Fall indicated that a geriatric nursing assistant (GNA) informed the nurse that Resident #2 was lowered to the floor which was a near fall. The nursing staff documented that Resident #2 stated that he almost fell, but due to both GNA's being in the shower, he was lowered to the floor. A review of the facility Fall Prevention and Management Policy on 06/30/26 revealed the facility policy had an effective date of 05/15/2025. The Fall Prevention and Management Policy defined a FALL as: an unintentional change in position, coming to rest on the ground, or a lower level. A NEAR MISS is defined as a slip, trip, or loss of balance that does not result in a fall to the ground. In an interview with LPN#2 on 06/30/26 at 2:48 pm, LPN#2 stated that a GNA informer her that Resident #2 had a near miss fall while in the shower and that Resident #2 was lowered to the floor. LPN#2 stated that she was aware of Resident #2 falling in the shower. LPN#2 stated that she did not notify Resident #2's responsible party of the fall because no one had informed her that Resident #2 fell in the shower. LPN#2 stated that later in the day on 06/13/26 at 4:30 pm, the oncoming nurse informed her that Resident #2 had a fall in the shower around 12 noon on 06/13/26 and that Resident #2's family was inquiring why there was not a phone call to the responsible party at the time of the fall in the shower.

Based on observation, medical record review, and staff interview, the facility failed to ensure that enteral nutrition was administered in accordance with physician orders and accepted standards of nursing practice for 1 (#4) of 3 residents reviewed for enteral feedings. This deficient practice resulted in the resident receiving significantly less enteral nutrition than ordered due to incomplete physician orders and the facility's failure to ensure the feeding was administered as prescribed.The findings include:During a complaint investigation (Complaint #3039711) conducted on 06/24/2026 at approximately 9:00 a.m., observation of Resident #4 revealed the enteral feeding formula bottle hanging empty at the bedside without a label identifying the date, time, or infusion rate. The resident stated that the tube feeding was supposed to continue until 1:00 p.m.At that time, the Unit Manager was requested to activate the enteral feeding pump so the surveyor could verify the volume administered. Review of the pump history revealed the resident had received 655 cc (cubic centimeter) of the 1,700-cc ordered.Review of the medical record at 9:15am revealed a physician order dated 06/16/2026 for Jevity 1.5 administered via intermittent pump at 85 cc/hour during the evening. The order did not specify the feeding start or stop times.During an interview on 06/24/2026 at approximately 9:30 a.m., Licensed Practical Nurse (LPN) #13 stated the feeding pump was already off when she began her shift. When asked how she determined when the feeding should start or stop, the nurse stated she would need to review the physician orders.During an interview on 06/24/2026 at approximately 9:40 a.m., the Director of Nursing (DON) accompanied the surveyor to Resident #4's room and observed that the feeding remained off and without a label identifying the date, time, or infusion rate. The DON stated she would speak with the assigned nurse to determine why the feeding was not infusing and was not labeled correctly.During a follow-up interview on 06/24/2026 at approximately 11:00 a.m., the DON acknowledged that the physician's enteral feeding order was incomplete because it did not include specific feeding start and stop times. She also stated the enteral feeding was not labeled correctly.During an interview on 06/24/2026 at approximately 4:00 p.m., the Registered Dietitian stated the resident is now receiving the correct amount of enteral nutrition and indicated that the feeding order should have been corrected upon the resident's return from the hospital on [DATE]. He stated the order was not correctly transcribed as written in his assessment.Following surveyor intervention, the attending physician was notified, and the enteral feeding orders were revised to clearly identify the appropriate feeding schedule.

Based on medical record review and interviews it was determined the facility failed to ensure that a comprehensive care plan was revised, and to ensure a scheduled care plan meeting was conducted. These deficient practices were identified for 2 (#1, #5) of 5 residents reviewed during a complaint investigation conducted at the facility.Findings include: A care plan is intended to identify and address each resident's unique needs, goals, and preferences. It serves as a guide to coordinate, assess, and evaluate the effectiveness of care and services provided. 1. A review of Resident #1's medical record on 06/24/2026 at 10:30 AM revealed a progress note dated 05/23/2026 at 04:32 PM that stated While eating lunch, resident was observed coughing and having difficulty swallowing food. The resident stated that he/she was having difficulty swallowing. A review of Resident #1's medical record on 06/24/2026 at 10:45 am revealed a physician's order dated 05/23/2026 at 03:15 PM for a modified mechanical soft, chopped meat diet. Further review revealed a physician order dated 05/23/2026 at 03:15 PM for a Speech-Language Pathologist swallowing study to be done. A review of Resident #1's care plan on 06/24/2026 at 11:00 AM revealed a nutritional focus area with corresponding goals and interventions initiated on 12/05/2024. Further review demonstrated that the facility failed to revise the care plan to include Resident #1's change in clinical status regarding swallowing difficulties and the subsequent modification to the diet. During an interview on 06/24/2026 at 4:30 pm the Administrator Staff #1 and the Director of Nursing Staff #2 were made aware of the concerns for failure to update a care plan to address a resident's change in condition status. 2. Resident #5 was admitted to the facility with diagnoses that included, but were not limited to, dementia and Parkinson's disease. A review was conducted on 6/24/26 at 11:30AM of the resident'selectronic medical record and documents provided to the survey team revealed invitations for care plan meetings scheduled on February 10, 2026, at 11:30 a.m. and May 28, 2026, at 11:30 a.m. Documentation also included progress notes dated May 26, 2026, and May 28, 2026. There were no meeting notes for the scheduled meeting for February 10, 2026. An interview was conducted with the complainant, a family member of Resident #5, on June 24, 2026, at approximately 3:00 p.m. The family member stated that she contacted the facility on multiple occasions regarding concerns about the resident's care and did not receive a response. She further stated that a care plan meeting was supposed to occur earlier in the year; however, she was not contacted regarding the meeting until May 2026, despite multiple attempts to communicate with facility staff. An interview was conducted with the Social Services Director (SSD) on June 24, 2026, at approximately 3:30 p.m. When asked whether the care plan meeting scheduled for February 10, 2026, had occurred, the SSD stated that the meeting was not conducted due to human error. The SSD acknowledged that the scheduled meeting was missed and stated that the next care plan meeting was held on May 26, 2026. The DON was informed of the concern regarding Resident #1's care plan and acknowledged the finding.

Based on record review and interviews, the facility failed to implement physician orders, and to provide the necessary care and services to assess, monitor, and timely respond to changes in a resident's condition. This was evident in 2 (#1, #4) of 5 residents reviewed for quality of care; treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. The findings include: 1. A review of Resident #1's medical record on 06/24/2026 at 10:30 AM revealed a progress note dated 05/23/2026 at 04:32 PM, that stated while eating lunch the resident was observed coughing and having difficulty swallowing food. The resident stated that he/she was having difficulty swallowing. The Nurse Practitioner Staff #10 was made aware and gave orders for the resident to have a Speech-Language Pathologist swallowing test and a diet change to mechanical soft/chopped meat. A review of Resident #1's medical record on 06/24/2026 at 10:45 am revealed a physician's order dated 05/23/2026 at 03:15 PM for a Speech-Language Pathologist swallowing study to be done. During an interview on 06/24/2026 at 02:40 PM Nursing Home Administrator (NHA) Staff #1 stated that there is one person who does the swallowing tests and that the test had not been done for Resident #1. The surveyor asked the NHA Staff #1 if the swallowing test had been scheduled with the speech therapist and NHA Staff #1 stated that he/she would verify if it was scheduled. During an interview on 06/24/2026 at 02:55 PM Dietician Staff #8 was asked by the surveyor if Resident #1's swallowing test had been scheduled. Dietician Staff #8 stated that he/she was never made aware of an order for a swallowing test and that nursing staff would have set this up. During an interview on 06/24/2026 at 04:25 PM with the Nursing Home Administrator Staff #1, the Director of Nursing (DON) Staff #2, the DON verified that the swallowing test for Resident #1 had not been scheduled and had not been done. 2. Resident #4 had diagnoses that included chronic urinary tract infection, Cystitis and an indwelling Foley catheter. Cystitis is a medical term for inflammation of the bladder. It is mostly caused by a bacterial infection (a lower urinary tract infection). Medical record review conducted on 06/24/2026 at approximately 11:30 a.m. revealed a nursing progress note dated 06/05/2026 at 4:04 p.m. documenting that the resident complained of burning with urination. The note indicated that an order was obtained to change the Foley catheter and obtain a urine specimen. The Foley catheter was changed, the urine specimen was collected, and the laboratory was contacted for a STAT specimen pickup. A nursing progress note dated 06/06/2026 at 6:56 a.m. documented that the urinalysis obtained on 06/05/2026 revealed abnormal findings including protein, blood, and leukocyte esterase. Documentation indicated the on-call Nurse Practitioner (Staff #12) was notified of the abnormal results and instructed that the findings be reviewed with the attending physician. The note further documented that the resident showed no signs of infection during that shift. Although the Foley catheter had been changed, the medical record contained no evidence that antimicrobial therapy or additional clinical interventions were initiated following the abnormal urinalysis findings. Review of an MDS Focus Note dated 06/08/2026 at 9:06 a.m. documented, for the look-back period of 06/02/2026 through 06/08/2026, No reported signs and symptoms of infection at this time from use of Foley catheter indwelling. This documentation was inconsistent with the nursing note dated 06/05/2026, which documented the residents' complaint of burning with urination. Review of the laboratory report revealed that on 06/08/2026 at approximately 10:00 a.m., the facility was notified that the urine culture specimen appeared contaminated and that a repeat urine culture was recommended. The medical record revealed that a repeat urine culture was not ordered until 06/09/2026 at 11:56 a.m. A Social Services progress note dated 06/09/2026 at 11:22 a.m. documented that during the resident's scheduled interdisciplinary care plan meeting, the resident was unable to remain awake or actively participate. The resident's sister expressed concern that the excessive sleepiness was not consistent with the resident's baseline condition and requested that the meeting be postponed pending a medical evaluation. The interdisciplinary team agreed that further medical assessment was warranted. Medical record review revealed that on 06/09/2026 at 12:16 p.m., approximately four days after the resident's initial complaint of burning with urination, orders were obtained for Ceftriaxone 1 gram intramuscularly STAT, Bactrim DS twice daily for seven days for cystitis, and STAT laboratory testing including a complete blood count (CBC), basic metabolic panel (BMP), and C-reactive protein (CRP). A nursing progress note dated 06/09/2026 at 7:22 p.m. documented that the resident was lethargic, difficult to arouse, and did not respond to verbal commands or stimuli. Assessment findings included a blood pressure of 67/49 mmHg, pulse of 83, respirations of 14, oxygen saturation of 94%, and temperature of 99.8 degrees F. The physician was notified, and the resident was transferred to the Hospital via 911 for evaluation of suspected sepsis. The resident's emergency contact was notified of the transfer. During an interview conducted on 06/24/2026 at approximately 2:00 p.m., the Director of Nursing stated the facility delayed initiating treatment while awaiting urine culture and sensitivity results. When asked why additional interventions were not initiated after the resident complained of painful urination, the abnormal urinalysis findings were received, and the laboratory recommended repeating the contaminated culture, the Director of Nursing stated that the Nurse Practitioner who had initially been notified of the abnormal findings was no longer employed by the facility. The facility failed to ensure that Resident #4 received timely assessment, monitoring, diagnostic follow-up, and treatment after exhibiting symptoms of a possible urinary tract infection and after abnormal laboratory findings were identified. This failure resulted in a delay in clinical intervention and culminated in the resident experiencing significant clinical deterioration requiring transfer to the acute care hospital for suspected sepsis. The resident admitting diagnosis to the hospital was Cystitis.

Based on medical record review and interviews with facility staff, it was determined that the facility failed to ensure a physician's medically necessary visit addressed a resident's change in clinical status regarding swallowing difficulties and subsequent follow-up orders. This was evident for 1 (#1) out of 1 resident reviewed during the complaint survey. Findings include:A review of Resident #1's medical record on 06/24/2026 at 10:30 AM revealed a progress note dated 05/23/2026 at 04:32 PM, that stated while eating lunch the resident was observed coughing and having difficulty swallowing food. The resident stated that he/she was having difficulty swallowing. The Nurse Practitioner Staff #10 was made aware and gave orders for Resident #1 to have a Speech-Language Pathologist swallowing test, a diet change to mechanical soft/chopped meat and a chest x-ray. A review of Resident #1's medical record on 06/24/2026 at 01:00 PM revealed a progress note completed by Physician Staff #9 dated 05/26/2026 at 12:30 PM that stated History and Physical Patient seen for pre-op H&P for Bilateral Retrograde Pyelogram scheduled for 5/28/26. There was no entry that addressed Resident #1's 05/23/2026 change in condition related to difficulty swallowing, diet changes, chest x-ray or swallowing test order. During an interview on 06/24/2026 at 4:30 pm the Administrator Staff #1 and the Director of Nursing Staff #2 were made aware of the concerns for lack of documentation by physician services regarding Resident #1's swallowing risks and follow up for the swallowing evaluation.

Based on observations and interviews with the facility staff it was determined the facility failed to ensure that a resident call bell was within reach. This was found to be evident for 1 (#5) of 6 residents observed during a complaint survey conducted at the facility.Findings include: During observation rounds on 6/24/26 at approximately 10:50AM Resident #5's call light was observed on the floor behind the head of the bed.A dual observation was obtained at that time with the nurse (LPN # 7) and she picked the call light up from the floor and placed it near the resident. The nurse stated that when the resident was provided with morning care the aide should have made sure the resident's call light was within reach.The observation findings were discussed at the exit conference on 6/24/26 with the Administration team.

Based on a review of administrative records, medical records, and interviews with family members and facility staff, it was determined that the facility failed to ensure residents' rights were protected by restricting visitation in residents' rooms. This deficient practice was identified for 1 (#5) of 5 residents reviewed during a complaint investigation conducted at the facility.Findings include:Complaint Intake #3015004 was reviewed on June 24, 2026, for multiple allegations. One allegation stated that all visitation with the resident was required to occur in a large common room on the first floor and not in the resident room.During the survey, an observation was made of a notice posted on the glass at the front desk that stated:Attention Residents, Visitors, and Staff: Effective immediately, in our continued effort to ensure the safety, privacy, and well-being of all residents, visitors will no longer be permitted in individual resident rooms. We kindly ask that all visits take place in designated common areas, such as the game room or front lobby, where everyone can enjoy a comfortable and welcoming environment.An interview was conducted with the complainant, a family member of the resident, on June 24, 2026, at approximately 3:00 p.m. The family member stated that she had not been permitted to visit the resident in the resident's room because the facility had discontinued room visitation. She further stated that the resident preferred receiving visits in the comfort and privacy of his/her room and that the facility no longer allowed this preference.During observation rounds conducted on June 24, 2026, at approximately 11:00 a.m., Resident #5 was observed lying in bed. No clinical, safety, or other factors were identified that would prevent the resident from receiving visitors in his/her room.An interview was conducted with the Administrator and Director of Nursing (DON) on June 24, 2026, at approximately 3:25 p.m. When asked whether family members were permitted to visit residents in their rooms, the Administrator stated that room visitation was prohibited due to concerns that visitors could bring drugs into the facility. The Administrator further stated that this concern existed prior to her tenure as Administrator. However, the Administrator was unable to provide documentation demonstrating that drug activity was a current issue within the facility. The Administrator stated that exceptions were made for residents who were bedbound or had health-related concerns, but that other residents were not permitted to receive visitors in their rooms.The Administrator was informed that restricting room visitation in this manner constituted a violation of residents' rights.

Based on record review and observation, it was determined that the facility did not ensure that enhanced barrier precautions were maintained while Resident #28 received wound care on 05/12/2026. This was evident for 1 (Resident #28) out of 2 residents reviewed for pressure ulcers. The findings include: Facility's Enhanced Barrier Precautions (EBP) Policy and Procedure. Enhanced Barrier Precautions are intended to reduce transmission of multidrug- resistant organisms through the appropriate use of gowns and gloves during high-contact resident care activities for residents at increased risk of transmission. Multidrug-Resistant Organisms (MDRO): Organisms resistant to multiple antimicrobial agents, including but not limited to: MRSA, VRE, ESBL-producing organisms, CRE, Candida auris and other organisms identified by public health authorities. High-Contact resident care activities requiring gown and gloves- Staff shall wear gown and gloves during the following care activities for qualifying residents: dressing assistance, bathing or showering. wound care. (reviewed November 2025) On 05/11/2026 at 2:15 PM, during a review of Resident #28's EMR (electronic medical record) the surveyor noted that Resident #28 was ordered on 12/8/2025 by MD 20 Enhanced Barrier Precautions for CRE (Carbapenem- Resistant Enterobacterales- a family of bacteria that is highly resistant to many antibiotics ), foley, wound and enteral feedings q (every) shift for precautions. On 5/12/26 at 10:12 AM, while observing Resident #28's wound performed by the Wound Care Nurse Practitioner (Staff #22) the surveyor noted that Staff#22 did not use the yellow isolation gown that is required for enhanced barrier precautions when providing high-contact resident care activities. On 5/12/26 at 2:20 PM, during an interview with the Director of Nursing (DON), a surveyor informed the DON of the observation of Resident #28's wound care without the appropriate PPE (personal protective equipment).The DON stated that Resident #28 is colonized for resistant infections and PPE should be worn with high-contact care.

Based on record review and interview, it was determined that the facility failed to provide care in accordance with the standards of practice, when Resident #28 was documented to not have a stool for 8 days (from 05/03/2026 to 05/10/2026) and no PRN bowel protocol medications were ordered or administered nor were abdominal assessments documented in the progress notes as per facility policy. This was evident for 1 (Resident #28) out of 18 residents reviewed for quality of care. The findings include: Facility's Bowel Management Protocol Policy and Procedure: Purpose- To establish a standardized bowel management protocol to prevent constipation, fecal impaction, avoidable hospital transfers, discomfort, and bowel-related complications. Policy- Residents shall receive individualized bowel management based on assessment findings, diagnosis, medications, risk factors, providers orders, and clinical condition. Nursing staff shall proactively monitor bowel function and intervene timely.High risk residents; includes but is not limited to: opioid use, reduced mobility. poor oral intake. 4. Intervention Escalation-. NO BM (bowel movement) for 48 hours: implement ordered first-line intervention, examples- stool softener, senna, miralax, PRN (as needed) ordered bowel medication, NO BM for 72 hours: Licensed nurse must: reassess resident, notify provider, implement additional intervention per provider order. On 05/11/2026 at 10:45 AM, during the screening process Resident #28 stated, I have not had a BM in 6 days. On 05/12/2026 at 9:41 AM, a review of Resident #28's EMR (electronic medical record) revealed that Resident #28 was admitted on [DATE] with diagnoses including but not limited to, C5-C7 (cervical spine) complete quadriplegia, S/P (status post) gastrostomy (feeding tube directly to the stomach) and polyneuropathy. A review of Resident #28's EMR also revealed that there was no evidence of Resident #28 having a BM from 05/03/2026 to 05/10/2026 (a total of 8 days) in the bowel movement task section of the EMR. Further review of Resident #28's EMR revealed no evidence of any documentation in the progress notes dated 05/03/2026 to 05/10/2026 by nurses or GNAs of Resident #28 having a bowel movement nor was there any documentation referencing constipation, an abdominal assessment or notification of a provider regarding the lack of bowel movement. A review of Resident #28's orders lacked evidence of any PRN medication orders to alleviate constipation during this time frame. It should be noted that during these 8 days, Resident #28 was administered 17 doses of PRN oxycodone (an opioid pain medication) for pain. On 05/13/2026 at 9:37 AM, during an interview the Director of Nursing stated that once a resident is noted to not have stool for 3 days, the unit manager and nurse confirm that the resident has not had a stool in 3 days. Then they initiate the bowel protocol. Bowel protocol consists of PRN medications such as a fleets enema, stool softener and miralax. On 05/13/2026 at 10:28 AM, during an interview with Licensed Practical Nurse (Staff #4) (ADON/ unit manager) stated, When residents are without stool for 3 days, the nurse call the physician for a fleets enema order. We don't have standing orders for fleets. [Resident #28] does have a standing order for senna (stimulant laxative) each night and miralax (osmotic laxative) each morning. I will look to see if there is a note from a nurse about how they were treating his lack of stool from 5/3 to 5/10. During this interview, LPN4 confirmed that the GNAs should document in the bowel movement task section when a resident had a stool. 05/13/2026 at 11:04 AM, a follow up interview with Staff #4 stated, I was not able to find any notes documenting the staff reaching out to the providers for PRN bowel protocol medications or documenting an abdominal assessment for the 8 days that Resident #28 did not have a stool. I put a call out to the provider for an order for a fleets enema.

Based on observation, record review and interviews, it was determined that the facility failed to obtain Resident #66 complete admission orders necessary for appropriate care. This was evident for 1 (Resident #66) out of 3 residents reviewed for hospitalizations.The findings include: On 05/11/2026 at 9:15 AM, Resident #66 was observed to have an indwelling foley catheter. Resident #66 stated that he/she utilizes a foley catheter at all times due to his/her paralysis. On 5/12/2026 at 12:48 PM, during a review of Resident #66's EMR (electronic medical record) the surveyor noted that Resident #66 was originally admitted to the facility on [DATE] with diagnoses including paraplegia, methadone dependence and neurogenic bladder requiring chronic catheterization. Further review of Resident #66's EMR revealed that Resident #66 was transferred to the hospital on [DATE] for an altered mental status. According to [hospital's] discharge summary, Resident #66 was diagnosed and treated during this hospitalization with intravenous antibiotics for acute pyelonephritis (bacterial infection of the kidney), severe sepsis (a life-threatening reaction to an infection) with bacteremia from MSSA (methicillin-susceptible Staphylococcus aureus) and ESBL (extended-spectrum beta- lactamase- enzymes that causes resistance to common antibiotics) proteus. Resident #66's EMR documented that Resident #66 returned to the facility on Saturday, 05/9/2026. On 05/12/2026 at 1:34 PM, continued review of Resident #66's EMR, in particular Resident #66's admission orders, which the regulations define as physician orders for the immediate care, lacked evidence of orders for: the care of Resident #66's indwelling foley catheter, the care of Resident #66's right upper extremity PICC (peripherally inserted central catheter) line, which was necessary for Resident #66 to be administered IV antibiotics, Enhanced Barrier Precautions as Resident #66 had two indwelling medical devices that qualify for enhanced barrier precautions, and the weekly laboratory tests necessary to monitor Resident #66 while being treated with IV antibiotics. Additionally, Resident #66's EMR lacked evidence of an order for Resident #66's maintenance methadone dose. The review of Resident #66's MAR (Medication Administration Record) documented Resident #66 receiving a dose of methadone on Monday, 5/11/26 at 10:56 AM. On 05/12/2026 at 2:58 PM, an interview with the Director of Nursing (DON) revealed that the facility typically did not admit residents on methadone on Fridays or Saturdays because the Wellness Director is not available to obtain the methadone for the resident from the community methadone clinics. DON stated, We did get Resident #66's methadone dose Monday [05/11/2026] so only Sunday's [05/10/2026] dose was missed. On 05/13/2026 at 2:35 PM, an interview with the DON confirmed that Resident #66's admission orders written on 05/9/2026 lacked orders for foley care, PICC line care, enhanced barrier precautions and weekly laboratory orders; all of which were essential to Resident #66's care.

Based on resident record reviews and staff interviews, it was determined that the facility failed to complete a comprehensive assessment within 14 days of a significant change in the resident's condition. This was evident for 1 (Resident #11) of 6 residents reviewed for Minimum Data Set( MDS) assessments during the facility's recertification/ complaint survey. The findings include:The Minimum Data Set is a federally mandated, standardized assessment tool used in skilled nursing facilities to comprehensively assess a resident's clinical and functional status. The Minimum Data Set is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.On 05/11/2026 at 10:55 AM, during the facility tour, the surveyor observed Resident #11's bed in the lowest position. During an interview with the resident, he/she stated that he/she had experienced a fall some time ago.On 05/13/2026 at 11:02 AM, review of Resident #11's electronic health record showed a nursing progress note dated 01/20/2026 revealed documentation stating: Status post unwitnessed fall. During unit rounds, the resident stated, 'I had a fall right there on the floor.' When asked what he/she was doing prior to the fall, the resident stated he/she was attempting to turn off the television. The resident reported attempting to transfer from the wheelchair to the bed. The resident denied pain and denied hitting his/her head during the fall. No injuries were observed at the time of assessment. Further review of the resident's change in condition documentation revealed X-ray results indicating a left intertrochanteric fracture. Documentation also revealed that the findings were reported to the physician, who ordered transfer to the Emergency Department (ED)for further evaluation. The resident denied pain during the assessment, and no facial grimacing was observed. Emergency Medical Services were contacted, and the resident was transferred to the hospital.On 05/13/2026 at 11:16 AM, review of the Minimum Data Set assessment dated [DATE] revealed the resident was assessed as having a significant change in condition.On 05/13/2026 at 1:44 PM, during an interview, the Minimum Data Set Coordinator stated the significant change assessment was completed because the resident experienced a fall on 01/19/2026, was transferred to the hospital on [DATE], and was diagnosed with a left hip fracture requiring surgery on 01/23/2026. The coordinator stated the resident returned to the facility on [DATE] with a decline in condition. When asked when the facility became aware of the resident's significant change and decline in condition, the coordinator stated the facility became aware upon the resident's return on 01/24/2026. When asked when the significant change assessment was completed, the coordinator stated it was completed on 02/19/2026.On 05/13/2026 at 1:49 PM, during a follow-up interview regarding the process for completing a Minimum Data Set significant change assessment, the coordinator stated the assessment should be completed as soon as the facility becomes aware of the significant change, or within 14 days of the change. When informed the assessment was not completed within the required timeframe, the coordinator acknowledged the concern.On 05/14/2026 at 12:40 PM, the concern was discussed with the Director of Nursing (DON), who acknowledged the findings.

Based on medical record review and staff interviews, it was determined that facility staff failed to accurately code the resident's status on the Minimum Data Set assessment. This deficient practice was identified for 2 (Resident #100 and #2) out of 6 residents reviewed for Minimum Data Set assessments.The MDS is a federally mandated, comprehensive, standardized clinical assessment tool of all residents in Medicare/Medicaid nursing homes that evaluates functional capabilities and health needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care that they need. The findings include: (1) On [DATE] at 9:49 AM, during the review of complaint 2977960, it was noted in Resident #100's electronic health record that he/she was readmitted to the facility on [DATE] and transferred to the hospital via Emergency Medical Services (EMS) on [DATE]. On [DATE] at 11:31 AM, review of progress notes in Resident #100's electronic health record revealed that Resident #100 had an order for intravenous normal saline fluids on [DATE] due to dehydration and attempts to establish intravenous access were unsuccessful. The medical provider was notified and ordered transfer to the hospital. The spouse was notified, and 911 was called. Paramedics arrived and transferred the resident from the unit to the hospital. Documentation indicated he/she was stable at the time of transfer. On [DATE] at 1:31 PM, review of Resident #100's Emergency Department records summary indicated that he/she presented to the hospital on [DATE] at 4:20 PM with altered mental status, dehydration, and shortness of breath. The resident's medical history included peripheral vascular disease, coronary artery disease, chronic kidney disease, hypernatremia, dehydration, sacral pressure ulcers, open amputation wound, osteomyelitis, hypertension, and small bowel obstruction with colostomy. Upon arrival at the Emergency Department, Resident #100 was nonverbal, appeared delirious, and was not following commands. Prior to successful establishment of intravenous access, the resident experienced cardiopulmonary arrest. In accordance with his/her Medical Orders for Scope of Treatment indicating Do Not Resuscitate status, cardiopulmonary resuscitation was not initiated. Brief assisted ventilation was provided while cardiac arrest was confirmed, and the resident was pronounced deceased at 4:40 PM. On [DATE] at 1:07 PM, during an interview with the facility's Minimum Data Set Coordinator regarding the process for unplanned hospital discharges, the coordinator stated that such discharges were coded as Discharge Return Anticipated when the facility expected the resident to return. The coordinator stated that facility staff would follow up with the hospital to determine whether the resident had been admitted . When asked who was responsible for communicating the outcome of the follow-up, the coordinator stated that the nursing team would provide updates during clinical meetings. When asked about coding requirements for a resident who dies within 24 hours after transfer from the facility, which was the case for Resident #100, the coordinator stated that she was not aware the resident had expired shortly after transfer to the hospital. The MDS coordinator further stated that she had not completed the original discharge coding and had recently begun employment at the facility. When asked what the correct coding should have been, the coordinator stated that the discharge should have been coded, or updated, as death in facility if the original coding was inaccurate. When asked whether the coding was incorrect, the coordinator acknowledged that it was. On [DATE] at 1:54 PM, during an interview with the Director of Nursing (DON), it was stated that palliative care had been recommended upon admission; however, the family declined those services. The Director of Nursing stated that shortly after admission, a family member informed the facility that they tested positive to COVID-19, adding that they had contact with the resident. The Director of Nursing further stated that the resident later developed respiratory symptoms, tested positive for COVID-19, and was placed on appropriate precautions. The DON added that Resident #100's condition continued to decline, and the resident was transferred to the hospital on [DATE] due to dehydration and unsuccessful attempts to establish intravenous access for rehydration. The Director of Nursing also stated that the facility was later informed by a family member that the resident died a few hours after transfer to the Emergency Department. On [DATE] at 7:44 AM, during an interview with Licensed Practical Nurse (LPN#19), the nurse stated that the resident appeared dehydrated on the day of transfer and that two attempts to establish intravenous access were unsuccessful. The nurse stated that the attending provider (Staff #19) was contacted and subsequently ordered transfer to the hospital for further evaluation and treatment. When asked if the resident was admitted into the hospital, he stated that he was uncertain whether the resident was admitted to the hospital because the facility was informed shortly after transfer that the resident had died at the emergency department of the hospital On [DATE] at 9:35 AM, the Minimum Data Set coding issue was discussed with the Director of Nursing, who acknowledged and confirmed that the coding was entered in error. (2) On [DATE] at 10:30 AM, a review of Resident #2's EMR (electronic medical record) revealed that Resident #2 was admitted on [DATE] with diagnoses including but not limited to schizoaffective disorder and major depressive disorder. Further review revealed that the Facility Physician (Staff#20) prescribed Invega Sustenna (an antipsychotic medication) for Resident #2 to receive intramuscularly every 28 days. Resident #2's quarterly MDS dated [DATE] failed to document in Section N Medications that Resident #2 was prescribed and being administered an antipsychotic medication. On [DATE] at 1:20 PM, during an interview with the MDS coordinator (Staff #5) confirmed that Resident #2's MDS from [DATE] did not accurately document Resident #2's medications by failing to code for antipsychotics.

Based on observation, record review and interview, it was determined that the facility failed to implement a care plan with interventions regarding Resident #66's indwelling catheter. This was evident for 1 (Resident #66) out of 1 residents reviewed for urinary catheter. The findings include: On 05/11/2026 at 9:15 AM, during screening Resident #66 was observed to have an indwelling foley catheter. Resident #66 stated that he/she utilizes a foley catheter all the time and his/her foley catheter was changed during his/her recent hospitalization. On 5/12/26 at 12:48 PM, during a review of Resident #66's EMR (electronic medical record) the surveyor noted that Resident #66 was diagnosed with paraplegia and neurogenic bladder requiring chronic catheterization. Review of Resident #66's most recent hospitalization discharge summary documented that Resident #66 was transferred from the facility on 5/2/26 to the hospital, where Resident #66 was diagnosed with acute pyelonephritis (bacterial infection of the kidney), severe sepsis ( a life-threatening reaction to an infection) with bacteremia from MSSA (methicillin-susceptible Staphylococcus aureus) and ESBL (extended-spectrum beta- lactamase- enzymes that causes resistance to common antibiotics) proteus. Resident #66 was discharged back to the facility on [DATE]. Further review of Resident #66's EMR revealed that Resident #66's care plan, which was updated as recently as 05/11/2026 did not address or have any interventions for Resident #66's indwelling foley catheter care to prevent a recurrence of a urinary tract infection and pyelonephritis. On 05/13/2026 at 2:35 PM, Director of Nursing confirmed that Resident #66's care plan lacked any reference to his/her indwelling catheter and the necessary care to prevent urinary tract infections.

Based on record review and interview, it was determined that the facility failed to have the provider respond to Medication Regimen Review recommendations in a timely manner. This was evident for 3 (Resident #2, #8 and #63) out of 5 residents reviewed for unnecessary medications.Facility 's Medication Regimen Review (MRR) Policy and Procedure. It is the policy of this facility that each resident's medication regimen shall be reviewed by a qualified consultant pharmacist at least monthly, and more frequently as clinically indicated, to identify medication irregularities, unnecessary medications, adverse outcomes, monitoring deficiencies, and opportunities for optimization.POLICY STANDARDS: 1. Every resident shall receive a monthly medication regimen review. 2 Medication irregularities shall be promptly reported. 3. Provider responses shall be documented. 4. Recommendations shall be tracked through resolution. (reviewed November 2025) The findings include: (1) On 5/11/2026 at 1:38 PM, record review revealed that Resident #8 had an active order for Quetiapine (antipsychotic medication) 400 mg. On 5/12/2026 at 11:28 AM, review of medication medication regimen review dated 2/9/2026 revealed that the consultant pharmacist recommended decreasing Quetiapine from 400 mg to 300 mg. The recommendation was signed by both the pharmacist and physician. Further record review of discontinued medications revealed no evidence that an order had been processed or implemented to decrease the dosage, and Resident #8 remained on an active order for Quetiapine 400 mg. On 5/13/2026 at 8:25 AM, an interview with the Director of Nursing revealed that the expectation was that once a physician accepted the pharmacist's recommendation, staff would process and submit the corresponding order. On 5/15/2026 at 8:34 AM, the concerns were addressed with the Director of Nursing and she indicated that she understood. (2) On 5/12/2026 at 10:30 AM, Resident #2's EMR (electronic medical record) revealed that Resident #2 was admitted on [DATE] with diagnoses including but not limited to schizoaffective disorder and major depressive disorder. Further review revealed that on 03/05/2026 the Consultant Pharmacist (Staff #21) recommended review of Resident #2's five psychotropic medications for eligibility for a GDR (Gradual Dose Reduction). On 05/12/2026, after surveyor intervention, Facility Physician (Staff #20) responded to the Pharmacist recommendation from three month prior stating Follow up with the Psychiatrist for GDR. On 5/13/2026 at 8:25 AM, During an interview the Director of Nursing (DON) stated that the unit managers are suppose to review and follow up on pharmacist recommendations. The DON stated that because the facility had vacancies for unit managers, DON would now be assuming that role as well until unit managers were in place in the facility. The facility failed to respond to Resident #2's 03/05/2026 MMR recommendation in a timely manner and failed to track the recommendation through to resolution. (3) On 5/12/2026 at 12:26 PM, a review of Resident #63's records was conducted. Resident #63 had a Medication Regimen Review (MRR) with irregularities or recommendations after pharmacist review on 1/7/2026 and 5/6/2026. This surveyor requested the pharmacist's note for both dates from the Director of Nursing, as they were not available in the resident's chart. On 5/12/2026 at 2:10 PM, a review of Resident #63's MRR was conducted. In the 1/7/2026 MRR, the pharmacist recommended that Hydroxyzine to be discontinued or replaced because it is a highly anticholinergic antihistamine. The provider checked other (out of the agree, disagree, and other box) and documented, Follow up with the Psychiatrist for GDR. The provider signed their response on 5/12/2026 (4 months after the recommendation). On 5/12/2026 at 2:12 PM, a review of the facility's MRR policy was conducted. No specific timeframes for response times from the pharmacist or the provider were in the policy. On 5/12/2026 at 2:23 PM, an interview with the Administrator was conducted. The surveyor expressed concern with the delay in physician review of the MRR and expressed concern with no timeframes of responses (physician or pharmacist) in the MRR policy. The administrator agreed with the concern.

Based on record review and staff interviews it was determined that the facility failed to ensure a resident was free of abuse. This was evident for 1(Resident # 3) out of 1 resident reviewed for abuse during the complaint survey The Findings include:Record review was conducted on 3/2/26 at 10:30 AM for a facility reported incident # 2735744. The record review revealed that GNA # 5 and Resident # 3 got into an argument regarding clothes on 2/4/26. During an interview conducted on 03/2/26 at approximately 10:45 AM, the Director of Nursing (DON) reported that on 2/4/26 Resident # 3 threw his/her IPAD and snack tray at GNA # 5. The GNA caught the snack tray and slammed the tray down on top of Resident # 3's hand which was laying on the nurses desk. Resident # 3 sustained a broken fingernail. GNA #5 was sent home pending investigation and GNA #5 was later terminated. Her name was sent to the Maryland Board of Nursing. The DON was notified 2/4/26 at 5:45PM and administrator was notified on 2/4 26 at 5:35 PM. Resident #3 was assessed head to toe with no injuries except for a broken fingernail. The ombudsman was notified. Police were not notified. The incident occurred at the nursing station 2nd floor on 2/4/26. On 3/2/26 at 11:19 AM an interview was conducted with Licensed Practical Nurses (LPN), Staff #4 and #6 who were sitting at the nursing station along with GNA #5 at the time of the incident. Resident # 3 was also at the nursing station complaining that his/her laundry had not come back yet. GNA # 5 explained to her that the dryer was down and this is why his/her clothes weren't back from the laundry. Resident # 3 started cursing and yelling at GNA #5. Resident # 3 then picked up his/her IPAD and a heavy metal tray and threw it at the GNA # 5 and Staff # 4 and #6 who were sitting at the nursing station. GNA #5 caught the metal tray and slammed the tray on the nursing station desk, but it hit the hand of Resident # 3 causing a broken fingernail. Resident # 3 was wheeled back to his/her room. The administrator was notified on 3/4/26 at 1:00PM of the findings.

Based on observation and interviews, it was determined that the facility failed to store and process linens to prevent the spread of infection This was evident for 1 out of 1 observation made in the facility's laundry room. The findings include: On 11/25/2025 at 1:06 PM, an observation upon entering the laundry room hallway (which is a common hallway used by staff) revealed the door to the clean laundry room from the common hallway was propped open all the way, with a large fan in the doorway, which was on and faced the inside of the room (blowing air from the common hallway into the clean room). There were staff actively folding clean linen. Further observation at the same time revealed clean laundry (consisting of towels, reusable bed pads, comforters, sheets, resident gowns, and blankets) which was folded and stacked on an entire linen cart full (which was not covered). There was also clean linen folded and stacked on top of the linen cart across the width of the cart and approximately 3 layers high (all of the linen being exposed). In addition, in the same clean laundry room there was more of the same linen (consisting of towels, reusable bed pads, comforters, sheets, resident gowns and blankets) which covered an entire rectangular table width, stacked several layers high throughout the width of the table (ranging from 8 to 14 layers high). Several of the layers were stacked against the wall of the room. The entire table full of clean laundry which was stacked several layers high was exposed with no covering. On 11/25/2025 at 1:07 PM, an observation of the dirty laundry room revealed the ceiling had multiple vent tubings that extended across the room; the tubing was covered in layers of dust. On 11/25/2025 at 1:08 PM, an additional observation revealed that the door in between the dirty and clean room was propped open all the way, and the clean room where the several stacks of clean and folded exposed laundry were (on the rectangular table and linen cart), with no covering. There was an additional fan in the doorway between the dirty and clean room that was not on at the time of the observation. On 11/25/2025 at 1:13 PM, an interview with the Environmental Services Director (Staff #29) revealed that the expectation was that both doors (the door between clean and dirty room, as well as the main door from the common hallway to the clean laundry room) be shut at all times. She further indicated that the ventilation in the room was poor and the clean linen room can get hot so they prop open the door from the clean room to the dirty room as well as the other door from the common hallway into the clean room. She further indicated that the fans help with the poor ventilation as well so that the air circulated. On 11/26/2025 at 7:30 AM, the concern was reviewed with the Director of Nursing and she indicated that she understood.

Based on interviews and medical record review it was determined that the facility failed to honor the resident's preferences of getting showers. This was evident for 1 (Resident #84) of 1 resident reviewed for choices during the survey. The Findings Include: On 11/20/2025 at 12:33 PM, Resident #84 expressed a concern that they had not received a shower since being moved to the second floor in early November. The resident stated that they have only been provided with bed baths and that a physical shower has not been done. On 1/21/2025 at 11:07 AM, review of the resident's Annual MDS from 2/3/2025, under section F- Preferences, revealed that during an interview with the resident for daily/activity preferences it is very important that the resident is able to choose how they are bathed. On 11/21/2025 at 11:36 AM, review of the second floor shower logs failed to reveal shower forms filled out for the resident in the month of November. On 11/21/2025 at 11:50 PM, in an interview with Staff #8, Geriatric Nursing Assistant (GNA), she stated that when a resident gets a shower the expectation of the staff is to complete a shower form and to put it in the shower log book. She also stated that if the shower form is not in the log book then the resident most likely did not get a shower. On 11/21/2025 at 11:55 PM, during an interview with the second floor Unit Manager, she stated that if a resident gets a shower the form is filled out and put into the shower log book. If the resident refused a shower it would be documented on the shower log and put into the log book or you would find it documented in the electronic medical records (PCC). At this time the surveyor revealed the concern that there were no forms filled out for resident #84 found in the Shower Log book. She stated that she would look into this concern and get back to the surveyor. On 11/24/2025 at 10:40 AM, during a follow up interview with the second floor Unit Manager, she stated that she was not able to find any proof that the resident had gotten a shower in the month of November.

Based on record reviews and interviews, it was determined that facility staff failed to ensure an advance directive was on file for a resident. This deficient practice was evident for 1 (#75) of 4 residents review for advance directive during the annual survey.The findings include: On 11/20/2025 at 1:43 PM, during an interview with the Director of Social Services (SW) #3, she stated that she began working at the facility October 2025. When asked about the process for newly admitted residents regarding advance directives, she explained that a resident should have an advance directive either prior to admission, at the time of admission, or be offered the paperwork during the care plan meeting. When questioned about Resident #75's advance directive, she stated she would follow up with her team to obtain the information. On 11/21/25 at 8:27 AM, a review of Resident #75's medical record revealed a social service assessment dated [DATE], in which the social worker documented that the resident has an advance directive on file. Further review of the resident's electronic and paper chart failed to show any evidence of an advance directive. At 8:30 AM, the surveyor requested evidence of an advance directive for Resident #75 from the Director of Nursing (DON). The DON stated that the social worker who completed the assessment was no longer employed at the facility as of October 2025, but she would search for the resident's advance directive. At 11:21 AM, during a review of the resident's electronic medical records, the surveyor observed a new social service progress note dated 11/21/25 at 8:43 AM. The note written by SW #3 indicated that attempts had been made to obtain an advance directive for Resident #75 and the facility has reached out to the resident's family member multiple times. To date, no response has been received. On 11/24/2025, the surveyor reviewed Resident #75s electronic medical record which showed that the DON upload an advance directive into the chart on 11/24/2025. The DON then provided the surveyor with a copy of the advance directive, signed on May 6, 2025, and acknowledged that the facility did not have an advance directive on file as previously documented in June 2025.

Based on review of medical records, facility policies, facility investigation reports, interviews, and observations, it was determined that the facility failed to: 1. Assess known smokers on admission, re-assess residents deemed as safe smokers after they were found to be unsafely smoking, and adequately supervise residents while smoking. 2. Failed to prevent a Resident with documented unsafe use of smoking material from having smoking material in their room. 3. Failed to ensure that a resident's room was free from hazards. This was evident for 8 of 27 residents reviewed for smoking/accidents. (Resident #78, #41, #90, #63, #28, #463, #464 and, #368) The findings include: 1.) On 10/16/2023 at 10:32 AM, the surveyor reviewed Resident #78's safe smoking assessment completed on 5/4/23 and signed on 6/5/23. The assessment stated Resident #78 was a safe smoker but required supervision. On 10/16/2023 at 9:24 AM, the surveyor reviewed an investigation completed by the facility for an event that was reported to have happened on 6/1/2022. In the investigation report, the Nursing Home Administrator (NHA) states that a staff member, who was attempting to provide care for the residents, detected smoking activity due to an unpleasant odor emanating from the room. It further stated that Resident #78 was found smoking in his/her room. On 10/12/23 on 8:30 AM, the surveyor reviewed a progress note written by Licensed Practical Nurse (LPN) Staff #70. The note stated Resident #78 was educated on the risk of smoking in the room, specifically the risk of a fire and the potential result in death. The Resident verbalized an understanding and the note further stated that staff would encourage and support safe smoking in the right designated area. On 10/18/23 at 9:44 AM, the surveyor reviewed Resident #78's care plan. A care plan was initiated on 6/1/23 and stated, Resident #78 is a smoker and was found smoking in his/her room. The care plan was updated on 8/20/23, and included an incident on 8/6/23 where Resident #78 was reported smoking in his/her room and another incident on 8/20/23 where Resident #78 was observed smoking in another resident's room. It was updated again on 10/18/23 and stated Resident #78 was observed smoking in the room on 10/17/23. On 10/27/2023 at 11:09 AM, the surveyor conducted an interview with Regional Director of Clinical Operation Staff #39. During this interview Staff #39 stated that any resident that smokes within their room is considered an unsafe smoker. On 10/27/2023 at 11:55 AM, the surveyor showed staff #39 documentation that indicated Resident #78 was smoking in the room on several occasions and most up-to-date safe smoking assessment completed on 6/23/23 assessed Resident #78 as a safe smoker. 2.) On 10/16/23 at 10:32 AM, the surveyor further reviewed documentation included in the investigation report from the 6/1/23 incident. Information about an additional Resident was included in the report regarding Resident #41. In the facility's investigation report, a progress note written by LPN staff # 70 was included. The note was dated 6/5/23 and stated that Resident #41 was educated on the risk of smoking in the room. On 10/18/23 at 9:44 AM, the surveyor reviewed Resident #41's care plan. The review revealed Staff #70 initiated a care plan on 6/1/23 that stated Resident #41 was found smoking in their room. On 10/25/23 at 9:24 AM, the surveyor reviewed Resident #41's progress notes. On 6/1/23 a note written by Wellness Program Director Staff #29 described that Resident #41 was observed coming out of the bathroom where smoke and the smell of Marijuana was noted. In the note Resident #41 confirmed he/she had been smoking in the room. On 6/25/23 a note was written by LPN Staff #47 at 11:02 AM. The note described as strong smell coming from Resident #41's room and when asked, Resident #41 apologized for smoking. An additional note written on 10/4/23 by LPN Staff #24 stated Resident #41 was found smoking cigarettes behind the closed door. The note further states this is not the first time Resident #41 exhibited this behavior. On 10/25/23 at 9:30 AM, the surveyor reviewed Resident #41's safe smoking assessments. Resident's #41's most recent safe smoking assessment was dated 6/5/23 and indicated that Resident #41 was a safe smoker and required supervision. 3.) On 10/24/2023 at 4:55 PM the surveyor reviewed an investigation report the facility conducted from an incident that happened on 8/18/23. The report stated that Resident #78 and Resident #90 were found smoking in a room together in a room with another Resident that was on oxygen. On 10/16/2023 10:48 AM, the surveyor reviewed Resident #90's medical record. The review revealed that Resident # 90 had an assessment conducted for safe smoking on 7/24/23. The assessment indicated Resident #90 had a dexterity problem and appeared to have physical limitations that interfere with the ability to perform safe smoking techniques. The observation section of the assessment described that the resident was able to hold tobacco material safely and extinguish material completely. Resident #90 was determined to be an unsafe smoker and needed supervision. On 10/25/2023 3:12 PM, the surveyor reviewed a census report from the facility from August 2023.The review revealed that Resident #90 was roommates with Resident #10. On 10/24/2023 at 11:59 AM, the surveyor reviewed Resident #10's medical record. Further review revealed that Resident #10 had a Minimum Data Set assessment completed 8/3/23. In section O, it was documented that Resident #10 was on oxygen. On 10/25/23 at 9:41 AM, the surveyor reviewed a progress note written on 8/18/23 by Licensed Practical Nurse (LPN), Staff #24, and stated Resident #90 was caught smoking with Resident #78 in Resident #90's room, in which the roommate of Resident #90 was on oxygen. On 10/24/2023 11:39 AM, the surveyor conducted an interview with Resident #10. During this interview the surveyor noted an oxygen concentrator next to resident #10's bed. During the interview, Resident #10 confirmed that Resident #90 was his/her roommate and smoked in the room. Resident then stated a roommate after Resident #90 also smoked in the room and stated it was Resident #63. On 10/25/2023 3:12 PM, the surveyor reviewed a census report from the facility from September 2023. The review revealed that Resident #63 was roommates with Resident #10 after Resident #90 left. 4.) On 10/24/2023 11:39 AM, the surveyor Reviewed #63's medical record. The review revealed a care plan dated 7/29/23 that stated, Resident #63 has behavior issues, non compliance, and smokes in the room. Further review revealed Resident #63 was placed in the room with Resident #10 on 8/29/23. This was after Resident #10 was identified as being at risk due to non-compliance of smoking in the room by his/her previous roommate, Resident #90. On 10/24/23 at 11:40 AM, the surveyor reviewed a progress note written by LPN Staff #24 on 10/4/23 that stated Resident #63 was in the room with a group of friends smoking cigarettes behind closed doors. The whole room was smelling, and one could see smoke in the room and cigarette butts and ashes on the table. On 10/25/23 at 9:30 AM, the surveyor reviewed Resident #63's most up-to-date safe smoking assessment. The safe smoking assessment was dated 6/5/23 and indicated Resident #63 was a safe smoker requiring supervision. There was no safe smoking assessment documented after Resident #63 was noted to be smoking in his/her room. On 10/27/2023 at 11:55 AM, the surveyor showed Staff #39 the documentation from Resident #63 medical record where it was documented that the Resident was smoking in the room, however, the most up-to-date safe smoking assessment, completed on 6/5/23, stated Resident #63 was a safe smoker. 5.) On 10/25/23 at 9:24 AM the surveyor reviewed Resident #28's medical record. The review revealed that Resident #28 had a care plan that was created on 7/31/23 and stated Resident #28 was observed smoking again in the room despite education. Further review of Resident #28's medical records revealed the most up-to-date safe smoking assessment was completed on 6/3/23. In this assessment Resident #28 was considered a safe smoker, however in the personal protection section a comment was written stating, keep reminding that smoking is not allowed in the rooms. On 10/27/2023 at 8:54 AM, the surveyor interviewed Licensed Practical Nurse (LPN) staff # 21. During this interview staff #21 stated that on admission the nurses assess if a resident smokes. Staff # 21 stated this is done on admission and done quarterly as well. Staff #21 further stated that the computer can tell her when the assessment is due to be completed. She stated that if a resident is found to be smoking in their room, she would consider them an unsafe smoker. 6.) On 10/27/2023 at 9:24 AM, two surveyors made an observation on the 4th floor where there was a strong odor of cigarette smoke in the hallway. Both surveyors knocked and went into the room of Resident #464 and Resident #463, where the odor of smoke was amplified. The surveyors interviewed Resident #464 and Resident #463 in their shared room. Both Residents stated they were smokers but denied smoking in the room. On 10/27/23 at 10:30 AM, the surveyor reviewed Resident #464's medical record. The review revealed that Resident #464 was admitted on [DATE]. No assessment was completed to evaluate the safety of the resident's smoking. On 10/27/23 at 10:33 AM, the surveyor reviewed Resident's #463 medical records. The review revealed that Resident #463 was admitted on [DATE]. No assessment was completed to evaluate the safety of the resident's smoking. On 10/27/23 at 9:32 AM, the two surveyors walked into the dining and activities room on the first floor. Within this room, the doors leading to the smoking patio were closed, and a cart was located next to the door. Several residents were outside smoking. No one was by the door. A person was noted to be across the room, turned away facing the vending machine on the opposite wall. On 10/27/23 at 9:33 AM, the person who was at the vending machine turned and walked over to the cart by the smoking patio and stated she was an Activities Assistant Staff #11. At this time the Restorative Aide, Staff # 68, assisted Resident #27 to the smoking area and asked Staff #11 for a smoking apron. Staff #11 opened the cart and gave Staff #68 a smoking apron for Resident #27. The surveyor asked Staff #11 if any of the Residents smoking out on the patio needed to be supervised. Staff #11 stated, all those Residents that were able to get to the patio themselves can account for themselves and do not require her supervision. She further stated, she is expected to supervise Resident #27. Staff #11 explained for any Residents to get out onto the smoking patio she would have to enter a code but they can let themselves back in by pushing a button that is located on the outside door. On 10/27/23 at 9:37 AM, both surveyors observed the courtyard smoking area. On 10/27/23 at 9:38 AM, the surveyor interviewed Resident #41. During this interview Resident #41 stated the burn holes on his/her sweatpants were from smoking but the pants were old and this happened a long time ago. After the interview the resident was observed throwing the lit end of his/her lit cigarette on the ground. On 10/27/23 at 9:52 AM, the surveyor walked inside from the smoking patio and reported to Staff #68, who was at the smoking cart, that that Resident #41 threw his/her lit cigarette butt on the ground. Staff #68 stated that Staff #11 had just walked away to get coffee started for the next Resident activity. She further stated she normally does not supervise smoking and then stated, I don't know what they do for smoking breaks. She followed up and stated, Staff #11 would be returning shortly. Staff #68 was observed walking out onto the smoking patio and talking to Resident #41. On 10/27/2023 11:09 AM, the surveyor conducted an interview with the Regional Director of Clinical Operation Staff #39. During this interview Staff #39 stated that any resident that smokes within the room is considered an unsafe smoker. She further stated the nurses are the ones that conduct the assessment and would assess using multiple factors to decide if a Resident was a safe smoker. She further stated that all residents should be monitored while smoking. The surveyor asked how it is communicated if a Resident is a safe smoker or requires interventions. Staff #39 stated if anyone is observed smoking within their room the staff should let leadership know, leadership should search the room with consent of the resident. If they object the police should be notified, however the police do not always respond to this type of request. Nursing should be documenting any unsafe smoking and documenting who they notified. On 10/27/23 at 11:50 AM, the surveyor conducted an interview with the Regional Director of Operations Staff #69. Present during the interview was the Nursing Home Administrator and Staff #39. Staff #69 stated that they often smell smoke in the building but have never seen a resident actively smoking. He further stated if we do see a resident smoking, we have a process in place and expect the process to be followed for all residents that are found smoking within the building. If we continue to suspect it, we give a behavioral contract and search the room. We also get the police involved if they refuse the search. If they continue to not follow the rules, we will give a 30 day notice and let the judge decide. He further stated however, sometimes when we do this and the judge decides they should be discharged , we still must keep them until we can establish a safe discharge and they would continue to reside here. The Administrator followed the interview by stating all Residents sign a smoking agreement when they are admitted and are aware of the smoking expectations. On 10/27/2023 at 11:55 AM, the surveyor showed the documentation from Resident #63, Resident #78 and Resident #28, where there was documentation of the Residents smoking in the room. At this time the Administrator confirmed that the smoking protocol was not followed for those residents. Staff #69 confirmed that if a resident smokes within the room they are considered to be an unsafe smoker. The surveyor followed up by and showed the Staff #69 the most up to date smoking assessments completed for these residents. Resident #63's most recent safe smoking assessment was completed on 6/5/23 and was assessed as a safe smoker with supervision. Resident #78's most recent safe smoking assessment was completed on 6/23/23 and was assessed as a safe smoker with supervision. Resident #28's most recent safe smoking assessment was completed on 6/3/23 and was assessed as a safe smoker with other in the comment. The surveyor also informed Staff #69 that there were two residents admitted in September that were documented as smokers and had no safe smoking assessment completed. On 10/27/23 at 12:11 PM, Staff #39 confirmed that education was needed to address non-adherence to the smoking policy, activities personnel should be educated on supervision and nursing needed to be educated on assessments. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy and the facility was verbally notified of this determination on 10/27/23 at 7:00 PM. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ at 11:37 PM after 4 initial plans were submitted at 8:48 PM, 10:59 PM, 11:20 PM, and 11:29 PM. The plan included: Reviewing and updating safe smoking assessment and skin assessment for Residents #78, #41, #90, #63, #28, #463 and #464. The Nursing Home Administrator (NHA) to educate the Activities department on the process of providing supervision during smoke times. The facility's smoking policy was updated to include smoking assessments to be done on admission and upon noncompliance with the smoking policy as needed. The date of completion was 10/31/23. Additionally, the facility's plan for removal included the following: the Regional Director of Clinical Operations to complete a house wide audit of current residents to evaluate for following: If current smokers were assessed upon admission. Review Residents with non-compliant smoking behaviors, identified in care plans, and ensure reassessed for safe smoking are completed. Evaluate supervision of smoking during smoking times and supervision on units to ensure Residents are adhering to the facilities smoking policy. Listed the following actions would be taken if non-adherence to the smoking policy were found: The NHA will be notified, behavioral contract will be initiated, a room search done with permission, and if a Resident continues to be non-complaint the police will be notified. The date of completion was 10/31/23. The Regional Director of Operations will update the current smokers list with a completion date of 10/27/23. The education plan included the Regional Director of Operations to educate the Unit Managers on the importance of adhering to the facility's smoking policy and ensure smoking is assessed on admission and any noncompliance actions will be followed as outlined. The Unit Managers will then educate all licensed staff. The Administrator will educate the facility staff on the facility' s smoking policy. The plan for monitoring included the Director of Nursing to complete a record review audit to validate smoking assessments were completed appropriately and conduct observational rounds. The audits are to be performed randomly once a week for four weeks and then monthly for three months. The Audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review. The NHA will complete observational rounds once a week during smoke times as well as on the units to validate that supervision is being provided. The audits will be done once a week for four weeks and then monthly for three months. The Audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review. After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on 11/2/23 after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents. 7.) On 10/23/23 at 9:57 AM, the surveyor reviewed a progress note written by a Nurse, Staff #90 on 11/19/22. The note describes that the nurse was smelling cigarette smoke from the hallway and while checking residents' rooms, She opened Resident #368's door. The note further describes the room was filled with smoke and 2 cups filled with water had parts of cigarette in them. The note stated education was given on the risk of smoking and that smoking in the room was not allowed. Resident #368 refused to give up her lighter and cigarettes that were found in her room. On 10/23/23 at 9:31 AM, the surveyor reviewed the safe smoker assessment completed on 12/4/22 for Resident #368. The assessment states that Resident #368 has a visual deficit that impairs ability to smoke safely. An observation was documented on the assessment and further stated, Resident was not able to extinguish smoking material completely in an appropriate receptacle. Also noted on the assessment was documentation that stated Resident #368 lies in bed and smokes cigarettes. The assessment further stated Resident #368's roommate is on oxygen. After the statement unsafe smoker was checked with an explanation that stated, Resident smokes in room while in bed and lights are off, Resident has poor vision, and roommate is on oxygen. Supervision was checked with a comment after; Resident keeps cigarettes in room, ashes in bed and on floor, additionally Residents uses paper cups to put out cigarettes. On 10/23/23 at 9:40 AM, the surveyor reviewed the smoking policy which was updated on 1/17/23. In the policy section 13 states, smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. The last statement in the policy states, flammable materials are not allowed in resident rooms. These materials include, but are not limited to, candles, matches, lighters, E-cigarettes, pipes, diffusors, ect. If a resident violates this rule, they may be issued a 30-day involuntary discharge. Further review revealed a note written on 1/16/23 from Registered Nurse (RN) Staff #91. The note describes Resident #368 reported he/she had lit a candle by the television then fell asleep. The television had caught on fire and the Resident was able to put out the fire but the television was destroyed. The nurse further stated she had warned Resident #368 of the risks of smoking in the room over the last few days. There was no evidence in the medical record that indicated staff took possession of Resident #368's prohibited smoking materials. On 10/23/23 at 11:46 AM, the surveyor conducted a phone interview with the previous Nursing Home Administrator Staff #52. During this interview Staff #52 confirmed that smoking materials were not allowed at the bedside. Staff #52 remembered the fire from Resident #368 and stated she believed a staff member had given Resident #368 the candle as a Christmas present. She stated a house wide audit was done and no other candles were found. She also stated education was done for staff and Residents that candles were not permitted. She remembers Resident #368 was given a 30-day involuntary discharge. 37277 8. On 09/28/2023 at 11:24 AM, Resident #63 said that he/she cannot get across their room in his/her wheelchair without hitting a power strip block that hangs off the wall. A subsequent observation revealed that hanging off the wall was a tan, multiplug power strip block. It was hanging 13 above the floor and the bottom stuck out 9 from the wall. It was being utilized as an extension cord by Resident #63's roommate. On 09/29/2023 at 1:10 PM, Staff #3, the Unit Manager, was shown the power strip and acknowledged it's a hazard. On 10/04/2023 at 9:50 AM, Staff #7, the Maintenance Director, observed the hanging power strip and explained that the facility does not provide power strips or extension cords, usually it's visitors that bring them and that they are not approved. Per Staff #7, the problem is there are not enough outlets in the room. He acknowledged the hanging power strip was a safety concern.

Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE drug overdoses). The first identified occurrence was on [DATE] (Resident #131) which resulted in resident death. Without effective QAPI intervention, 22 additional drug overdose SPAEs occurred (Residents #2, #53, #58, #63, #66, #76, #90, #93, #101, #118, #132, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, and #420). The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 10:00 AM on [DATE]. The findings include: The Centers for Medicare and Medicaid Services (CMS), defines Quality Assurance (QA) and Performance Improvement (PI) as a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem-solving. Narcan is a medication that rapidly reverses an opioid overdose. On [DATE] at 8:10 AM, the surveyor requested a list of all residents who received Narcan. The Regional Director of Clinical Operations (RDCO) stated the information is not easily accessible and she would have to go through medical records. On [DATE] at 11:00 AM the (RDCO) provided a list of the following Residents: #2, #53, #58, #63, #90, #93, #101, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, & #420, that received Narcan following suspected illicit drug abuse from the dates of [DATE] through [DATE]. The surveyors additionally identified Residents #66, #76, #118, #131, and #132 on [DATE] at 7:30 AM during record reviews. The overdoses included six fatalities (Residents # 53, #131, #132, #136, #154, and #160). The surveyors reviewed the six death certificates on [DATE] at 9:05 AM for cause of death. Resident #53 died on [DATE] of Mixed Drugs (Fentanyl, Despropionyl Fentanyl, methadone, and oxycodone) intoxication with cocaine use. Intoxication. Resident #131 died on [DATE] of Acute Diphenhydramine and Fentanyl Intoxication. Resident #132 died on [DATE] of Combined Drug (Fentanyl, Despropionyl, Para-fluorofentanyl, and Xylazine) Intoxication. Resident #136 died on [DATE] of Fentanyl and Oxycodone Intoxication. Resident #154 died on [DATE] of Fentanyl and Despropionyl Fentanyl. Resident #160 died on [DATE] of Fentanyl intoxication. The Medical Director was interviewed by the surveyors on [DATE] at 03:15 PM. When asked about his role with the facility he stated that he conducted the weekly risk meetings, QAPI meetings, and participated in the Facility Assessment. He added the QAPI team looks at residents at risk for any concerns, treatment, family, weights, altered mental status, wounds, rehab, psychotropic new meds, inappropriate meds, and diagnosis. When asked if drug overdoses were discussed the response was, Of course, we refer overdoses to psych. We do counseling and methadone. When asked if the facility tracks and tallies drug overdoses, he responded they track behaviors, and to refer to the risk minutes for details. No documentation was provided by the facility on tracking behaviors and tallying resident drug overdoses. When asked about the QAPI meeting, he stated he conducts the meeting and that all disciplines report at the Committee meetings. The Director of Nursing reports at risk residents. When asked how they prioritize concerns he stated, We do skin sweeps and identify skin breakdowns. When further asked what his biggest concern is with the facility he stated: drug use, drug use, drug use. When asked if drug overdoses were discussed in the QAPI meetings, he stated that the facility admits residents with Substance Use Disorder (SUD). We do counseling, educate, refer to clinics, methadone, and psychiatric care. When asked how many overdoses there were in [DATE], he stated that he could get the exact number. He stated, we give Narcan and call 911 for all overdoses. He further stated that drug overdoses should be a sentinel event and he believed all drug overdoses should be reported to the state. On [DATE] at 03:46 PM when the Medical Director was asked if the facility had conducted a performance improvement plan on drug overdoses, he responded that they had PIPs in process for only smoking and MOLST concerns. The surveyor reviewed the [NAME] Park 2022 - 2023 QAPI plan, the Facility Assessment, and QAPI committee notes on [DATE] at 9:57 AM. The facilities plan indicated that the QAPI Methodology uses a systemic approach to determine the root cause of identified problems using a variety of tools including Performance Improvement Projects (PIP), Root Cause Analysis (RCA), and Failure Mode and Effect Analysis (FMEA). The facility's plan further stated that PIPs prioritize high-risk, high frequency, and/or problem prone areas that impact the quality of care and quality of life for the residents and the QAPI Committee's overall responsibility is to develop and modify the plan, analyze information, and set priorities for PIPs. However, there was no evidence that drug overdoses were tracked, reviewed, or analyzed by the QAPI committee. During an interview on [DATE] at 2:00 PM, the Administrator stated that there was not a PIP for drug overdose because it wasn't occurring at the frequency it is now. However drug overdoses occurred for Resident: #131 on [DATE], #136 on [DATE], #160 on [DATE], #66 on [DATE], [DATE], and [DATE], #118 on [DATE], #149 on [DATE], #132 on [DATE], #2 on [DATE], #147 on [DATE], #154 on [DATE], #76 on [DATE], #93 on [DATE], #373 on [DATE], #58 on [DATE], #53 on [DATE], #90 on [DATE] and [DATE], #418 on [DATE], #101 on [DATE] and [DATE], #269 on [DATE] and [DATE], #63 on [DATE], #267 on [DATE], #420 on [DATE], and #268 on [DATE]. During an interview on [DATE] at 2:15 PM, the Wellness Director stated that tracking of overdoses just started in October. She confirmed that although they had discussed drug use in the QAPI meeting, they had not put a PIP in place. The facility had failed to initiate an effective QAPI response after 23 SPAEs over 16 months beginning on [DATE], that by the time of the survey had resulted in six resident deaths. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ on [DATE] at 6:05 PM after 3 initial plans were submitted to the surveyors at 1:19 PM, 4:22 PM, and 5:45 PM. The abatement plan included: The education of the QAPI Committee on the process of utilizing a systemic approach to ensure that a high-risk event such as drug overdoses are examined during QAPI meetings by tracking, reviewing, and analyzing the root cause of overdoses and providing performance improvement plans tailored to the root cause to ensure adequate management of residents with Substance Use Disorder (SUD) to reduce relapse or the risk of drug overdose by the Regional Director of Clinical Operations (RDCO). Identification of current residents with SUD to evaluate if they are tracked, reviewed, and analyzed for the root cause to ensure adequate interventions to reduce relapse or the risk of drug overdose. The residents identified by the screening tool will be discussed in the weekly risk meeting and behaviors reviewed for an appropriate plan of care. The Director of Nursing would educate the Licensed Nurses, Agency Nurses, and new hires on the importance of screening residents using the screening tool to identify a history of illicit drug use, interest in treatment, and screening for suspected drug overdose when they are found to possess drugs. The Administrator will complete random audits monthly for four months, and Quarterly for three Quarters, to validate that the QAPI Committee follows the process of tracking, trending, reviewing, and analyzing high risk events to validate that the performance improvement plan to reduce relapse or drug overdose is initiated, verify the screening tool has been completed upon admission for residents with a history of substance use, and validate that they have been offered treatments by the facility. The Immediate Jeopardy was removed on [DATE] after the survey team validated that the facility met the compliance date of their action plan.

Based on observation, interviews, and medical record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This was evident for 1 resident (# 266) out of 1 reviewed for CPR initiation. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 3:00 PM on [DATE]. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE]. The findings include: According to the American Heart Association (AHA) Cardiopulmonary Resuscitation (CPR) is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple the chances of survival after cardiac arrest. A Code Status means the type of emergent treatment a person would or would not receive if their heart or breathing were to stop. Full code means that if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. During a random observation conducted on [DATE] at approximately 6:00 AM, the surveyors observed Licensed Practical Nurse (LPN) #6 assigned to Resident #266 entered the resident's room, quickly exited, and returned to the nursing station. The surveyors observed LPN #6 search through papers on the nursing station desk. The LPN asked Geriatric Nursing Assistant (GNA) #85 who sat at the nursing desk if she knew the 3rd floor nursing station phone number, and the GNA replied No. At approximately 6:11 AM, LPN #6 located the phone number and requested for Registered Nurse (RN) #25 to come to the 4th floor, however, she did not state why she requested the RN to come to the 4th floor nursing station. At approximately 6:14 AM, RN #25 arrived at the 4th floor nursing unit. LPN #6 advised RN #25 that Resident #266 had died and that she was only an LPN and could not perform the assessment. The RN #25 responded, Okay, I need to go get my stethoscope on the 3rd floor nursing unit. A Do Not Resuscitate (DNR) order is a legal document that means a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops. RN #25 returned to the 4th floor nursing unit at approximately 6:18 AM. The surveyor observed the RN pull a resident's physical chart at the nurses' station and stated the resident had a code status of Do Not Resuscitate (DNR). The surveyors observed the RN perform an assessment on resident #266 at which time the RN stated the resident was deceased . On [DATE] at 08:13 AM, this surveyor reviewed Resident #266's physical chart and located a Maryland Order for Life Sustaining Treatment (MOLST) form dated [DATE] with the direction to perform CPR. During an interview conducted on [DATE] at 08:34 AM, the surveyors asked LPN #6 what her first steps were when she identified Resident #266 was unresponsive. The LPN stated I saw that the resident was not breathing, I attempted to take the pulse and found the resident did not have a pulse and was cold. I then attempted to call the Director of Nursing (DON) and Administrator but was unsuccessful. I then called RN #25 on the 3rd floor nursing unit to come to the 4th floor. The LPN further stated she learned Resident #266's code status was CPR and not DNR when the Emergency Medical Services (EMS) arrived. On [DATE] at approximately 9:00 AM, the surveyors requested the facility's policy and procedures for calling a code and CPR. The surveyor was provided with a Mock Code evaluation checklist and a CPR policy. The Mock Code Evaluation Checklist stated - First person arrives on scene assess airway- breathing noted to be absent or gasping with a pulse within 10 seconds, if no pulse & abnormal breathing proceed with the steps: call out for other staff to help, command given to call 911 and call a code, code on overhead page, other staff arrive with the crash cart, command given for someone to meet the EMS and direct to the resident's location, perform hand hygiene, PPE donned, resident placed in a supine on firm surface (backboard or floor), if on an air filled mattress; deflated mattress for compressions. The Mock Code Evaluation Checklist continues in its guide providing detailed procedures for performing chest compressions on a resident who does not have a pulse and the use of a handheld resuscitation bag. The CPR policy stated It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation. The Policy explanation and Compliance Guidelines included: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services: 2a. In accordance with the resident's advance directives, or 2b. In the absence of an advanced directive or a Do Not Resuscitate order; and 2c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). 3. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in -person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. An automated external defibrillator (AED) is a medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal. During an interview conducted on [DATE] at 10:39 AM, the Regional Director of Clinical Operations stated the facility staff expectations for when a resident is found unresponsive are the first responder will call a code while remaining with the resident, the code cart and physical chart is taken to the area where the resident was found unresponsive. CPR would be initiated if directed on the MOLST form. If the resident is a full code the staff would use an AED until EMS arrives and takes over. The event is documented with a detailed timeline. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE]. The plan included an audit of all licensed nurses, agency licensed nurses, and newly hired licensed nurses to evaluate their knowledge of correctly identifying the accurate code status for the correct resident and providing education accordingly. An audit of all licensed nurses, agency licensed nurses, and newly hired licensed nurses was conducted to evaluate the knowledge of what to do when a resident is found unresponsive, calling a code, and conducting a code. Education was provided based on the findings of the audit. A mock code was conducted on all shifts with all nursing staff, the findings were evaluated, and education was provided accordingly. The plan also included future mock codes that will be conducted weekly for 4 weeks and then monthly for 3 months. The results of the mock codes will be submitted to the Quality Assurance Improvement Plan (QAPI) Committee. The survey team confirmed the facility met the compliance date of their action plan and the Immediate Jeopardy was abated on [DATE].

Based on medical record review, review of pharmacy records, review of a facility's program description, and interviews with staff it was determined that the facility: (1) failed to timely implement physician instructions and orders related to SUD treatment, and (2) failed to effectively plan care for residents with Substance Abuse Disorder (SUD) and (3) failed to initiate a Substance Use Disorder care plan for Residents identified with Substance Use Disorders. This was evident for 5 (Residents #147, #90, #101, #141 & #154) of 18 residents reviewed for Substance Use Disorder during survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death. The findings include: 1. Suboxone: is part of a family of medications used in Medication Assisted Treatment (MAT). Medication Assisted Treatment (MAT): is an addiction recovery treatment plan that includes medications designed to treat opioid use disorders. Substance Use Disorder: is a treatable mental disorder that affects a person's brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications. Narcan: A medication given to help reverse an opioid overdose. On [DATE] at 11:38 AM, the surveyor reviewed Resident #147's medical record. The record revealed a progress note written on [DATE] by the Wellness Program Director, Staff #29. The note stated Staff #29 visited with Resident #147 and introduced the Wellness Pathway Program to the resident. After the introduction, Resident #147 discussed his/her history of substance abuse with Staff #29. Resident #147 reported having cravings and requested to be prescribed Suboxone stating, this has worked in the past. Staff #29 wrote in her note she would make the physician aware of the request. On [DATE] at 10:53 AM, the surveyor interviewed Staff #29. During this interview Staff #29 stated she was an advocate for residents with Substance Use Disorders (SUD). She further explained that she is made aware by the administrator or nursing staff when a Resident with a history of SUD is being admitted to the facility. Staff #29 stated she introduced herself to the Residents and introduced them to the program. She gets a history as well as assists Residents with identifying triggers that may cause them to relapse. Staff #29 also stated she relays medication needs with providers and communicates a need for a psychological evaluation if needed. She stated she helps in developing the care plans for SUD Residents. Staff #29 stated that nursing is responsible for assessing, monitoring, and implementing interventions to prevent relapse. On [DATE] at 6:26 AM, the surveyor reviewed the Wellness Program overview. The program description documents evidence-based services to support a life of recovery while at a skilled nursing/rehabilitation center. It further indicated that the Wellness Director (WD); develops, plans, organizes, evaluates, and directs the overall operation and therapeutic aspects of the Wellness Program. On [DATE] at 11:38 AM, the surveyor review of the progress notes written in Resident #147's medical record on [DATE] by a physiatrist (a doctor who specializes in physical medicine and rehabilitation) Staff #78. Under medication changes, Staff #78 wrote, Resident #147 stated he/she was previously on Suboxone, but the dose will have to be verified and restarted. Staff #78 added that Resident #147 reported his/her pain was not controlled by pain medications. A progress note written on [DATE] at 2:12 PM, by Social Service Staff #83 documented Resident #147 was reporting terrible sleep due to anxiety attacks and trouble concentrating. In a [DATE] progress note, Staff #78 recommended to verify Suboxone dosing and restart medications. This note concluded; thank you for allowing me to participate in the care of your patient. I will continue to follow. No evidence was found in Resident #147's medical record that the verification was obtained after the prior [DATE] note written with these same instructions. Further review of the medical record revealed that Resident #147 suffered a medical emergency on [DATE] at 2 PM. Resident #147 was found unresponsive and two doses of Narcan (an emergency treatment for a narcotic overdose) was administered. Resident #147 responded to the Narcan and requested to be transferred to the hospital. No evidence was found that the dose for Suboxone was clarified or that he/she had ever started on Suboxone after it was first recommended two weeks prior to the [DATE] clinical emergency. Further review of the medical record on [DATE] at 1:50 PM, revealed that Resident #147 returned to the facility on [DATE]. With the discharge paperwork, the hospital provided an order for Buprenorphine HCL 8mg Sublingual tablet. (Buprenorphine is the active ingredient in Suboxone). The surveyor reviewed the orders written for Resident #147 on [DATE] at 1:58 PM. The review revealed that on [DATE] an order was written for Buprenorphine Hydrochloride HCL sublingual 8 mg three times a day for smoking cessation. On [DATE] at 11:45AM, the surveyor reviewed a progress note written by Physician Assistant (PA) Staff #56 on [DATE] at 3:32 PM. In this note Staff #56 indicated that Resident #147 continued on Suboxone 3 times a day and had no signs or symptoms of withdrawal. On [DATE] at 11:51 AM, the Surveyor review of the Medication Administration Record (MAR) for Resident #147. The review revealed the documentation was incomplete and did not provide evidence the Buprenorphine was administered as directed. The documentation indicated that on 12 occasions from [DATE] through [DATE] the administration was coded, see progress note and on 3 occasions during that same time period the administration documentation was blank for administration on Buprenorphine. On [DATE] at 10:35 AM, the surveyor reviewed medication administration progress notes. On [DATE] at 5:57 AM, the MAR comment was, pharmacy to deliver, and on [DATE] at 6:31 AM, the MAR comment was, pharmacy to dispense med (medication). Further review of the clinical record revealed a note written on [DATE] at 2:46 PM, that stated Resident #147 was responsive only to a sternal rub and Narcan was administered. On [DATE] a note written at 3:25 PM, stated Resident #147 appeared to be sluggish. The note further indicated that the physician was aware and orders were received including a urine toxicology screen. On [DATE] at 9:10 AM, the surveyor conducted a phone interview with the Manager from the pharmacy the facility utilizes, Staff #80. During this interview Staff #80 stated the pharmacy received the order for Resident #147's Buprenorphine on [DATE] at 9:45 AM, however, it was sent back asking the provider for more clarification. At this point, Staff #80 asked a Staff Pharmacist, Staff #81 to join the phone conversation. Staff #81 stated a clarification was re-sent and dated [DATE] on the form, however the fax had a time stamp from the facility that indicated the order was sent on [DATE] at 7:48 AM from the facility and the pharmacy received the clarification order on [DATE] at 7:51 AM. Staff #81 reviewed the dispensing records for Buprenorphine to the facility for Resident #147. The review revealed that only a portion of the dose was sent to the facility on [DATE] and signed as received at 5:30 PM. The complete dose was not sent until [DATE] at 1:54 AM. On [DATE] 6:37 AM, the surveyor reviewed Resident #147's care plan. On [DATE] a care plan was created stating Resident #147 was receiving Medicated Assisted Treatment (MAT) for Substance Use Disorder (SUD) and was at risk for an overdose. This care plan was created 5 months after Resident #147's first overdose and the one intervention stated, to educate Resident #147 on risks related to substance abuse. No individualized interventions were planned for staff to monitor for triggers or withdrawal symptoms to prevent potential relapse. 2) On [DATE] 8:39 AM, the surveyor reviewed Resident #90's medical record the review revealed Resident #90 had a history of Substance Use Disorder. The review further revealed that Wellness Program Director Staff #29 wrote a progress note on [DATE] shortly after introducing the Wellness Pathways Program to Resident #90. In the note, Resident # 90 indicated he/she was currently taking Suboxone and was able to maintain abstinence with Medicated Assistance Treatment (MAT). However, no order was written for Suboxone for Resident #90 at this time. Staff #29 documented she would follow up as needed. On [DATE] at 5:22 AM, the surveyor reviewed Resident #90's care plan. A care plan was initiated on [DATE] by Staff #29. On [DATE] Staff #29 updated the care plan and initiated the following interventions: Monitor and report any unusual behavior to the physician; Wellness coordinator to follow-up with treatment; Follow up with social worker; Psychiatry consult for substance abuse; and Continue with medications for opioid use disorder. The plan did not include any interventions for monitoring for individualized triggers or signs of withdrawal, to reduce risk for relapse. Further review revealed a [DATE] progress note. That documented Resident #90 was found unresponsive in another Resident's room in a suspected overdose. Narcan was given twice, and Resident #90 became responsive after. On [DATE] at 1:15 PM, Wellness Program Director Staff #29 wrote a progress note after visiting with Resident #90. In this progress note, Staff #29 documented that Resident #90 reported struggling with cravings and reported when on Suboxone in the past he/she had less cravings and urges to use. Staff #29 stated she would follow up with the medical team about MAT. On [DATE] a progress note documented that Resident #90 was found unresponsive and after 3 doses of Narcan Resident #90 became responsive. Resident #90 was placed on 1:1 monitoring, and psychiatry was ordered to evaluate for possible transfer to the hospital for an evaluation. On [DATE] at 9:12 AM, the surveyor reviewed the orders written for Resident # 90. The review revealed Suboxone was first ordered on [DATE] by Physician Staff #50. On [DATE] at 9:20 AM, the surveyor reviewed a progress note written by Physician Assistant PA Staff #56 on [DATE] in Resident #90's medical record. In the assessment and plan section, Staff #56 documented the plan after the overdose for Resident #90 was to continue to assist with activities as needed and would evaluate for Suboxone. The note concluded; the plan of care was discussed with Medical Director Staff #19. On [DATE] at 11:35 AM, the surveyor reviewed Resident #90's September Medication Administration Record (MAR). The review revealed that Suboxone was documented as given on [DATE] in the am and given twice a day [DATE]-[DATE]. Further review of the care plan initiated on [DATE] revealed that the care plan stated Resident #90 was receiving Medication Assisted Treatment for Substance Use disorder. The care plan was updated on [DATE] by Unit Manager Staff #3, who stated Resident #90 was receiving MAT for Substance Use Disorder and was found unresponsive. However, after reviewing Resident #90's medical record he/she did not receive MAT until [DATE]th 2023, after the second overdose. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy and the facility was verbally notified of this determination on [DATE] at 10:00 AM. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ at 6:50 PM after 4 initial plans were submitted at 1:19 PM, 4:22 PM, 6:15 PM, and 6:37 PM. The plan included: Education for Staff #29 on effective management for Residents with SUD, to include communication with physician and nurses on Resident changes such as withdrawal symptoms or craving for substance use. Education was provided for Staff #78 to include, communication on the use of MAT for Residents who are noted as craving for substance use as well as communication with the nursing team if there is a recommendation for residents with substance use. The Wellness Director completed a house wide audit of current Residents with Substance Use Disorder to evaluate if any other Residents are reporting carvings for substance use or any symptoms of withdrawal to ensure MAT is ordered according to their person centered plan of care. The facility's plan for removal also included the following: Education on the use of a screening tool, used on admission, to identify any residents with a history of substance use disorder and evaluate if they are interested in receiving treatment. Nursing will then update the care plan accordingly. The Director of Nursing will educate the Unit Managers on the effective management of residents with Substance Use Disorders. This will include using the screening tool on admission; Ensure Residents with SUD are ordered appropriate medications on admission; Communicate any changes noted with SUD Residents with the Wellness Director and physicians to ensure MAT is implemented if indicated; Ensure if a MAT medications is unavailable the physician is notified and symptoms of withdrawal and triggered are monitored, if needed obtain a order for MAT; Ensure comprehensive care plan are completed to include resident's history of SUD, withdrawal symptoms, triggers, relapse, and treatments. The Unit Manger will then educate the licensed nurses. The DON will complete random questionnaires audits for physician, nursing team and wellness services to validate the team is communicating changes. The Medical Director will complete random audits of the Residents receiving MAT to validate effective MAT treatment. The DON will complete random medical record audits for those SUD residents identified on MAT where the MAT was not available. The audit will evaluate if assessments are being made to monitor for signs of withdrawal and an order effective treatment is in place to prevent drug overdose. The audits will be done weekly for four weeks then monthly for three months and the findings will be reported to the Quality Assurance/Performance Improvement Committee (QAPI) for review. After determination of Immediate Jeopardy concerns, the Immediate Jeopardy was removed on [DATE] after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents. 3) Medical record review for Resident #101 on [DATE] 7:23 PM, revealed that Buprenorphine HCl-Naloxone HCl (Suboxone) Sublingual (applied under the tongue) ,d+[DATE] Milligrams, 2 times daily, for SUD, was ordered on [DATE] at 9:00 PM. The order was written at 9 PM with the first administration documented as given on [DATE]. Medical record review on [DATE] at 7:41 AM, revealed that Staff #29 created a new care plan for Resident #101 for Medication Assisted Treatment (MAT) for Substance Use Disorder (SUD) related to opioid use disorder on [DATE]. Medical record review on [DATE] 7:31 AM, revealed a potential overdose event on [DATE]. In an initial progress note dated [DATE], Staff #29 documented seeing Resident #101 for a change in condition related to substance abuse. Staff #29 indicated that Resident #101 had been found on the floor after suspected use on [DATE]. Staff #29 further documented that Resident #101 reported struggling with cravings. Staff #29 concluded the progress note indicating a plan to follow up with the medical team. Medical record review revealed inconsistent documentation entered by Staff #56 on [DATE]. Although the [DATE] event was documented in the medical record, Staff #56 inconsistently documented on [DATE] that Resident #101 was on Buprenorphine, had experienced no changes in mental status, and that no evidence of withdrawal was evident. Staff #56 documented that the plan of care was discussed with Medical Director Staff #19. Additional medical record review on [DATE], revealed that the [DATE] MAT care plan was revised on [DATE]. The revisions included documenting the new [DATE] change in condition associated with substance use and interventions were added including to monitor and report any unusual behaviors to the doctor, for the wellness coordinator to follow-up with treatment, for the social worker to follow up, for psychiatry consult related to substance abuse, and to continue Medicated Assisted Treatment. However, no interventions were initiated in the plan to monitor for individualized triggers and/or withdraw symptoms. Medical record review revealed a second potential overdose event for Resident #101 on [DATE]. A nursing note by LPN Staff #24 on this date indicated that Narcan HCL nasal liquid 0.1 milligram was given at 8:45 AM for suspected overdose. In a later note at 2:50 PM on the same date, Staff #29 documented that she met with Resident #101 due to substance use. Again Resident #101 reported to Staff #29 experiencing carvings and again Staff #29 documented the plan to update the medical team. After the second event, the MAT care plan was still not revised to ensure that staff would begin to monitor Resident #101 for individualized triggers and/or withdrawal symptoms. 18819 4. Review of Resident #149's closed medical record on [DATE] revealed Resident #149 most recent admission to the facility was on [DATE] with diagnoses that included anxiety, depression, bipolar disorder, alcoholic cirrhosis of the liver, heart failure, chronic kidney disease, insomnia, and psychoactive substance dependance. Resident #149 was receiving the following medications: Aripiprazole, bupropion HCL, Lexapro, Methadone HCL, Risperdal, Trazodone, Lasix, Xanax, Gabapentin, and oxycodone. Review of intake MD00186021 on [DATE] revealed an investigation that Resident #149 was observed to be drowsy, lethargic, and unresponsive with a bottle of diazepam found next to Resident #149 on [DATE] at 10:15 AM. The facility staff identified Resident #149 as having an overdose and administered 2 doses of Narcan. Resident #149 was observed to become more alert and was transferred to the emergency room . After a few hours, Resident #149 returned to the facility and was educated on the risks and dangers of ingesting medications not prescribed by the facility physician. Resident was issued and signed a behavior contract on [DATE]. Resident #149 explained to the facility staff that he/she brought the medications from home when he/she went on a leave of absence. The facility investigation indicated that the facility staff were educated on the importance of rounding to identify residents with illicit drug use, Resident #149 was educated on the risk and dangers of ingesting medications not prescribed by a facility physician, and a Behavioral Contract was presented to the resident. Review of facility reported incident MD00188974 on [DATE] 23 revealed an investigation that on [DATE] Resident #149 was observed with an unknown pill and ingested the pill in front of a staff member. Resident #149 was also observed with agitation, slurred speech, and was having difficulty forming thoughts into sentences. Another bottle of pills was discovered with Resident #149 who stated that a family member gave them to him/her. Resident #149 was sent to the emergency room . The facility determined that Resident #149 had another overdose on illicit medications. Further reviews of the closed medical record failed to reveal the facility staff had implemented a care plan for Resident #149's diagnosis of psychoactive substance dependance. 5. Review of Resident #154's closed medical record on [DATE] revealed Resident #154's most recent admission to the facility in [DATE]. The State Survey Agency (SA) received complainant allegations (Intake MD00194736) indicating that Resident #154 suffered an overdose and died on [DATE]. A review of facility reported incident MD00189238 on [DATE] revealed information that Resident #154 was found unresponsive on [DATE] at 1:40 AM. Staff administered Narcan twice, initiated CPR, and called 911. EMS personnel arrived and continued to perform CPR. Resident #154 was shortly pronounced dead. The facility investigation listed a summary of events that indicated no evidence to support active drug use. After the incident, staff were educated on the importance of reporting any suspicion of illicit substance use. Closed medical record review on [DATE], revealed that Resident #154 suffered a drug overdose event on [DATE]. Record documentation indicated that on this date at 8:30 PM, Resident #154 was observed by a staff member unresponsive and lying on the floor. The staff administered 2 doses of Narcan nasally. Resident #154 was sent to the emergency room . Per the hospital documentation, Resident #154 was diagnosed with an opioid overdose in the emergency room . Additional review of the closed record revealed that on [DATE] Resident #154 suffered another drug overdose event. On this date at 3:27 PM, staff observed Resident #154 to be lethargic with little to no response to verbal or tactile stimuli, speech that was described as sluggish, and s/he could not sit straight in his/her wheelchair. With consent, a toxicology test was conducted which later returned (returned on ,d+[DATE]). The reported event of [DATE] was therefore the third overdose event for Resident #154. Nonetheless, no care plan was ever opened providing staff direction on what and how to manage Resident #154's needs related to his/her substance abuse disorder.

Based on a review of the medical record and other pertinent documentation and interviews facility staff, a resident, and hospital staff, it was determined the facility failed to honor a resident's right to return to the facility following the resident's stabilization and treatment after an emergency petition (EP); a decision that was based on the resident's mental state at the time of the EP and the resident's history of incarceration. The facility further failed to evaluate the same resident and determine their ability to meet the resident's needs. This was found to be evident for 1 of 11 residents (Resident #2) reviewed for transfers during a complaint survey conducted at the facility. This deficiency was identified during the investigation of complaint MD 519. During the survey on November 4, 2021 at 11:35 AM an Immediate Jeopardy (IJ) was called related to the facility's delay in permitting a resident to return to the facility after the resident was transferred to a hospital by emergency petition and then stabilized. The facility submitted an initial plan of correction to remove the immediacy on 11/4/21 at 2:30 PM, this plan was not accepted. Additional plans of correction were submitted by the facility on 11/4/21 at 2:40 PM, 3:10 PM, 4:12 PM, 6:00 PM, and 6:36 PM, the plans were reviewed and not accepted. On 11/4/21 at 9:10 PM a plan of correction was reviewed by surveyors and the Office of Health Care Quality. The plan was accepted on 11/4/21 at 9:24 PM, but the IJ was not abated until Tuesday, 11/9/21 at 3:15 PM, when implementation of the facility's corrective action was verified. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm and a scope and severity of a D. The findings include: An emergency petition statute allows a violent or suicidal person with a mental disorder to be brought to an emergency facility for rapid evaluation regarding the need for emergency treatment. On 11/1/21 a review of Resident #2's medical record revealed the resident was admitted to the facility from another skilled nursing facility owned by the same entity on 5/24/21. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/21 at 10:30 AM a review of Resident #2's Social Worker Admission Assessment, dated 5/24/21, documented the resident reported was previously incarcerated for [AGE] years and seven (7) months. On 11/2/21 at 10:35 AM a review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #2] who is transferred from another nursing home from [Name of other facility ] to [name of current facility] for further care. The patient apparently was nasty with the staff and possibly may have used drugs along with a couple of other people and he was then asked to leave the nursing home. He is finally here in this nursing home to be cared. The patient denies any symptoms at the moment, however, he has a history of bilateral below knee amputation, has been getting rehab to have prosthesis fitted and he has been trying to walk. Further review of the record on 11/2/21 revealed that on 9/4/21 Resident #2 had a Brief Interview for Mental Status (BIMS) assessment with a score of 15 out of 15, indicating the resident was cognitively intact and can make his/her needs known. The resident had a care plan in place initiated on 6/2/21 and 6/4/21 for behavioral issues which included verbal abuse and aggression. Interventions included the following: 1. Administer medications as ordered 2. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. 3. Continue to offer care, do so in pairs, report each behavior issue to the charge nurse and or supervisor to assist with intervention if possible. 4. Give the resident as many choices as possible about care and activities. 5. Staff walk away when the resident becomes verbally aggressive and document behavior, and involve nurse management to assist in communication with the resident when verbally aggressive during care. If the resident persists then give the resident time to calm down and retry to deliver care. Document behaviors and responses to track and trend responses potentially identifying triggers to outbursts. On 11/2/21 the continued review of all of Resident #2's progress notes revealed between the time of admission on 5/4/2021 and 10/16/2021, the day the resident was emergency petitioned and sent to the hospital, there was documentation that describes Resident #2's behaviors, as verbally aggressive, difficult, or resistive to care, making false allegations against staff, and one note (dated 9/10/21) documented inappropriate gestures or comments to females. There was no documentation to indicate that the resident was physically abusive/aggressive or that the facility felt the resident was a danger to himself or others. There was no documentation to indicate that the facility had concerns about their ability to manage Resident #2's behaviors or that the facility felt the resident's needs could not be met at their location. There were three social services notes that indicated the facility attempted to find placement for Resident #2 on 7/29/21 and 8/19/2021. On 8/17/21 documentation in the medical record stated the resident requested a transfer. There was no other documentation in the record to show that the facility had discussed the possibility of discharging the resident in relation to the resident's behaviors or at the request of the resident. On 11/01/21 a review of Resident #2's medical record revealed the following concurrent review: Resident is upset over the previous Administrator leaving and expressed feelings of being abandoned. The resident wants to let everyone know that s/he is on edge and thinking of killing someone. The resident has a plan. The physician was notified, and an order obtained to transfer to the Emergency Department (ED) for evaluation. 911 called. Resident #2 was getting anxious while awaiting the ambulance to arrive. The police arrived and assessed the situation and the resident made it clear that they will kill someone if s/he does not go to the hospital. The officer remained with the resident while waiting for the ambulance. An interview was conducted with the Social Worker (SW) and Director of Nursing (DON) on 11/1/21 at 1:30 PM and they both explained that Resident #2 had a good rapport with the previous Administrator and when the resident learned that she would be leaving the facility, the resident became agitated and homicidal, threatening to kill someone if not allowed to leave the facility. The DON stated that the police were called due to the resident's behavior and that the police Emergency Petitioned (EP) the resident to the hospital after interviewing the resident. The SW explained that when a resident is EP out to the hospital the facility will follow up with the hospital and an evaluation is done to ensure that the hospital did what was needed for the resident. The DON went on to explain that the Corporate Medical Director (MD) will follow up with the hospital to ensure that the resident was evaluated and treated by Psychiatric Services and confirm that the resident is stable to return. The DON stated that she would follow-up with the Corporate MD to get an update on the resident status. The DON and SW were unable to provide documentation of communication from the hospital regarding the resident's status. There was no evidence that facility the DON or SW had followed up with the hospital or MD. On 11/2/21 a review of the facility's transfer and discharge policy (revised on 3/10/21) listed under policy explanation and compliance guidelines revealed: 1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. On 11/2/21 at 11:45 a.m. an interview with the facility's social worker revealed that prior to 10/16/2021 Resident #1 had requested to be transferred to another facility; however, the resident refused to cooperate with the transfer process. The process for transfer was never completed due to the resident's non-compliance. An interview was conducted with the hospital Case Manager Director (CMD) on 11/2/21 at 1:38 PM. She stated that the resident was brought to the hospital on 10/16/21 and had been sitting in the emergency room (ER) for 285 hours. She further explained that Resident #2 was emergency petitioned to the ER from the facility for making homicidal threats. She went on to say the resident was followed by the hospital's Behavioral Health team from 10/16/21 through 10/18/21 and was seen by Psychiatric Services on 10/19/21. She stated that on 10/19/21 the resident behavior improved, the resident was stabilized. The CMD explained that Resident #2 was then placed on the medical side of the hospital on 10/19/21 while the hospital tried to find a facility to discharge the resident to. The hospital has tried to find placement for Resident #2; however, due to the resident's previous behavior history no one would take the resident. She explained that the resident expressed a desire to return to the facility. The CMD explained that the resident had been in theER on a stretcher for 15 days. The CMD stated that she spoke with the facility Liaison several times, with the last contact made on 11/1/21, but the facility would not permit the resident's return to their building. The CMD stated that the facility's liaison was made aware on 10/22/21 that the resident was stable and that the liaison had access to the resident's electronic medical record for review and updates. The CMD provided correspondence documentation on 10/22/21 of communication with the facility's liaison which indicated that she would follow up with upper management regarding Resident #2's return to the facility. In addition, the CMD stated that she spoke with the Administrator on 10/29/21 regarding the resident's return to the facility with no resolution. An interview was conducted with the facility Administrative Team (NHA, DON and Regional Director) on 11/2/21 at 2:25 PM and they were asked to explain the plan for Resident #2 to return to the facility. The facility Regional Director (RD) stated that the resident had homicidal threats of hurting someone prior to EP by police to the hospital on 10/16/21. The RD went on to say that the facility was unaware of the resident's previous history of being incarcerated for murder and that the facility was concerned about the vulnerable residents in the facility. The administrative team was made aware of the recent interview conducted with the hospital CMD and that she provided an updated status on the resident and the resident's desire and right to return to the facility. At this time the Administrator provided a copy to the survey team of an email, dated 11/1/21 at 2:54 PM, authored by the facility's Medical Director (MD) and addressed to the facility's Administrator. Before leaving the interview, the administrative team stated that they would review the guidelines for permitting residents to return to the facility. On 11/2/21 at 2:35 p.m. a review of the email between the facility's MD and Administrator dated 11/1/2021 revealed the MD wrote that during a team meeting conducted on 10/21/21 the consensus of the group felt that Resident #2 represented a real threat to the safety of both the staff and vulnerable residents and that the resident was previously incarcerated for murder and/or attempted murder. The email further presented the following rationale for discharge: 1. We were unaware of Resident #2's apparent predisposition to violence upon admission to the facility, 2. We managed Resident #2 sometimes difficult behaviors up to the point of actual threats of physical harm and 3. Resident #2 personally expressed a desire to not return to the facility. The Physician Assistant covering the hospital was advised that the facility would decline to accept Resident #2 back. However, according to the Social Worker Admission Assessment, completed on 05/24/2021, the facility was aware of Resident #2's history of violence and incarceration. An interview was conducted with the Administrator on 11/3/21 at 8:10 AM and he was asked if the facility had an update on the status of the resident return to the facility and he stated that he was awaiting instruction from the facility's owner. The Administrator was asked if the Corporate MD had been in touch with the hospital regarding Resident #2. The Administrator was unable to provide any updated information on Resident #2 to the survey team. The Administrator provided a copy to the survey team of a behavior contract for Resident # 2. The contract was dated 10/4/21 and bulleted as the first condition was that verbal and/or physical aggression to staff is not acceptable. The behavior contract bulleted additional behaviors that would not be tolerated but failed to list any consequences to the behaviors. At the time of review, the Administrator remained present and was asked about the behavior contract not having consequences; he was unable to provide an answer but stated that the contract was put in place by the previous Administrator. On 11/3/21 at 9:30 AM the Regional Director (RD) told the survey team that the facility was in contact with the hospital regarding Resident #2's return to the facility. The RD stated that they had documentation of the hospital summary and provided a copy to the survey team. Resident #2 was interviewed on 11/3/21 at 4:50 PM shortly after returning to the facility. The resident stated that after receiving an evaluation while at the hospital and the physician making changes to their current medication regimen s/he wanted to return to the facility. The resident further expressed that s/he wanted to return to the facility five days prior to their return but was told that the facility did not want to bring them back. Due to the findings, an IJ was called on 11/4/2021 at 11:35 AM related to the facility's delay in permitting a resident to return to the facility after the resident was transferred to a hospital by emergency petition and then stabilized. The facility submitted an initial plan of correction to remove the immediacy on 11/4/21 at 2:30 PM, this plan was not accepted. Additional plans of correction were submitted by the facility on 11/4/21 at 2:40 PM, 3:10 PM, 4:12 PM, 6:00 PM, and 6:36 PM, the plans were reviewed and not accepted. On 11/4/21 at 9:10 PM a plan of correction was reviewed by surveyors and the Office of Health Care Quality. The plan was accepted on 11/4/21 at 9:24 PM, but the IJ was not abated until Tuesday, 11/9/21 at 3:15 PM, when implementation of the facility's corrective action was verified. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm and a scope and severity of a D. The facility's corrective action included the following: Resident # 2 was readmitted to the facility on [DATE]. The facility revised the transfer/discharge policy on 11/4/21 to include the following: If a resident is transferred to the hospital the facility must be in communication with the hospital to assess the resident's status and determine the plan to ensure the resident is not left at the hospital if cleared and stable to return to the facility. When a resident transfers to an acute care setting it is the residents' right to return to the facility after being stabilized unless the resident expresses not to return or to be discharged to another facility. Identification: The current Administrator will review current residents to evaluate if there are any residents that were transferred to the hospital in the past 30 days that readmission was denied. -A review of 15 residents who were transferred to the hospital in the last 30 days was completed on 11/4/21 and no residents have been denied readmission. System Correction/Education: The Administrator educated the AD and Social Services Director (SSD) on 11/4/21 on the importance of communicating the status of residents who have been transferred out to the hospital to determine the treatments, medications and services provided at the hospital to help the center evaluate how the resident can be cared for upon return, as well as on the transfer/discharge policy and re-admission process including but not limited to permitting residents return to the facility on ce stabilized or cleared by the hospital. The Regional Director of Clinical Operations (RDCO) educated the Administrator and DON on 11/4/21 on transfer/discharge policy and re-admission process including but not limited to permitting residents return to the facility on ce stabilized or cleared by the hospital. The Regional Senior Administrator (RSA) educated the Corporate Medical Director (CMD) on 11//4/21 on transfer/discharge policy and re-admission process including but not limited to permitting residents return to the facility on ce stabilized or cleared by the hospital. The current Administrator and the DON educated the Licensed Nurses and those who accept residents from the hospital on transfer/discharge policy and re-admission process including but not limited to permitting residents return to the facility on ce stabilized or cleared by the hospital. -Staff education was initiated on 11/4/21 and completed on 11/9/21. The Administrator, DON, Nursing Supervisors, Licensed Nurses, Admission Coordinator, SSD and those who accept residents from the hospital were educated on 11/4/21 and 11/5/21 on the revised transfer/discharge policy (revision-11/4/21) to include the responsibility of the facility to be in communication with the hospital to access residents status and determine the plan to ensure that the residents are not left at the hospital if cleared and stable as well as ensure that the resident rights to return to the facility is honored, unless the resident expressed not to return or be discharged to another facility. - The compliance date of education is 11/9/21 with a letter of attestation signed by the Administrator indicating that licensed nurses who received certified mail will not be allowed to work until they have completed the onsite training on the revised Transfer/ Discharge Policy (revision- 11/4/21). Monitoring: The current Administrator or DON will conduct reviews of residents who have been transferred out to the hospital to validate they have been permitted to return once stable or cleared by the hospital weekly for four weeks then monthly for three months. These audits will be submitted to the Quality Assurance and Performance Improvement (QAPI) Committee for review and further recommendations as necessary. The date of compliance will be 11/9/21 with continued monitoring.

Based on resident interview, record review, and staff interview, it was determined the facility staff failed to 1) obtain an ordered medication for a resident with Human Immunodeficiency Virus ,[MEDICAL CONDITION]. and a history of [MEDICAL CONDITION] for 23 days, while the resident was being treated for [REDACTED].#99), 2) to provide care to a venous stasis ulcer to prevent infection (#101), and 3) follow a physician's orders [REDACTED].#20), 4) ensure that residents receive treatment and care in accordance with professional standards of practice (#32, #14). This was found to be true for 6 of 104 residents (#99, #101, #20, #32 #14, and #42) reviewed during this survey. The facility's failure resulted in actual harm to Resident #101. As a result of these findings, a state of immediate jeopardy was declared on 11/21/2019 at 11:36 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 11/21/2019 around 4:00 PM and the State Agency was unable to accept this plan. After several requested revision the facility submitted a plan on 11/21/19 at 8:17 PM and the removal plan was accepted at 8:27 PM. The immediate jeopardy was removed on 11/27/19 at 1:54 PM. After removal of the immediacy, the deficiency remained for potential for more than minimal harm at a scope and severity of [NAME] The findings include: 1) A medical record review on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Certified Registered Nurse Practitioner (CRNP) #21 on 10/23/19, which documented that Resident #99 was admitted due to a right knee prosthetic joint infection to continue Intravenous (IV) (directly in the vein) antibiotics and rehabilitation. She noted in this document that the resident was receiving Triumeq to [MEDICAL CONDITION].In addition, review of the Physician order [REDACTED]. Review of the progress notes revealed a pharmacy review conducted on 11/5/19 documented no irregularities found. Review of the Medication Administration Record (MAR) for (MONTH) 2019, revealed the following: - On 10/23/19, 10/24/19, and 10/25/19, the medication was documented not available by Registered Nurse (RN) #39: - on 10/26/19, it was documented as in progress (There was no clear definition for this notation which was why staff were not to use, per DON interview on 11/20/19 at 12:43 PM) by RN #39, and -10/27/19 - 10/31/19 it was documented by various nurses as being administered. In addition, review of the physician's progress notes dated 10/23/19, signed by CRNP #21, 10/24/19 signed by attending physician #44, and 10/25/19 signed by CRNP #35 revealed documentation that the resident was receiving Triumeq. Review of the MAR for (MONTH) 2019, revealed the following: -On 11/1/19, it was documented as in progress by RN #39, -11/2/19 and 11/3/19, it was documented as administered, -on 11/4/19, documented as in progress by RN #39, -on 11/5/19 documented as administered, -on 11/6/19 documented in progress by RN #39, -11/7/19 - 11/9/19 it was documented as being administered by various nurses, -11/10-19 - 11/12/19 it was documented as not available by RN #39 and RN #53, and -on 11/13/19 it was documented as administered. Review of the progress notes dated 10/22/19 - 11/13/19, revealed no documentation that the physician was made aware of the medication not being available for the resident. During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq since being admitted to the facility on [DATE] until yesterday (11/14/19). The resident reported speaking with various nurses and a supervisor regarding this issue and was told his/her insurance would not cover the medication. He/she stated I told them to call my doctor at (acute care facility) to get the medication. On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand. This confirmed that Resident #99 went 23 days without his/her Triumeq. In addition, once the medication was restarted the resident's Infectious Disease Physician was not informed, the resident was not assessed by a nurse or a physician, and no labs were obtained to evaluate the possible effects of the discontinuation of the medication. According to the United States Department of Health and Human Services, an individual taking Triumeq should not stop and restart the medication because [MEDICAL CONDITION] can become resistant to the treatment causing an increase of [MEDICAL CONDITION] in the blood that can lead to immune suppression (meaning the immune system would not have the ability to fight infections and other complication associated with [MEDICAL CONDITION]). The adverse effects [MEDICAL CONDITION] immune suppression greatly increases the risk for the resident to have poor health and an early death. (https://aidsinfo.nih.gov/drugs/534/triumeq/169/professional) During an interview with the DON on 11/20/19 at 12:43 PM, she confirmed the medication was not sent from another pharmacy. She was made aware that facility staff had been signing that it was administered during the time it was not available from the pharmacy. During the review of the documentation on the MAR, DON stated staff should not use in progress because there was no clear definition of what that meant. An interview with RN #39 on 11/20/19 at 1:28 PM, revealed that she had called the pharmacy on 10/24/19 and was informed the Triumeq was going to cost $3,000.00 because insurance was not going to cover it. She reported that she handed the information on sticky note to the Assistant Director of Nursing (ADON) #15, whom was the acting Unit Manager, that day. She reported calling the pharmacy a second time on 11/10/19, and was informed that they had faxed a form to the facility. She stated she was aware that the house supervisor gave it to the Director of Nursing (DON) to complete. RN #39 reported that the resident also talked with the social worker that day regarding the missing medication. An interview on 11/20/19 at 2:04 PM, with ADON #15, revealed that the pharmacy was expected to send a form to obtain permission to bill the facility for medications that were not covered by insurance. However, the form was not consistently received for each non-covered medication. At times the nurse would report the medication missing during a medication pass and at that time the pharmacy was contacted and would inform the facility it is non-covered, so there was no set process of how the facility finds out about a non-covered medication. Once the form was received it must go to the DON for approval or denial of payment. The physician should be notified as well to see if there was an alternative medication that was covered. The ADON stated she expected staff to write a progress note that the physician was made aware of the issue. The ADON reported that she was aware of the non-covered medication for Resident #99 and remembered RN #39 making her aware that the medication was going to cost $3,000 and she told RN #39 to call the pharmacy for the form and give it to the DON. Also, the ADON informed the DON during the stand-up meeting on the same day. She stated that she heard nothing more about it and did not follow up to ensure that the medication was received even though she was the acting Unit Manager for the unit in which Resident #39 resides. The DON was interviewed on 11/20/19 at 2:29 PM, regarding the process for obtaining a non-covered medication from the pharmacy. She stated that the nurse should call the pharmacy and when the pharmacy sends the form the nurse was to give it to the Unit Manager or the DON for approval. She stated that usually the pharmacy would send a 7 day supply. She denied she was told on 10/24/19, about the issue with Resident #99's Triumeq and stated the first time she heard about it was on 11/10/19, when she was in the facility to conduct an investigation for another issue. Resident #99 informed her about the missing medication. She reported that she signed the form and sent it to the pharmacy and the medication was received a few days later. She stated that she did not investigate the issue, assess the resident, or call the physician. She stated I should have. During an interview with Nurse Practice Educator (NPE) RN #4 on 11/21/19 at 11:26 AM, he revealed that the process for missing medication was to notify the pharmacy and the physician and document this information in the progress notes in the electronic MAR or in the progress notes field. He confirmed that he was aware that he had mistakenly signed the Triumeq as being administered to Resident #99 on 10/28/19. An interview with LPN #6 on 11/21/19 at 2:33 PM, regarding the process staff used when a medication was not available, revealed she would document NN (nurse note) on the MAR and then call the pharmacy to find out why it was not available. When it was a non-covered medication they would send a form over for the physician to sign and then place the form in the chart for the physician. She reported she does not call the physician until she could tell them what the issue was because they don't like to be called beforehand. When asked she reported that Resident #99 had asked her about the Triumeq, but she was unsure of the date. When asked about signing the Triumeq as being given on 10/27/19 and 10/31/19, she stated she mistakenly signed it as being administered. An interview with the Corporate DON #47 on 11/21/19 at 3:35 PM, revealed the process in the electronic medication administration record allows staff to mark each medication with a Y to show that they had prepared the medication and then go back through and press save once administered. He confirmed that it was expected that staff only click the Y once they have confirmed the medication was available for administration. During an interview with CRNP #21 on 11/21/19 at 1:12 PM, via a phone call, revealed she was not aware the medication was not being administered to Resident #99 until asked to re-enter the order on 11/13/19. She went on to say that she expected staff to resolve medication issues with the pharmacy and not call her. An interview with Resident #99's attending Physician #44 on 11/22/19 at 10:20 AM, via a phone call, he confirmed he was not aware the resident was not receiving the Triumeq since admission until after surveyor intervention on 11/21/19. On 11/21/19 at 11:36 AM, the survey team conducted a meeting with the Director of Nursing, Administrator #2 and Administrator #3 regarding the concerns for discontinuation of Resident #99's medication, the multi-system breakdown that allowed this to continue for 23 days, the fact that staff marked medication as administered 50% of the time it was not available, and the lack of follow up after the issue was discovered on 11/10/19. There were 2 related potential harms associated with the discontinuation of this medication: 1) [MEDICAL CONDITION] potentially not being suppressed which could lead to an increase in [MEDICAL CONDITION] and a decrease in immune function (CD4 count) putting the resident at risk for difficulty with fighting infection and other complications of [MEDICAL CONDITION] and 2) the potential for [MEDICAL CONDITION] to develop resistance to the medication, making it a less effective treatment (with same consequences). As a result of these findings, an immediate jeopardy was declared on 11/21/2019 at 11:36 AM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 11/21/2019 around 4:00 PM and the State Agency was unable to accept this plan. After several requested revision the facility submitted a plan on 11/21/19 at 8:17 PM and the removal plan was accepted at 8:27 PM. The removal plan included the following: A plan of correction from the facility was accepted by the State Agency on 11/21/19 at 8:27 PM, which included the following: a.The CQS validated that resident #99's medications are available for the nursing staff to administer on 11/20/19 at approximately 1400. The Medical Director requested on 11/21/19 at approximately 1200 to speak with the residents Infectious Disease Doctor to determine if any additional treatment changes are needed. b. All residents currently residing in the center will have their medication orders checked against the medication carts by the CQS, Director of Nursing and Unit Managers to assure all medication is available for administration on 11/21/19. c. All licensed nurses of the facility Manor and appointed agency nurses will have education on Medication Administration NSG305, Medication Errors NSG306, Escalation Protocol for (pharmacy name) Pharmacy and the process required to obtain medication when it is not covered by a patient's insurance plan (see attached) by the Director of Nursing. Aspects of the education include but are not limited to OPS100 Accidents/Incidents, Medication Errors, 10.2 Medication-Related Errors, 7.0 Medication Shortages/Unavailable Medications, administering medication according to the Five Rights and the process to obtain medication when it is not covered by the resident's insurance plan. Education will be ongoing by the Director of Nursing until 100% of the licensed nurses are completed prior to their next scheduled shift. Unit Managers will be educated on initiating care plans with [DIAGNOSES REDACTED]. d. Process Change(s): New admission medications will be requested on the next pharmacy run after being entered into the electronic health record. The admitting nurse will verify that new admissions have their medications available during their shift. If the pharmacy has not delivered the medications during the admitting nurse's shift, the shift supervisor will be notified during shift to shift rounds to investigate why a medication is not available. If medication is not available due to non-coverage, (pharmacy name) will send a concurrent fax to the admitting unit and an electronic alert to the Director of Nursing where resident was admitted . The shift supervisors will reconcile the medication orders to medications delivered to ensure pending medications are delivered as ordered. If medication is not available, the escalation process will be followed and the Director of Nursing will be notified of the delivery discrepancies. e. The night shift Supervisor will run the new order(s) report for all new medication orders for the prior 24 hours to verify medications are available as ordered. The new order report and its findings will be given to the Director of Nursing for review. A copy of NSG305 and the Escalation Protocol have been laminated and placed on the nursing units for ongoing reference as of 11/20/19 by the Director of Nursing. f. Monitoring: Current medication orders and cart check audits will be completed each shift for 7 days by the Director of Nursing and Unit Managers starting 11/21/2019. The medication order and cart check audits will continue weekly times 4 weeks and monthly times two months by the Director of Nursing. Compliance results will be reported to the QA committee for further recommendation. A copy of each Policy and Procedure was provided by the facility and reviewed by the survey team. The immediate jeopardy was removed on 11/27/19 at 1:54 PM. (Cross Reference: F580, F658, F755, F760, and F842) 2) Interview of resident #101 on 11/18/19 revealed that s/he got a wound infection due to the facility staff not being able transport the resident to weekly wound clinic appointments. S/he indicated that the staff were to wrap her/his leg and was not being seen by a nurse. Review of resident #101's medical record on 12/3/2019 revealed that the resident had developed a right lower leg ulcer associated with venous stasis disease and was being seen at a local wound clinic once per week beginning on 6/17/19. The weekly wound clinic documentation was found scattered in the paper hard chart. The weekly wound consultation reports were found to be multiple pages with handwritten and typed components. At times the reports included cumulative documentation related to previous visits. Measurements of the venous leg ulcer on the right medial posterior lower leg were taken and recorded at each wound clinic visit. Review of a 8/13/19 wound consultation report revealed the venous leg ulcer was classified as a full thickness without exposed support strictures wound measuring; length (L) 9.0 cm x width (W) 2.8 cm x depth (D) 0.1 cm the report included the total area of the wound 19.782 cm and the volume at 1.979 cm. Additionally, details of the wound were provided as to amount of drainage, necrotic tissue and the appearance of the skin around the wound. The report indicated the wound to be cleansed with soap and water, apply [MEDICATION NAME] w/ Calcium alginate dressing and protect surrounding skin with [MEDICATION NAME]. The dressing change frequency indicated Do not change dressing for One Week. For [MEDICAL CONDITION] control Unna Boot compression therapy was applied to the right lower extremity. (Unna Boot itself is a compression dressing, usually made of cotton, that has a zinc oxide paste applied uniformly to the entire bandage, which can be used for the treatment of [REDACTED]. The resident was to return to the clinic in 1 week. Additional instructions included Do not remove dressing unless you are ready to put back on another Unna boot! PLEASE Resident #101 was scheduled to return to the clinic on 8/20/19 at 1 PM. Review of the wound consultation notes revealed that the resident did not return to the clinic until 9/10/19. A nurse's note was written on 8/20/19, included wound appt rescheduled due to w/c being too wide to fit on transportation van. There was not any indication in progress notes that the resident attending was notified. At telephone order was created by the unit manager (staff #5) at 3 PM on 8/20/19 written as; Wound care: RLE (right lower extremity) clean with wound cleanser , apply Calcium Alginate to base, cover with ABD pad and wrap with Kerlix prn Mon, Wed, Fri prn Unna Boot not in place. Review of the attending physician's note dated 8/20/19 7:41 PM did not reveal any documentation related to the skin/wound status for resident #101. The attending physician had failed to provide an assessment and evaluation related to the dressing change phone order. Clinical visit notes of 8/22/19 and 8/27/19 by a Certified Registered Nurse Practitioner (CRNP-staff#35) did not reveal any documentation related to assessment and/or evaluation of the leg ulceration. Under the plan section of both notes, revealed local dressing care of wound rt ankle per wound nurse. Review of the skin integrity report for the RLE did not reveal weekly documentation for the progress of the condition of the wound. There was some documentation of the wound progression but with lapses of ongoing weekly documentation. The assessments and evaluations of the wound were provided by the licensed practical nurse unit manager (staff #5). Between 8/13/19 to 9/10/19 progression of the wound was documented on 8/20/19, 8/28/19, and 9/5/19. The Unna boot would have to have been removed to measure, assess, and evaluate the wound. Review of the treatment administration record (TAR) revealed that the physician's telephone order of 8/20/19 was only performed 3 times (8/23/19, 8/25/19, 9/5/19) during the time period resident #101 was absent from the wound clinic. The staff failed to follow the prescription for dressing change. There were not any indications found in the record that the resident had refused wound clinic appointments or refusal of wound treatments during the time period s/he was not seen at the wound clinic. The wound clinic consultation documentation of 9/10/19 was written as I have not seen (name of resident) since 8/13 at which time he had an Unna boot with [MEDICATION NAME]. S/he has had continued pain. (Resident #101) has [MEDICATION NAME] on today and it is only half on his calf (like tennis socks). All that was present was ABD (abdominal) Pad and gauze. He has maggots in the wound and on the lower leg. (name of resident) reported that he has not had a dressing change since Friday 9/6/19. The wound measured L 8.9 cm x W 3 cm x D .2, area = 20.97 and volume = 4.194 .There is Fat Layer (Subcutaneous Tissue) Exposed .there is a large amount of serosanguineous drainage noted. Foul odor after cleansing was noted. The report indicated that the wound was debrided, and subcutaneous tissue was removed. 1 specimen was taken by a tissue culture and sent to the lab. The dressing was changed to [MEDICATION NAME] 7 Flex and Unna boot was applied. As of 12/3/19, the medical record was missing wound consultation reports. Upon request at 12:40 PM the facility had the wound center fax weekly consultation reports dated 9/17/19, 10/1/19, and 10/8/19. Review of the 9/17/19 wound consultation report revealed a positive tissue couture of pseudomonas and proteus mirabilis. The resident was required to be treated with IV antibiotics combat the infected wound. Resident #101 had agreed to go the emergency room for admission to the hospital. The resident was readmitted to the nursing home on 9/20/19. Review of the care plans for resident #101 revealed a focus area initiated on 8/14/18 as Resident has actual skin breakdown related to chronic venous wound to right medial leg. The goal of this care area; The resident's wound will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and presence of granulation x 90 days. The interventions to meet the goal included, 1) Observe skin condition with ADL care daily and report abnormalities. 2) Provide wound treatment as ordered. 3) skin check per policy. 4) weekly wound assessment to include measurements and description of wound status. The interventions did not include weekly wound clinic consultations. A care plan evaluation was conducted on 9/5/19 during the 4-week absence from the wound clinic. The unit manager (staff #5) wrote Resident seen by wound center for Unna boot weekly, will continue plan of care. The evaluation did not reflect the wound status. The wound was not decreasing in size and the Unna boot was not being utilized and by 9/5/19 had missed 3 weekly wound clinic appointments without indication of physician oversight. At 12:40 PM on 12/3/19 the unit manager was asked questions related to the telephone order that she had written on 8/20/19. She indicated that the dressing should have been changed on Monday, Wednesday, and Friday when the Unna boot was not in place. She revealed that the resident was not seen by the in house wound consultant nurse as the resident was to go to the local wound clinic weekly. Resident #101 was interviewed on 12/3/19 at 2:53 PM s/he acknowledged going to the wound clinic and the wound is close to being completely healed. When asked about the maggots being found in the wound s/he blamed the facility for not providing transportation or not having an escort to go along with her/him. S/he indicated that the facility would not have the supplies to do the treatment and/or staff would pass the treatment of [REDACTED]. The unit manager was interviewed on 12/4/19 at 11:14 AM, She was asked about identification of maggots being found in the wound. She indicated that there were not maggots when she measured resident #101's wound. She acknowledged that she did not do the dressing change when she measured the wound. She had indicated that resident #101 was seen by the in-house wound consultant on 12/4/19. A phone interview was conducted with the certified registered nurse practitioner wound consultant (staff #20) on 12/4/19 at 12:45 PM. She when a resident is seen at a wound clinic, she does not see those residents. She indicated that it would not be ethical for her to review a resident that is being seen by another consultant. She acknowledged visiting the resident on 12/4/19 as the resident is reportedly to be discharged from the local wound clinic. At 1:05 PM the medical director was informed of the facility's inability to get the resident to weekly wound clinics with the lack of documentation from the resident's attending or CRNPs related to wound assessments/evaluations. The medical director was informed of the facility's inactions and the discovery of maggots in the wound and ensuing wound infection requiring hospitalization of the resident. Ongoing review of resident #101's medical record had revealed that CRNP (staff #21) had made visits to the resident on 8/23/19 and 8/29/19. Under the physical exam part of the visit notes indicated identical statements written as Right leg wound 7 x 4 x 0.2 cm. 100% necrotic. Periwound is intact. Mod drainage. Slight odor. At 2:20 pm on 12/4/19 an interview was conducted with CRNP (staff #21). She was shown printed copies of the 8/23 and 8/29/19 note. She indicated that she did not provide those wound measurements. She acknowledged that the facility utilizes templated notes and the measurements and observation data on the visitation notes was old data. She indicated that she had not assessed and/or evaluated the residents wound. At 3:45 PM on 12/4/19 the director of nursing was asked if the Quality assurance and performance improvement committee (QAPI) did any interventions when the resident was found to have had maggots in the wound on 9/10/19. She acknowledged that she was aware of this for the first time upon surveyor request for wound consultation notes. The QAPI committee was not aware that a resident was found to have had maggots in a wound. 3) Review of Resident #20's (MONTH) 2019 physician orders [REDACTED]. Apply every day on Q (every) am off Q hs (hour of sleep/bedtime) every shift and Prevalon Boots to BLE while in bed every shift. (Prevalon pressure-relieving heel protector features pillow-style cushioning and is made with ultra-soft, open-weave fabric.) Resident #20 was observed by two surveyors at 2:27 PM on 11/15/19 and did not have the prescribed treatments applied to his/her lower extremities. On 11/15/19 at 2:45 PM, a review of Resident #20's TAR (treatment administration record) revealed both skin treatment orders to bilateral lower extremities were documented as done/applied. Continued observations were made on 11/18, 11/19, and 11/20/19 at the end of each day shift. The two skin protecting devises were not observed on Resident #20 lower extremities. On 11/19/19 at 9:57 AM interview of Resident #20, indicated/stated that s/he had not worn the boots (Prevalon) in a long time. Review of the TAR on 11/20/19 at 3:30 PM revealed that both orders were signed off as applied on 11/18/19 and 11/20/19 without any further documentation. With ongoing daily reviews of Resident #20's medical record, it was noted that there were two prescriptions to clean the filter on the oxygen concentrator on every Sunday day shift and on every Wednesday night shift. On the morning of Thursday 11/21/19 observations of the filter on the side of the oxygen concentrator was observed with build up dust on and around the perimeter of the filter. The TAR was signed off as done/performed by the night shift staff for the previous night shift. On 11/21/19 at 1:04 PM during an in interview of the licensed practical nurse (LPN #6) assigned to Resident #20 while she was in the resident's room, she acknowledged that the protective skin treatments were not on the resident's lower extremities. She indicated that medigrips are on a roll and that they are to be cut from the roll and applied each morning. The nurse confirmed that the Prevalon boots were not in the resident's room. She searched for a box of the medigrip size [NAME] and was unable to find any on the unit. The nurse did find an open box of the medigrip size F to show the surveyor and she provided instructional information as the how to apply the product as prescribed. At 1:47 PM on 11/21/19 the unit manager (Staff #5) was informed that staff have signed off as applying the Prevalon boots on all three shifts for the month of (MONTH) except for day shift of 11/19/19 and the prescribed medigrip socks were signed as applied every day shift accept for 11/8/19 and 11/19/19. The prevalon boots were not observed on the resident or in the room based on observations between 11/15/19 and 11/21/19. The filter to the oxygen concentrator was pulled off to show the build up dust around the sides of the sponge like filter and that staff signed off twice per week as performing a cleaning of the filter without evidence of the filter being cleaned. 4a) On 11/25/19 at 11:26 AM, Resident #32's medical record was reviewed. Review of Resident #32's (MONTH) 2019 TAR (treatment administration record) revealed a 1/22/19 physician order [REDACTED]. There was no documentation on the TAR to indicate Resident #32's abdominal girth had been measured in (MONTH) 2019. On 11/15/19 a 2:33 PM, in a progress note, the nurse indicated that the resident's abdominal girth was not measured because the resident was in an activity. No further documentation was found in the medical record that would indicate further attempts were made to measure the resident's abdomen or that the physician had been made aware. On 11/25/19 at 1:26 PM, the Director of Nurses (DON) was made aware of the finding. The DON stated that if the resident's abdominal girth had not been obtained, the DON would expect the nurse to pass on in report to the next shift and would expect that it would later be obtained and documented in the medical record. 4b) Review of Resident #32's (MONTH) 2019 MAR (medication administration record) revealed a 6/22/19 physician order [REDACTED]. This task was signed off as being done on 11/4/19, 11/11/19 and 11/18/19, indicating that Resident #32 had been weighed on those dates. Review of Resident #32's weight summary in the electronic medical record (EMR) revealed Resident #32 had only one weight recorded in (MONTH) 2019, on 11/19/19. Resident #32 had no weights recorded on 11/4/19, 11/11/19 or 11/18/19 which was in contradicted the documentation on resident's (MONTH) 2019 TAR. Review of Resident #32's weight summary since 6/24/19 revealed the resident had a weight recorded on 7/2/19, 81/19, 8/26/19, 9/12/19, 10/25/19 and 11/19/19 which was 7 times in 22 weeks. The facility staff failed to follow the physician's orders [REDACTED].#32's weight every week. The Director of Nurses was made aware of these findings on 11/26/19 at 3:20 PM 5) On 12/5/19 at 9:00 AM, a review of Resident #14's medical record revealed an 8/6/19 an Endocrinologist (doctors who specialize in glands and the hormones) consult progress note that stated the reason for the appointment was [MEDICAL CONDITION] Nodule (solid or fluid-filled lumps that form within the [MEDICAL CONDITION], a small gland located at the base the neck, just above the breast bone). The physician wrote that the resident had been found to have [MEDICAL CONDITION] nodules from a prior [MEDICAL CONDITION] ultrasound (imaging method to see the [MEDICAL CONDITION]) and was referred for further evaluation. The physician documented that he/she did not have a copy of the [MEDICAL CONDITION] ultrasound study results or actual images to review, that he/she would request a copy and indicated either physician or staff would call to discuss the nex

Based on medical record review, interviews and observations it was determined that the facility failed to provide care consistent with professional standards of practice to prevent the development of pressure ulcers and to provide care to promote healing of identified ulcers as evidenced by: 1a) the failure to ensure a newly identified pressure ulcer was assessed by a health care practitioner for more than two weeks (Resident #110); 1b) failure to re-evaluate the nutritional needs of a resident with a pressure ulcer when a protein supplement order expired (Resident #110) 1c) failure to ensure staff provided [DEVICE] supplemental feedings as ordered (Resident #110) and 1d) failure to ensure nursing staff provided dressing changes as ordered (Resident #110); 2) failure to ensure primary care provider or wound nurse practitioner were made aware of signs of a wound infection (Resident #82). This was found to be evident for 6 out of 10 residents (Resident #110, #82, #101, #36, #17, #114) reviewed for pressure ulcers during the survey. This deficient practice resulted in actual harm to Resident #110. The findings include: 1. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). On [DATE] review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, [MEDICAL CONDITION], high blood pressure, diabetes and lung disease. The resident has had a [DEVICE] since (YEAR) although the resident does consume meals by mouth. Review of the [DATE] minimum data set assessment revealed the resident requires extensive assist from staff for bed mobility and eating. The resident's weight in (MONTH) 2019 ranged from 124.8 - 130.4 lbs. 1a) Review of the [DATE] Care Plan Evaluation note revealed resident's skin was intact at that time. Review of the physician orders [REDACTED]. Review of the [DATE] Care Plan Evaluation note revealed the following: Resident noted with a closed blister to inner ankle. Treatment in place. Will have wound nurse eval on next visit. Review of the corresponding Skin Integrity Report revealed documentation of an in house acquired pressure ulcer to the left medial (inner) ankle. The Skin Integrity Report has areas to document the progression of a skin wound over a 10 week period. The area of this Skin Integrity Report for the initial wound date failed to reveal a legible date. The initial wound documentation revealed the wound was 2.1 by 1.6 cm. The second week's documentation was dated [DATE] and revealed the wound was documented as a stage 2 pressure ulcer measuring 2.1 x 1.0 cm. According to state regulations staff shall document the progression of a skin condition weekly until the condition is healed. Further review of the Skin Integrity Report for the ankle wound revealed documentation from ,[DATE] thru ,[DATE]. No weekly documentation was found for the weeks of (MONTH) 28; (MONTH) 9 or (MONTH) 23. The Director of Nursing (DON) reported on [DATE] at 1:12 PM that the wound nurse typically comes every Wednesday but some Wednesdays she does not. She went on to report that the wound nurse does not see every resident (with wounds) every week. When asked how it is determined who the wound nurse sees the DON reported that there are skin sheets (Skin Integrity Reports) in the book and the wound nurse sees these sheets when she comes in. The DON also reported that the unit nurse managers are aware to let the wound nurse know if someone needs to be seen. Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's ankle wound when she was scheduled to be in the building on Wednesday (MONTH) 7th or Wednesday (MONTH) 14. Review of the wound nurse progress note for a [DATE] date of service revealed the left medial ankle wound was 4.1 x 3.2 cm x UTD (unable to determine depth) and was currently unstageable with 95% of the wound with necrotic tissue. The order for the treatment to the wound was changed on [DATE] to cleanse left medial ankle with wound cleanser, apply [MEDICATION NAME] to base and cover with foam dressing every day and as needed. Further review of the medical record failed to reveal documentation that the wound nurse re-assessed the resident's ankle wound until more than a month later on [DATE] at which time the wound was assessed to be 1.9 cm X 3.1 cm x 0.1 cm and a stage 4. On [DATE] nurse #40 completed a change in condition note that revealed the presence of skin wound on the resident's backside. The note revealed the primary care nurse practitioner was made aware and wanted the wound nurse to evaluate the patient. The corresponding Skin Integrity Report revealed an in house acquired pressure ulcer, stage 2 measuring 1 cm in length with a width of 0. Further review of the Skin Integrity Report for the sacral pressure ulcer revealed documentation from [DATE] thru [DATE]. This is an 11 week period but there is only documentation for 9 weeks. No weekly documentation was found for the week of (MONTH) 9th. There is only one assessment documented between ,[DATE] and ,[DATE] but the date is not legible. There is a section at the bottom of this form for the nurse's signature/initials and an area for initials when the weekly assessment is completed. Of the nine assessments completed, only one has a corresponding nurse signature. This was for licensed practical nurse #40 who completed the initial assessment only. On [DATE] at 10:21 AM the DON reported that the nurse assigned to the resident is responsible for assessing and documenting newly identified pressure ulcers. She went on to report that if the assigned nurse is an LPN the LPN would let the supervisor know to come look at the wound and stated that there is always an RN in the building. DON also reported that the unit nurse managers are expected to measure and document the progression of a pressure ulcer when the wound nurse is not completing the wound assessment. Surveyor reviewed the concern that the initial assessment of the sacral wound was completed by an LPN #40. On [DATE] surveyor requested from the DON identification of the nurses who initialed the assessments for the sacral wound Skin Integrity Report on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 11/(illegible), and [DATE]. When the DON provided the requested information a new copy of this report was provided that had documentation for [DATE] added in the margin. No documentation was found, or provided, to indicate a wound assessment was completed for the week of [DATE]. A signature for registered nurse #8 was found to have been added to this Skin Integrity Report that corresponded to the assessments completed on [DATE] and [DATE]. The DON failed to provide information regarding the identification of the nurses who completed the [DATE], [DATE] and 11/ (illegible date) assessments. Further review of the medical record revealed the wound nurse practitioner gave an order for [REDACTED]. Review of the care plan revealed it was updated on [DATE] to include the presence of the sacral wound and resident to be seen on wound rounds was added to the interventions. On [DATE] at 8:58 AM the wound NP #20 reported that she sees all of the residents with wounds on the rehab unit each week and alternates wound rounds on the two long term care units, thus seeing the long term care residents with wounds every other week. She went on to report that the expectation is that the unit nurse manager conduct the wound rounds on the alternate weeks and alert her is a wound is not stable. If there is a new wound the staff usually asks the wound NP to see the wound but she clarified that she typically does not assess stage 1 or stage 2 wounds. She confirmed that even if there is a new stage 2 wound she would not assess it until it is a stage 3. She went on to report that she will see anything they ask me to see, sometimes the staging isn't correct. Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's new pressure ulcer when she was scheduled to be in the facility for wound rounds on Wednesday (MONTH) 11 or 18. On [DATE] at 9:28 AM the wound NP #20 reported she was in the facility on (MONTH) 11 and 18 but was not sure why she did not see the resident. Review of the primary care physician progress notes [REDACTED]. Further review of the medical record failed to reveal documentation that a physician or a nurse practitioner assessed the residents sacral wound from the time it was first documented on ,[DATE] thru [DATE]. Further review of the medical record revealed the wound nurse practitioner (NP) #20 assessed the resident on [DATE]. Review of the progress note for this visit revealed the left ankle wound as being 1.9 x 3.1 x 0.1 cm stage 4 and the sacral wound 3 x 4 x 0.1 cm with heavy drainage and a stage 3. Further review of the medical record revealed that on [DATE] the resident was seen by the primary care physician. This note revealed documentation under Physical Exam Skin section that was identical to the assessment completed by the wound NP #20 in her [DATE] note. There is no notation that these measurements were from the [DATE] NP note. Interview with the primary care physician (PCP) #44 on [DATE] at 10:11 AM revealed that he was aware the resident currently had sacral and ankle ulcers. Confirmed that he does not assess pressure ulcers every time he sees the resident and went on to state that they have a wound nurse that comes once a week. The PCP went on to confirm that he did not measure the resident's wounds as indicated in the [DATE] note, stating that he goes with the measurements provided by the wound nurse. On [DATE] the wound NP #20 saw the resident. Review of the note from this visit revealed the left ankle wound with a bit of decline and was 1.3 x 0.6 x 0.1 cm stage 4. The Physical Exam section of the note documented the sacral wound: 4 x 3.5 x 0.1 cm. 100% slough, 0% granulation. heavy drainage. stage 3, however in the [DIAGNOSES REDACTED]. Too moist. The documentation on the Skin Integrity Report for [DATE] documented the stage as: unstageable. 1b) Review of the medical record revealed that from [DATE] until [DATE] the resident's [DEVICE] feeding order was for 80 cc [MEDICATION NAME] 1.5 after meals. On [DATE] the resident's weight was 128.9 lbs. On [DATE] there was an order for [REDACTED]. Review of the Medication Administration Record (MAR) revealed documentation that the supplement was administered as ordered from ,[DATE] thru [DATE]. Review of the medical record revealed the resident was seen by the Registered Dietician (RD #17) on [DATE]. Review of the note from this visit revealed average oral intake was 50 - 75% with assistance by staff. The note also documented the presence of pressure ulcers: Sacrum stage 1 and left ankle unstageable; and that the resident has increased nutrition needs for PU (pressure ulcer) healing. The note revealed the resident was currently receiving the Proheal 30 ml two times a day and [MEDICATION NAME] 1.5 (1.5 calories per ml) 80 ml via the feeding tube after meals three times a day. The RD's recommendations included to continue regular liberalized puree diet, assist with PO intake; continue tube feeding as ordered; and continue Proheal 30 ml two times a day for wound healing. Further review of the medical record failed to reveal an RD re-assessment on [DATE] when the order for the protein supplement stopped. During an interview on [DATE] at 2:23 PM with RD #17, she reported she did not think she wrote the protein supplement order and did not recall if she was aware that it was only for 30 days. The RD went on to report that the protein supplement did not add that many calories (in regard to weight loss) but confirmed it was a significant amount of protein. The protein supplement provided an additional 30 gms of protein and 200 calories to the resident's diet per day. On [DATE] review of the medical record revealed a physician order, originally written [DATE], for 100% supervision with all PO intake with meals. Further review of the GNA documentation revealed the coding for documentation for Eating -Self performance as follows: 0- Independent - no help or staff oversight at any time; 1 - Supervision- Oversight, encouragement or cueing; 2 - Limited Assistance - Resident highly involved in activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance; 3-Extensive Assistance - Resident involved in activity, staff provide weight -bearing support or 4 - Total Dependence - Full staff performance. Further review of the resident's care plan revealed an intervention of assist with PO (by mouth) intake was added on [DATE]. Review of the Geriatric Nursing Assistant (GNA) documentation for meals revealed staff documented set up help but that the resident wasindependent -no help or staff oversight at any time with eating for 18 out of 36 meals from (MONTH) 19 thru the 30th. Staff documented the resident as being totally dependant for eating for the other half of the meals provided during this time period. Review of the GNA documentation for assistance provided with meals for (MONTH) and (MONTH) also documented the resident as independent for more than half the meals provided to the resident. On [DATE] at 4:07 PM surveyor reviewed the concern with the DON that GNA documentation from past 30 days revealed staff documenting resident as independent with meals on many occasions. Further review of the [DATE] wound NP #20 note revealed: on tube feeding and supplements. Further review of the medical record failed to reveal any documentation that the resident received, or had current orders for, a nutritional supplement after the protein supplement order expired on [DATE]. From ,[DATE] thru ,[DATE] the resident did not receive any protein supplement or increase in [DEVICE] feeding. On [DATE] the resident's weight was recorded as 114 lbs indicating a significant weight loss. On [DATE] the resident's weight was 114.4 lbs. On [DATE] RD #17 completed a weight change progress note which addresses the significant weight loss of 11.2 % x 30 day; 9.4% loss in 90 days and 14.6% loss over 180 days. PO (by mouth) intake varies at meals, needs assistance , on average 50% intake notes Resident has increased nutrition needs for wound healing. The RD recommended increasing the tube feeding to 1 can (237 ml) [MEDICATION NAME] 1.5 after each meal. A corresponding order, dated [DATE], for the 1 can of [MEDICATION NAME] after meals was found in the medical record. The RD also recommended weekly weights times 4 weeks. On [DATE] surveyor reviewed the concern with the RD #17 that the supplement ended and was not re-evaluated, the resident's wound worsened and the resident experienced a significant weight loss. On [DATE] the wound NP #20 assessed the resident's wounds. The note for this visit revealed left ankle wound was 1 x 1.2 x 0.1 x 0.1 cm and bit of decline. The Sacral wound was 4 x 2.5 x 1.0 cm with heavy drainage Stage 4 and decline. On [DATE] the resident's weight was recorded as 132.6 lbs. This represents a gain of more than 15 lbs in less than 2 weeks. No documentation of a re-weight was found in the medical record. On [DATE] at 8:19 AM RD #17 reported that staff is suppose to get a re-weight if greater than 5 lb change either way. The next recorded weight was on [DATE] and was 113.4 lbs. 1c) On [DATE] at 9:48 AM surveyor observed an unopened container of [MEDICATION NAME] on the resident's overbed table. On [DATE] at 11:04 AM the unit nurse manager #8 observed the [MEDICATION NAME] container with the surveyor. The nurse manager reported it had been opened but was not empty at this time and proceeded to throw out the container. On [DATE] at approximately 2:45 PM review of the medical record revealed documentation that nurse #40 had administered the [MEDICATION NAME] on [DATE] at 10:00 AM. On [DATE] at 3:04 PM nurse #40, who had been assigned to care for the resident during the day shift, reported the resident was a feeder (a resident in need of assistance with eating). When surveyor asked nurse #40 if the resident received all nutrition by mouth, the nurse reported: yes. The nurse went on to report if the resident doesn't eat up to 50% he would give the resident a bolus (can of feeding via [DEVICE]). He confirmed that he had not administered any [MEDICATION NAME] today, stating the resident has been going over (the 50%) for eating. When surveyor reviewed with Nurse #40 that the documentation revealed that the resident is to receive one can of [MEDICATION NAME] after meals and that he had documented the administration of the [MEDICATION NAME] the nurse reported that he would have to strike it because the resident ate and he did not give the [MEDICATION NAME]. He confirmed that he did not administer the [MEDICATION NAME] in the morning either. On [DATE] at 3:09 PM the nurse was observed reviewing the orders in the electronic health record and stated looks like they changed the order, how they had (him/her) was if (he/she) eats over a certain amount we don't give the bolus, when I work with (the resident) that is how it's been. The nurse went on to report that he is employed by an agency and usually works on this unit or the rehab unit. On [DATE] at 3:28 PM surveyor reviewed the concern with the DON regarding Nurse #40's documentation that the [MEDICATION NAME] had been administered despite his report that the resident does not receive the [MEDICATION NAME] unless the resident eats less than 50% of meals and confirmation that he had not administered the [MEDICATION NAME] today. Further review of the MAR and the nursing notes revealed that Nurse #40 documented that the [DATE] [MEDICATION NAME] was administered at 10:00 AM. The dose due at 2:00 PM was documented as being held (not given). The corresponding nursing note with an effective date of [DATE] at 3:09 PM revealed a notation that the resident eat over 50% of (his/her) meal. Further review of the medical record revealed that from [DATE] until changed on [DATE] the resident's [DEVICE] feeding orders were: after meals give 1 can [MEDICATION NAME] bolus if PO (by mouth) intake is less than 50%. 1d) On [DATE] at 11:37 AM surveyor began the observation of Nurse #13 complete a dressing change for Resident #110's left ankle and sacral pressure ulcers. At 11:45 AM the nurse reported he just re-checked the orders. During observation of the sacral wound dressing the nurse cleaned the wound with wound cleanser, applied skin prep to the periwound area, applied [MEDICATION NAME] powder to the wound base and packed the wound with gauze moistened with the wound cleanser, and then covered the wound. On [DATE] review of the physician orders [REDACTED]. The nurse had not used Calazine during the sacral wound dressing change. During observation of the ankle wound treatment the nurse stated he was going to apply Calazine to the wound. The nurse was then observed covering the wound base with Calazine, then applied the silver alginate dressing. On [DATE] review of the physician orders [REDACTED]. The periwound is the tissue surrounding the wound. On [DATE] at 2:30 PM surveyor reviewed the concern with the unit nurse manager #8 that the nurse had failed to follow the wound care orders as evidenced by applying the Calazine to the wound base of the ankle pressure ulcer rather than the periwound as ordered; and failed to apply the Calazine to the edges of the sacral wound as ordered. On [DATE] at 2:57 PM surveyor reviewed with the DON the concerns regarding the development of the pressure ulcers for Resident #110 including: failure of a physician or NP to assess the resident's wounds for several weeks; failure to re-evaluate the need for supplementation when a protein supplement ordered due to the presence of the wounds expired; failure of staff to provide [DEVICE] feedings as ordered; and failure to complete all the steps of a dressing change as ordered. 2) On [DATE] review of Resident #82's medical record revealed a skin integrity report dated [DATE] that documented a stage 2 pressure ulcer on the the right lower extremity measuring 3 cm x 1.5 cm. No further documentation was found on this Skin Integrity Report. A corresponding progress note, dated [DATE] at 11:02 AM and written by the unit nurse manager #8, revealed the following: Pt has stage 2 pressure area to right inferior lower leg. Area measures approx. 3 cm X 1.5 cm. Drainage appears purulent and is malodorous. Purulent drainage and malodorous odor are indicators that a wound may be infected. On [DATE] further review of the medical record revealed an order, dated [DATE], to notify MD/NP or wound CRNP if skin breaks open. Further review of the medical record failed to reveal documentation that either the primary care provider, or the wound nurse practitioner, had been made aware of the [DATE] wound assessment. On [DATE] further review of the medical record revealed a wound NP progress note for a visit dated [DATE] which revealed the right inferior calf wound was healed. Prior to the [DATE] assessment the most recent wound NP progress note found was from (MONTH) 2019. Review of this note revealed a right inferior leg wound was healed and that nursing should report if the wound re-opened as soon as possible. On [DATE] at 9:18 AM the wound nurse practitioner #20 reported that she had not been notified about the [DATE] assessment. On [DATE] at 10:28 AM surveyor reviewed with the Director of Nursing the [DATE] note documenting a potentially infected wound with no documentation that a MD or NP had been notified. As of time of exit, [DATE] at 5:15 PM no additional documentation was provided regarding the [DATE] wound assessment. 3) Interview of Resident #101 on [DATE] at 10:31 AM revealed that s/he had wounds to his skin. The resident had indicated that one of the wounds was on her/his butt. Review of Resident #101's medical record on [DATE] revealed that the resident was being seen at a local wound clinic once per week beginning on [DATE]. The wound clinic had identified an abrasion on the Resident #101's buttock and ordered for Venelex ointment to the buttock abrasion twice daily. The treatment was started in the facility on [DATE]. The wound consult dated [DATE] indicated that the wound was classified as a partial thickness wound with etiology of Abrasion and is located on the right gluteal fold. Measurements and full description of the wound was provided. The wound was identified as a stage II pressure ulcer, with additional instructions to massage Venelex ointment well into the right buttock ulcer twice daily. The wound consultant reported dated [DATE] indicated the pressure ulcer to the right buttock was smaller when comparing the measurements to the [DATE] wound consultant documentation. Review of the (MONTH) 2019 treatment administration record (TAR) revealed that the order for Venelex ointment to the right buttock pressure ulcer was discontinued on [DATE]. The order was found to have been discontinued via a phone order from the resident's attending physician. A Licensed practical nurse (staff #5) signed off the Venelex ointment discontinuation order. Further documentation of the reason for the discontinuation and/or assessment of the wound was not found in the medical record. There was not any nursing note indicating that the resident's attending physician had been notified. Review of the attending physician's note dated [DATE] did not reveal any documentation related to the skin/wound status for Resident #101. The attending physician had failed to provide an assessment and evaluation with a response to notification of change to the resident's skin status. Ongoing review of the medical record revealed that the facility failed to assure that the resident was seen weekly at the local wound clinic. As of [DATE], the medical record was missing wound consultation reports. Upon request at 12:40 PM the facility had the wound center fax weekly consultation reports dated [DATE], [DATE], and [DATE]. During the request for missing documentation the unit manager (staff #5) indicated that Resident #101 was at the wound clinic. Review of the wound consultation report dated [DATE] indicated the resident had reopened her/his right butt/thigh ulcer from sheer. The consult indicated the wound was a stage II pressure ulcer with measurements of 0.7 x 0.6 x 0.1 and please use venelex ointment twice daily massage well x 1 min. The [DATE] consultation report included an order for [REDACTED]. REDUCE SHEER!!! for a stage II ulcer. On [DATE] the wound consultation wrote I have written 2 prescriptions for VENELEX ointment to prevent sheer and skin breakdown. Review of the record on [DATE] revealed that the order for Venelex ointment was written on [DATE] after Resident #101's return from the wound clinic. Review of the wound book with the skin integrity reports on [DATE] did not reveal a skin integrity report for the stage II buttock/thigh wound. There was not a skin integrity report for the time frame between [DATE] and [DATE] when there was documentation of ongoing treatment to the stage II buttock wound. The [DATE] wound clinic consultation report was reviewed with the unit manager (staff #5) at 11:36 AM on [DATE]. She indicated that she did not know if there was a skin integrity report related to the stage II buttock ulcer. She had documented on a skin integrity report related to a venous stasis ulcer on the resident's right leg but she did not provided any documentation or acknowledgement of the resident's stage II buttock ulcer. Review of the care plans revealed that the resident had actual skin breakdown relate to chronic venous wound to the right leg. The first intervention for the venous wound was initiated on [DATE] and was written as observe skin condition with ADL (activities of daily living) care daily and report abnormalities. There was not any documentation related the wound consultant's identification of the stage II pressure ulcer until [DATE]. 4) Review of Resident #36's medical record on [DATE] revealed the resident was admitted on [DATE] from an acute care facility. The discharge summary from the hospital on [DATE] documented that the resident had multiple wounds on the back. A skin integrity sheet was started on [DATE] for a rash on the mid back, abdominal folds and back of knee. A second skin sheet was started for a skin tear on the mid back and a third skin sheet was for an abscess on the lower back. There was no buttock skin sheet. The abscess notes of [DATE] documented a stage 2 on the sacrum, a lower back wound and notes documented that the wounds were improving. There was no further documentation on skin sheets which tracked the progress of the skin integrity. There was no skin sheet for the stage 2 on the sacrum. A care plan, resident at risk for skin breakdown related to surgical/ulcer and has actual skin breakdown type: surgical, ulcer, rash had the goal the resident's wound/skin impairment will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and or presence of granulation. An intervention on the care plan, weekly wound assessment to include measurements and description of wound status was created on [DATE]. The care plan was not followed as weekly wound assessments to include measurements and description of the wounds was not done. An interview was conducted with LPN #5 on [DATE] at 12:02 PM who stated that when the resident first came in the resident had antibiotics due to a large wound on the back [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) which is a bacterium responsible for several difficult-to-treat infections in humans. LPN #5 stated that the resident had skin folds with fungal dryness which would improve but had to deal with the constant moisture in the folds. LPN #5 stated, the last time I visualized his/her wounds was on the day he/she went out to the hospital, which was on [DATE]. He/she had some purulent drainage and the wound looked a little bigger. An interview was conducted with GNA #34 on [DATE] at 12:11 PM who stated, his/her bottom was red with 1 area open. An interview was conducted with CRNP #35 on [DATE] at 12:15 PM who stated, I saw his/her wounds. He/she had candidiasis in the groin area. CRNP #35 stated that the resident had issues with wanting care and that he/she would refuse care. The resident was followed by the wound care CRNP, CRNP #20, and was seen on [DATE], [DATE], [DATE], [DATE] and [DATE]. The only measurements of the wounds were done on the CRNP assessments. The CRNP did not see the resident weekly, therefore skin integrity was not being monitored and documented during the time period when the wound CRNP did not see the wounds. Discussed with the Director of Nursing on [DATE] at 3:30 PM who confirmed the lack of skin monitoring. 5) The facility staff failed to do weekly skin assessment and perform dressing changes as ordered for pressure ulcers for a resident. Review of Resident #17's medical record revealed the Resident was admitted to the facility in (MONTH) (YEAR). Further review of the resident's medical record revealed [REDACTED]. Review of the Resident #17's weekly skin assessment revealed the facility staff failed to perform a weekly skin assessments on [DATE], [DATE] and [DATE]. The standard of practice for the care of pressure ulcers is for the facility staff to conduct weekly assessments and document findings that include the location, measurement, stage and characteristics of a pressure ulcer. This information provides facility staff with information to determine whether the pressure ulcer is healing or worsening at future assessments and to evaluate which treatment plan would be most effective to heal the ulcer. Review of the Resident #17's Treatment Administration Records for (MONTH) and (MONTH) 2019 revealed the facility staff failed to perform dressing changes as ordered on: 1. Left lower leg and heel on [DATE], [DATE] and [DATE] 2. Right lower leg on [DATE] and [DATE] 3. Sacrum on [DATE] and [DATE] Interview with the Director of Nursing on [DATE] at 7:56 AM confirmed the surveyor's findings. 6) A medical record review for Resident #114 on [DATE], revealed the resident (TRUNCATED)

Based on record review, staff and resident interview it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 8 of 33 residents (#60, #116, #141, #142, #143, #133, #140, #63) reviewed for abuse and neglect. As a result of this failure, actual harm was identified for Resident #60. The findings include: 1) Review of Resident #60's medical record revealed the resident was admitted to the facility in (MONTH) 1998 with a [DIAGNOSES REDACTED]. Resident #60's medical record revealed 2 certifications of incapacity to make informed decisions dated 8/4/11 and 8/31/11. An assessment was completed by the facility staff on 10/4/19. The facility staff documented on 10/4/19 a Brief Interview for Mental Status (BIMS) Summary Score of 5/15. A score of 5 indicates severe cognitive impairment. Review of Resident #116's medical record revealed the Resident was admitted to the facility in (MONTH) (YEAR) from the hospital for rehabilitation. Resident #116's medical record revealed that on 11/30/18 the physician certified the resident had adequate decision-making capacity. An assessment was completed by the facility staff on 11/1/19. The facility staff documented on 11/1/19 a BIMS Summary Score of 14/15. A score of 14 indicates the resident is cognitively intact. Review of a facility reported incident (MD 600) revealed the facility submitted a report on 12/4/19 to OHCQ (Office of Health Care Quality) indicating that on 12/4/19 Resident #116 was observed by the Recreation Director with his/her hand in Resident #60's pants. The Recreation Director reported the incident to the Administrator. Review of the Resident #116's care plans revealed a care plan initiated on 3/22/19 for: Resident has a tendency to exhibit sexually inappropriate behavior related to tendency to make sexually suggestive remarks and inappropriate touching female residents. During interview with the Director of Nursing (DON) on 12/10/19 at 1:23 PM, the DON stated the care plan for sexually inappropriate behaviors was initiated for an incident that occurred on 3/21/19 where Resident #271 accused Resident #116 of touching the him/her on the buttocks on the elevator. The DON stated the incident could not be substantiated but a care plan was put in place to monitor Resident #116's behaviors. The DON stated there had been no other incidents since 3/21/19 of Resident #116 inappropriately touching other residents until 12/4/19. During interview with the Administrator (Staff#3) on 12/10/19 at 1:40 PM, she stated that on 12/4/19 Resident #116 was immediately placed on a 1 to 1 supervision and will remain on 1 to 1 supervision until discharge. She also stated Resident #116 was issued an involuntary discharge notice on 12/4/19 and the resident agreed to discharge. The Administrator (Staff #3) also stated the Resident #116 was seen by a psychiatrist after the incident. During interview with the Recreation Director on 12/10/19 at 1:48 PM, she stated on 12/4/19, she was standing inside the dining room watching residents come to church service, which was held in the dining room. Resident #60 was sitting in wheelchair outside the dining room. Resident #116 exited the dining room in a wheelchair after smoking on the patio, which is connected to the dining room. She saw Resident #116 stopped next to Resident #60 in the hallway outside the dining room. She then stated she saw Resident #116's hand under Resident #60's smoking apron and moving in Resident #60's lower private area. The Recreation Director stated she called Dietary Aide #2 over. She stated as she got closer, she saw Resident #116 remove his/her hand from Resident #60's pants and placed it on the Resident #60's shoulder. The Recreation Director then stated Resident #116 wheeled towards the elevator and she followed him/her. She asked Resident #116 what just happened, the Resident stated, you know what I was doing, I was making him/her feel good. I was playing with it. The Recreation Director stated she got the Administrator immediately. The Recreation Director was asked if she has ever seen Resident #116 inappropriately touching other residents before, she stated, no. She stated she has worked at the facility since (MONTH) (YEAR). The surveyor attempted to interview Resident #60 on 12/10/19 at 2:49 PM. The surveyor asked if anyone had touched him/her inappropriately. The resident stated no and just put his/her head down. The resident would not answer any further questions. During interview with Dietary Aide #2 on 12/11/19 at 8:41 AM, she stated the Recreation Director was inside the dining room by the doors decorating and she was by the kitchen area inside the dining room. She stated the Recreation Director called her over to where she was standing. Dietary Aide #2 stated when she went over to the dining room entrance, Resident #116 and Resident #60 were both in wheelchairs sitting next to each other and Resident #116 had his/her arm around Resident #60 asking if the Resident was fine. She stated Resident #116 then rolled away. During interview with Resident #116 on 12/11/19 at 8:30 AM about the incident, the resident stated that the incident was just misinformation and he/she never touched Resident #60 inappropriately. When asked if he/she touched Resident #60 at all, Resident #116 stated I just gave the Resident a bump on the elbow and asked how he/she was doing. Resident #116 stated the person that reported the incident was just hating on him/her and jealous. Interview with the Administrator (Staff #3) on 12/11/19 at 11:43 AM, confirmed the facility substantiated abuse by Resident #116 against Resident #60 on 12/4/19. 2) Review of facility reported incident MD 651 on 11/26/19 revealed on 11/10/19 Geriatric Nursing Assistant (GNA) #32 closed Resident #116's door to his/her room without consent, had a verbal altercation and then pushed the resident to the floor. The facility did an investigation and substantiated that the abuse occurred. The facility terminated GNA #32 on 11/13/19 and reported the abuse to the Board of Nursing. The Director of Nursing (DON) was advised that the facility would be cited for abuse on 11/27/19 at 10:20 AM. The DON stated, yeah, I can't believe she called me right away on the phone to tell me her side of what happened. 3) Review of facility reported incident MD 510 on 11/26/19 revealed that Resident #141 reported on 8/20/18 that on 8/18/18 GNA #61 told the resident, (expletive) you and gave the resident the middle finger. The resident sustained [REDACTED].#61 stated, if they would stop self-medicating they would not fall. There was a verbal altercation between GNA #61 and Resident #141. Verbal abuse was substantiated by the facility and GNA #61 was reported to the Board of Nursing. 4) Review of facility reported incident MD 294 on 11/26/19 revealed that Resident #142 was verbally abused by staff. The employee admitted to using a profane term when talking to the resident. The employee was terminated after staff and resident interviews and was reported to the Board of Nursing. 5) Review of facility reported incident MD 205 on 12/2/19 revealed Resident #143, a transgender resident, reported that he/she was on the elevator with another resident and Staff #62, a dietary aide. Resident #143 reported that Staff #62 referred to Resident #143 as a him or her or whatever. The facility reported as emotional abuse and terminated Staff #62. On 12/4/19 at 10:40 AM the DON stated that sensitivity training was done, however she could not find the sign-in sheets as to who was trained. 6) Review of facility reported incident MD 596 on 12/3/19 revealed on 8/26/19, Staff #58, a unit secretary, was verbally abusive to Resident #133 as Staff #58 was speaking to someone in front of the elevator and stated, I don't want to go out with this (expletive) crackhead. The facility validated the verbal abuse allegation through the interview process and Staff #58 was terminated. The resident was no longer in the facility, therefore was not available for interview. 7) Review of facility reported incident MD 048 on 12/6/19 revealed Resident #140 reported to the social worker on 8/11/19, that the 11-7 GNA, (GNA #59) from the previous night neglected to provide him/her with incontinence care. The resident reported that around 6 AM he/she turned on the call light and a female answered the call light. The resident reported that GNA #59 was told that Resident #140 had an accident and needed to be changed. The resident reported that GNA #59 came in, turned off the call light, found out what the resident needed and left saying, You alright, go back to sleep. The resident immediately turned the call light back on and GNA #60 answered the call light and provided incontinence care. Neglect was substantiated by the facility and GNA #59 was reported to the Board of Nursing. 8) Review of facility reported incident MD 638 on 12/10/19 revealed that on 11/22/19 Resident #63 reported that GNA #57 grabbed the resident's left arm, in the deltoid area, and pushed the resident back from a sitting position back to the mattress. On 12/10/19 at 12:05 PM Resident #63 was interviewed and stated, I had an incident a couple of weeks ago with a GN[NAME] The resident, who was alert and oriented, stated, the GNA was rough with me and grabbed my arm and pushed me down on the bed. The resident stated, I was trying to help her by pulling up the top of the sheet and blanket. She grabbed the top of my left arm and pushed me down. The resident demonstrated being pushed back on the bed. The surveyor asked if he/she was hurt and the resident stated, It hurt my bone. Luckily I didn't have any bruising. The surveyor asked if the resident was fearful of the GNA and the response was, Yes, I kept my mouth shut. I didn't know what she was going to do. She walked over and closed the curtain, so I didn't say anymore. When asked if she reported it to anyone she said, I told the nurse what happened. I don't cause anyone any trouble. I know the girls are overworked. On 12/10/19 at 12:10 PM an interview was conducted with the Nursing Home Administrator (NHA) Staff #3 who did the investigation. She stated that she had to substantiate the abuse because the agency GNA would not call her back. The NHA stated that the incident was reported to the Board of Nursing.

Based on medical record review, interviews and observations it was determined that the facility failed to ensure primary care physicians reviewed the resident's total program of care as evidenced by: 1a) failure to accurately address the presence of chronic venous stasis wound with failure to sign orders related to prescribed treatment changes to the wound (Resident #101) and 1b) failure to address the presence of two pressure ulcers, one of which had been identified by staff more than a week prior to the physician's visit but had not yet been assessed by a physician or a nurse practitioner (Resident #110); and failure to ensure the physician's documentation was current and accurate as evidenced by documenting a wound assessment in his note and failing to identify that this assessment had been completed two weeks prior by a nurse practitioner (Resident #110). This was found to be evident for 2 out of 10 residents (Resident #101 and #110) reviewed for pressure ulcers during the survey; 2) failure to ensure that physicians orders were written in a manner that ensured the resident was getting the care and services needed as evidenced due to a physician's orders [REDACTED].#114) reviewed for [MEDICAL TREATMENT] services. The Findings Include: 1a) Review of Resident #101's medical record on 12/3/2019 revealed that the resident had developed right lower leg ulcer associated with venous stasis disease and was being seen at a local wound clinic once per week beginning on 6/17/19. Review of the wound clinic consultation reports revealed that the facility did not transport the resident to the local wound clinic for 4 weeks. Resident #101 was absent from attending the wound clinic from 8/13/19 to 9/10/19. The care directed by the wound clinic was not maintained during Resident #101's absence from the weekly wound clinic visits. A nurse's note was written on 8/20/19, included wound appt rescheduled due to w/c being too wide to fit on transportation van. There was no indication in progress notes that the resident's attending physician was notified. A telephone order was created by the Unit Manager #5 at 3 PM on 8/20/19 written as; Wound care: RLE (right lower extremity) clean with wound cleanser, apply Calcium Alginate to base, cover with ABD pad and wrap with Kerlix PRN (as needed) Mon, Wed, Fri, PRN Unna Boot not in place. Review of the attending physician's note dated 8/20/19 7:41 PM did not reveal documentation related to the skin/wound status for Resident #101. The attending physician had failed to provide an assessment and evaluation related to the dressing change phone order. As of 12/3/19 there was no indication that the attending physician had signed the telephone order. Based on medical record review, Resident #101 had an above the knee left leg amputation in (MONTH) of (YEAR). Observations of the resident (initial on 11/15/19) revealed that Resident #101 had a left leg stump and full right leg with bandage/wrap on the lower right extremity. Review of the attending physician's 8/20/19 note revealed inaccurate data. The physician's note under Past Medical History indicated the resident had bilateral leg amputation and wound right stump. Under Physical Exam, the physician's note indicated the resident had an open area small right toe. Review of skin integrity reports indicated that the right 2nd toe area was healed on 5/15/19. Under the plan section the physician wrote local dressing care of wound right ankle per wound nurse. The resident was not being seen by the wound nurse as the resident was to have weekly visits at the wound clinic. There was no evidence that the attending physician or Certified Registered Nurse Practitioner (CRNP)'s reviewed the weekly wound consultation reports. Review of a 8/13/19 wound consultation report revealed the venous leg ulcer was classified as a full thickness without exposed support strictures wound measuring; length (L) 9.0 cm x width (W) 2.8 cm x depth (D) 0.1 cm. The report included the total area of the wound 19.782 cm and the volume at 1.979 cm. Additionally, details of the wound were provided as to amount of drainage, necrotic tissue and the appearance of the skin around the wound. The report indicated the wound to be cleansed with soap and water, apply [MEDICATION NAME] w/ Calcium alginate dressing and protect surrounding skin with [MEDICATION NAME]. The dressing change frequency indicated Do not change dressing for One Week. For [MEDICAL CONDITION] control Unna Boot compression therapy was applied to the right lower extremity. (Unna Boot itself is a compression dressing, usually made of cotton, that has a zinc oxide paste applied uniformly to the entire bandage, which can be used for the treatment of [REDACTED]. The resident was to return to the clinic in 1 week. Additional instructions included Do not remove dressing unless you are ready to put back on another Unna boot! PLEASE During the resident's 4-week absence from attending the wound clinic the use and/or prescription for Unna boot was never addressed. Additionally, the staff failed to follow the order as prescribed on 8/20/19. The resident's attending physician and CRNPs failed to address/evaluate the care of the right lower leg chronic venous stasis ulcer. Upon the resident's return to the clinic on 9/10/19, maggots were found in the wound and based on a tissue culture the wound was found to be infected with pseudomonas and proteus mirabilis as this was documented in the 9/10/19, and 9/17/19 wound consultation reports. The medical director was informed of the concerns on 12/4/19 at 1:05 PM as to the lack of care for Resident #101 and the erroneous documentation that was included in the physicians' progress notes. The medical director indicated that the facility's corporation makes the staff utilize pre-templated progress notes and acknowledged the erroneous data as written for Resident #101. Cross reference to F684 and F686, Resident #101 1b) On 11/19/19 review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, [MEDICAL CONDITION], high blood pressure, diabetes and lung disease. The resident has had a [DEVICE] since (YEAR) although the resident does consume meals by mouth. Review of the 8/3/19 minimum data set assessment revealed the resident requires extensive assist from staff for bed mobility and eating. The resident's weight in (MONTH) 2019 ranged from 124.8 - 130.4 lbs. In (MONTH) 2019 the resident developed a pressure ulcer on the left ankle. On 9/5/19 Nurse #40 completed a change in condition note that revealed the presence of a skin wound on the resident's backside (sacral area). The note revealed the primary care nurse practitioner was made aware and wanted the wound nurse to evaluate the patient. The corresponding Skin Integrity Report revealed an in house acquired pressure ulcer, stage 2 measuring 1 cm in length with a width of 0. Further review of the medical record revealed the wound nurse practitioner gave an order for [REDACTED]. Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's new pressure ulcer when she was scheduled to be in the facility for wound rounds on Wednesday (MONTH) 11 or 18, 2019. On 11/27/19 at 9:28 AM the wound Nurse Practitioner (NP) #20 reported she was in the facility on (MONTH) 11 and 18, 2019 but was not sure why she did not see the resident. Further review of the medical record revealed the resident was seen by the primary care physician #44 on 9/18/19. Review of the primary care physician progress notes [REDACTED]. Further review of the medical record failed to reveal documentation that a physician or a nurse practitioner assessed the residents sacral wound from the time it was first documented on 9/5 through 9/24/19. Further review of the medical record revealed the wound nurse practitioner (NP) #20 assessed the resident on 9/25/19. Review of the progress note for this visit revealed the left ankle wound as being 1.9 x 3.1 x 0.1 cm stage 4 and the sacral wound 3 x 4 x 0.1 cm with heavy drainage and a stage 3. Further review of the medical record revealed that on 10/9/19 the resident was again seen by the primary care physician. This note revealed documentation under Physical Exam Skin section that was identical to the assessment completed by the wound NP #20 in her 9/25/19 note. There is no notation that these measurements were from the 9/25/19 NP note. Interview with the primary care physician (PCP) #44 on 11/26/19 at 10:11 AM revealed that he was aware the resident currently had sacral and ankle ulcers. The PCP confirmed that he does not assess pressure ulcers every time he sees the resident and went on to state that they have a wound nurse that comes once a week. The PCP went on to confirm that he did not measure the resident's wounds as indicated in the 10/9/19 note, stating that he goes with the measurements provided by the wound nurse. On 11/27/19 surveyor reviewed the concern with the medical director that the physician failed to assess a newly identified pressure ulcer and concerns regarding the physician's documentation of the wound assessment without identifying that the assessment was two weeks old and had been completed by a NP. 2a) A medical record review for Resident #114 on 11/19/19 at 9:07 AM, revealed the resident was admitted on [DATE] following a surgical intervention for an abdominal abscess. The resident had the following Diagnoses: [REDACTED]. A review of the physician's orders [REDACTED]. Another order written on 10/22/19, was for an INR (International Normalized Ratio) every Monday and to start on 10/28/19. However, in reviewing the PT/INR results there were no results for 10/25/19. Review of progress notes revealed no information regarding a lab test on 10/25/19 or that the resident refused the laboratory test. Anticoagulants are medications that decrease the body's ability to clot the blood and therefore increases the risk for bleeding. A person receiving certain forms of these medications, such as [MEDICATION NAME] may have their blood closely monitored with a laboratory test referred to as PT/INR. The PT ([MEDICATION NAME] time) which is the time, in seconds, it takes for the blood to clot and may be expressed in the form of the INR (International Normalized Ratio). The physician uses these results to determine the amount of the anticoagulant to be given. An interview with Registered Nurse (RN) #42 on 11/19/19 at 10:55 AM, revealed that the staff nurses were not allowed to draw blood, and that a Phlebotomist came to the facility to perform blood draws. On 11/19/19 at 11:09 AM, and interview with RN #43, revealed the process for reviewing orders. She stated that the physician writes an order and then it is flagged for the nurse to review and at that time the nurse will complete any laboratory orders. When asked about a lab order for Resident #114 to have a blood draw on 10/25/19, the nurse pulled the order up and showed the surveyor that the medication order does not show the special instruction (which is where the order to draw the lab on 10/25/19 was written). She tried another view in the computer and the special instruction did not show up. She stated if it had they would need to call the doctor and add a new order for the lab work. Then they would complete a lab slip and place the resident's name in a notebook for the lab. The DON was made aware of the concerns on 11/21/19 at 1:28 PM. 2b) A medical record review on 11/19/19, revealed a physician's orders [REDACTED].#21 [MEDICATION NAME] HCL 10 mg (milligram) tablet, Give 1 tablet by mouth every 8 hours as needed for [MEDICAL CONDITION] (low blood pressure), BP (blood pressure) < (less than) 90 systolic (top blood pressure number) and give before [MEDICAL TREATMENT] times on HD ([MEDICAL TREATMENT]) days. There was no order for blood pressure monitoring for this order. On 11/19/19 at 1:38 PM, during an interview with CRNP #21, she stated that she did not indicate specific times to give the [MEDICATION NAME] because the resident's [MEDICAL TREATMENT] schedule may change. The CRNP #21 was informed that the Medication Administration Record [REDACTED]. When ask about combining the order she stated that the nurses are made aware in report and she is sure they can see the order to give it in the MAR. On 11/19/19 at 2:49 pm, during an interview with RN #50, reported she was not aware that Resident #114 was to receive [MEDICATION NAME] before [MEDICAL TREATMENT]. She showed the surveyor on her computer the view she had in the eMAR which was when a resident was due for a routine medication that medication turned green and when it was overdue it turned red. However for an as needed order, such as the [MEDICATION NAME] it was under another tab and did not indicate if a resident was due because it was only as needed. She reported that this was the first time she had been assigned resident and was not told in report about the [MEDICATION NAME] being given before [MEDICAL TREATMENT]. During an interview with Assistant Director of Nursing (ADON) on 11/19/19 at 3:04 PM, revealed she agreed that the staff would not be aware of this order the way it was written and stated it should have been written as two separate orders for staff to be able to properly administer the medication. The DON was made aware of the concerns on 11/21/19 at 1:28 PM. 2c) A medical record review for Resident #114 on 11/19/19, revealed on the physicians' order summary for 10/2019, an order for [REDACTED]. An interview with the DON on 11/22/19 at 1:29 PM, revealed that she did not agree with combining the orders for several wounds and had spoken with the corporate wound care nurse regarding CRNP #20's style of writing the orders. She stated there was a concern that something will be missed and when one area had healed it can be confusing to the staff. The DON was informed that according to the Skin Integrity Sheets (a form used to document all aspects of the wounds on a weekly bases for 10 weeks) the wound on the left superior buttocks was healed on 11/13/19, yet staff continued to sign the treatment as being completed until 11/20/19, when the order was discontinued.

Based on medical and administrative record review and staff interview it was determined the facility failed to provide appropriate and sufficient supervision to each resident to prevent an avoidable accident. Residents #3 and #8, who were at risk for substance abuse, were found unresponsive due to a drug overdose, necessitating the administration of [MEDICATION NAME] and transfer to the hospital for emergency care. The facility was aware that the residents had a history of [REDACTED].#8 had more than one episode, as well as Resident #9 acquiring drug paraphernalia and failing to supervise and determine how the incidents occurred in order to prevent them from happening again. This was evident for 3 of 3 residents reviewed for hospitalization s during this complaint survey. Based on the findings related to complaint MD 734, on 5/24/18 at 2:39 PM, an immediate jeopardy was identified. The facility submitted a plan of removal on 5/24/18 at 5:04 PM and the plan was accepted on 5/24/18 at 7:09 PM. The findings included: [MEDICATION NAME] is narcotic blocker that is used to treat narcotic drug overdose. 1. Medical record review on 5/22/18 revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of complaint MD 734 revealed a concern that residents in the facility had access to illicit drugs. A physician's history and physical note dated 3/29/18 reported the resident was admitted to rehabilitation services for continued treatment of [REDACTED]. It was not noted if the resident was treated for [REDACTED]. A Change in Condition Note written by LPN #1 (after the event occurred), dated 3/31/18 at 11:53 AM, reported the resident had loss of consciousness in the morning, the physician was notified at 10:30 AM and gave orders to administer [MEDICATION NAME] and send the resident to the emergency room via 911. Review of the Medication Administration Record [REDACTED]. A Skilled Nursing Note dated 3/31/18 at 11:15 AM reported the resident returned from the emergency room and the physician gave orders to place [MEDICATION NAME] (Narcotic pain reliever) and [MEDICATION NAME] (anti-anxiety) on hold for 24 hours. A Nurse Practitioner's Progress Note written by NP #2, dated 4/3/18, noted a plan was discussed for narcotic titration with the nurse that included the administration of [MEDICATION NAME] and [MEDICATION NAME]. Titration is the process of determining the medication dose that reduces symptoms to the greatest possible degree while avoiding possible side effects. A Transition of Care Note, written by NP #2, dated 4/3/18 reported the resident had daily heroin use. The Resident reportedly injected heroin over the weekend requiring [MEDICATION NAME] and transport to the emergency room . The Resident was sent back the same day and narcotics have been held since that time. It was noted that [MEDICATION NAME] would be resumed at a reduced dose and [MEDICATION NAME] as needed for pain as previously ordered. A Change in Condition Follow-Up Note written by RN #1, dated 4/3/18 at 12:23 AM reported the Resident was observed kneeling over in the bathroom with the IV line exposed with blood in the line. The resident had a cigarette lighter and was rinsing out a burned bottle top with the other hand. The resident was unsteady on her/his feet and lethargic. The nurse educated the resident on the importance of not tampering with her/his IV line. The nurse obtained an order for [REDACTED]. A Change in Condition Follow-Up Note written by RN #1, dated 4/4/18 at 3:12 AM, reported the resident was observed lying across her/his bed doing something with the dressing on her/his arm. S/he appeared very lethargic. On 4/5/18 Nurse Practitioner #2 documented the resident had a history of [REDACTED]. The plan was to continue with antibiotic treatment for 4 weeks. A Change in Condition Follow-Up Note written by RN #1, dated 4/5/18 at 1:54 AM, reported the resident was observed lying on bed, lethargic. A Late Entry Change in Condition Follow-Up Note, dated 4/24/18 at 11:55 AM reported the resident was observed to be lethargic. The Nurse Practitioner was informed and ordered [MEDICATION NAME]. The Resident expressed a desire to leave the facility. RN #1 clarified in interview on 5/29/18 at 1:38 PM that this event occurred on 4/25/18, 4/24/18 as labeled. Review of the Medication Administration Record [REDACTED]. A Nurse Practitioner's (NP#2) Note dated 4/25/18 reported the resident was evaluated for increased somnolence and concern for opioid overdose. It was noted the resident was not responding to voice command or deep sternal rub. The resident reportedly was seen with a visitor earlier, then was in the bathroom for 20 minutes and not opening the door at the nurse's request. [MEDICATION NAME] was discontinued with a plan to treat the resident's pain with Tylenol and [MEDICATION NAME] instead of narcotics due to the resident is self-medicating. During an interview with the surveyor on 5/29/18 at 1:38 PM RN #1 stated that on 4/3/18 s/he observed the cap and lighter while making rounds and noted the resident's IV was clogged. S/he requested an order for [REDACTED].#1 reported seeing Resident #8 with a visitor outside of the building and alerted staff that resident was outside of the building. RN #1 further stated the acquisition of drugs by residents happens too often. RN #1 also stated s/he spoke to the social worker several times about Resident #8's behavior and the need for treatment. Despite documentation and interviews that confirmed resident #8 received [MEDICATION NAME] twice during his/her stay at the nursing home and was noted to be in possession of drug paraphernalia the facility failed to investigate the incidents to determine possible sources of the illicit substances and other contributing factors. 2. Medical record review on 5/22/18 revealed that Resident# 3 was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. A Nurse Practitioner's (NP #2) Progress note dated 3/16/18 reported the resident was admitted to subacute rehabilitation for continued treatment of [REDACTED]. A Change in Condition Note written by LPN #1, dated 3/31/18 at 11:29 AM, reported Resident #3 had a loss of consciousness. A General Nursing Note written by LPN #2, dated 3/31/18 at 2:45 PM, further reported the resident was found unconscious in the hallway, [MEDICATION NAME] was administered and 911 was called and the resident was transported to the hospital. The resident then returned to the facility at approximately 1:00 PM and requested to be discharged from the facility. The resident was discharged , against medical advice. 3. Resident #9 was admitted to the facility with a history of intravenous drug use and [MEDICATION NAME] treatment. A Nurse Practitioner's (NP #1) Progress Note dated 4/17/18 reported the Director of Nursing raised concerns about the resident appearing over-sedated. The resident was observed in the dining room with her/his head on the table and was hard to wake up. Drug Paraphernalia, a crack pipe, was found amongst the resident's belongings. The writer observed the resident with slurred speech and excessive daytime drowsiness. The resident's medications included [MEDICATION NAME] (pain), [MEDICATION NAME] (anxiety), [MEDICATION NAME] and [MEDICATION NAME] (neuroleptic). The Nurse Practitioner told the resident there would be a dose reduction of her/his [MEDICATION NAME] and within the week s/he would be weaned off the opioid pain medication. In interview with the surveyor on 5/22/18 at 2:20 PM the Director of Nursing stated active substance use occurs with some of the residents they care for while they are in the facility. The Director of Nursing acknowledged the incidents involving Residents #8, #3 and #9 were not reported to the Office of Health Care Quality and were not investigated. S/he stated the facility was not sure how the drugs and drug paraphernalia were brought into the facility. During an interview with NP #1 on 5/23/18 at 11:46 AM s/he acknowledged that they have had issues with narcotics being brought into the facility. During an interview with the Director of Nursing on 5/23/18 she/he stated the facility was beginning to enter information about these incidents in a risk management database for investigation and tracking purposes. The surveyor reviewed the documents supplied on 5/23/18 regarding the incidents that occurred with Residents #3 and #8 on 3/31/18. The documents did not provide evidence that a thorough investigation was completed for these incidents, to include witness statements, to identify the systems breakdowns that possibly contributed to the events. During an interview with the Director of Nursing, Administrator and the Clinical Quality Specialist the surveyor inquired if the incidents after 3/31/18 that occurred with Resident #8 and the incident with Resident #9 were investigated. The Administrator acknowledged on 5/24/18 at 2:35 PM that those incidents were not investigated. The facility failed to conduct a thorough investigation of the circumstances surrounding the substance use, acquisition of drug paraphernalia and overdoses. As such, the lack of identification of the potential systems failures that lead to the incidents placed the identified residents and other residents at risk for harm. Because of the systems failures an immediate jeopardy situation was identified by the Office of Health Care Quality on 5/24/18 at 2:39 PM. The facility's plan of removal was submitted to the State Agency at 5:04 PM and the plan was accepted on 5/24/18 at 7:09 PM. The plan for removal included: 1. The center will report incidents requiring administration of [MEDICATION NAME] for suspected overdose. 2. The Center Executive Director, CED, and/or the Center Nurse Executive, CNE, will investigate known incidents of illicit substance use and document in the Risk Management System to include the witness, resident, and/or staff interviews when applicable. In the absence of the CED and/or the CNE, an investigation will be initiated by a licensed staff member. The investigation will be completed by the CED and/or CNE within 5 days of the incident. Risk Management System (RMS) is a [MEDICATION NAME] process that guides the reporting, communication, investigation, and analysis of a resident event and allows for customized reporting to assist with the quality assurance process and root cause identification. 3. The Center will investigate to attempt to determine the means by which residents obtained drugs and/or paraphernalia and document in the RMS. 4. All licensed nursing staff and management team will be educated on the requirement to report and investigate incidents as noted above. Education will begin immediately and will be completed for all licensed staff and management prior to the start of their next scheduled shift. A post education quiz will be conducted to determine staff competency of educated material. 5. An emergency ADH[NAME] QAPI meeting held on 5/24/18 to review IJ statement, formulate a plan, and complete abatement plan. 6. The results of the investigations will be reported to the Quality Assurance Performance Improvement Committee monthly for review.

Based on review of medical records, facility documentation and interview with facility staff, it was determined that the facility failed to honor the wishes of a resident that elected to forego cardiopulmonary resuscitation (CPR) in the event of their death as evidenced by having a Do Not Resuscitate (DNR) order on their Maryland Medical Orders for Life Sustaining Treatment (MOLST) form. This was demonstrated by the facility's failure to withhold CPR for Resident #2 upon his/her cardiopulmonary arrest on the evening of [DATE] despite having an active DNR order. Furthermore, when facility staff became aware of Resident#2's DNR order, staff failed to terminate CPR and honor the resident's wishes. This deficiency was evident for 1 (Resident #2) of 21 residents reviewed during the complaint survey. These actions resulted in the finding of an immediate jeopardy on [DATE] at 2:45 PM. A plan of action was given to the survey team and the Office of Health Care Quality for review on [DATE] at 5:42 PM but was not accepted. A second plan was submitted at 6:58 PM but was also not accepted. A third plan was submitted at 7:40 PM and the plan to remove the immediate jeopardy was accepted by the State Agency at 7:50 PM. After removal of the immediacy, the deficient practice remained at potential for more than minimal harm with a scope and severity of D. The findings include: The facility report MD 786 and Resident #2's record were reviewed on [DATE] at 12:07 PM. The record reveals that, on [DATE], Resident #2 lost his/her pulse while being evaluated by Licensed Practical Nurse (LPN) #1 and Nurse Practitioner (NP) #2. NP #2's note from the event stated that Resident #2 was receiving nebulizers due to difficulty breathing around 7:00 PM when he/she vomited, large copious amounts of brown thin gastric liquid via mouth and nose. The note indicated that CPR was begun at 7:05 PM. The note then stated that at 7:19 PM EMS arrived, reviewed Resident #2's MOLST form noting that it indicated the resident was No CPR Option A-2, and that CPR was ceased. The resident's MOLST form was reviewed by the survey team and was confirmed to have No CPR Option A-2 marked for code status. During an interview with NP #2 that took place on [DATE] at 1:30 PM, NP #2 stated that s/he was the staff member who first began CPR. S/he made the decision to begin because s/he thought (Resident #2) was a full code. NP #2 later indicated that another staff member had alerted those providing CPR that the resident's code status was actually DNR. Despite this information, NP #2 continued to provide CPR until EMS arrived. When asked why she continued to provide CPR even when the DNR status was identified, NP #2 stated that's what I thought was supposed to be done. During an interview that took place on [DATE] at 10:05 AM, the Director of Nursing (DON) stated that NP #2 was correct to continue providing CPR, citing the facility policy Cardiac and/or Respiratory Arrest with a revision date of [DATE]. The policy was reviewed on [DATE] at 2:00 PM and it contained instructions on when and how to provide CPR to residents who have arrested. The DON indicated a section of the policy under the heading, If there is no visual identification of DNR status or no DNR order on the patient's medical record. The section listed four criteria for ceasing CPR after beginning: 2.1.1 CPR/AED certified staff will initiate CPR/AED application; 2.1.2. Call 911 and notify the primary physician; 2.1.3 Designate an individual to record events on the CPR/AED Flow Sheet; 2.1.4 Continue CPR until one of the following occurs: restoration of effective/spontaneous circulation, care is transferred to team providing advance life support (EMS); the rescuer is unable to continue because of exhaustion / presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy; or if State regulation allows licensed nurse to pronounce / certify death, reliable and valid criteria indication irreversible death are met, The DON indicated that none of the four criteria were, 'if the resident is found to have an active DNR order.' The DON, who also served as the facility nurse educator, stated, CPR should not be stopped until EMS arrived, and that is what I teach my staff. The Medical Director was interviewed by the survey team on [DATE] at 11:15 AM and stated, I would counsel that if the status is found to be DNR (during a code), then resuscitative efforts should be halted. During a second interview with NP #2 that took place on [DATE] at 1:20 PM, he/she identified the staff member that notified him/her that Resident #1 was a DNR, as GNA #3. GNA #3 was interviewed on [DATE] at 2:57 PM. During the interview, GNA #3 stated that s/he had obtained Resident #2's chart halfway through the code (code is a name given to the sum of all resuscitative efforts during a particular arrest event). S/he concurred with NP #2 and stated that CPR was continued despite discovering that Resident #2 had a DNR order and did not stop until EMS arrived at 7:19. GNA #3 indicated that the Shift Supervisor, Supervisor #4, was also present at that time of the code and instructed staff to continue the code. Supervisor #4 was interviewed on [DATE] at 3:14 PM and stated that s/he came to Resident #2's room because a code had been called, but that s/he arrived after CPR had begun. Supervisor #4 confirmed that s/he was present when GNA #3 reported that Resident #2 had a DNR order and also confirmed that s/he herself advised the group to continue performing CPR. S/he stated that this advice was based on his/her understanding of corporate policy after attending education at another location between November and December. Supervisor #4 stated, this information was fresh in my mind from that education. On [DATE] at 10:20 AM, the DON clarified his/her statement by stating, if nurse practitioners can pronounce people deceased in Maryland, and (NP #2) knew that, I would have expected him/her to stop providing CPR when s/he found out the resident had a DNR order. As a result of this finding, an immediate jeopardy was announced on [DATE] at 2:45 PM. A plan of action was given to the survey team and the Office of Health Care Quality for review on [DATE] at 5:42 PM but was not accepted. A second plan was submitted at 6:58 PM but was also not accepted. A third plan was submitted at 7:40 PM and the plan to remove the immediate jeopardy was accepted by the State Agency at 7:50 PM. Interviews were conducted with nursing staff to assure that the facility's plan to remove the immediate jeopardy was being carried out and the immediacy was removed at 8:20 PM. The plan included the following provisions: - Immediately upon identification of the immediate jeopardy, an emergency QAPI meeting was held to develop a QAPI plan regarding MOLST. - Education for licensed nursing staff and nurse practitioners was initiated at 3:30 PM on [DATE]. Education included review of honoring patient's wishes regarding MOLST choices and immediate termination of CPR if initiated against the patient's wishes. - Licensed nursing staff and nurse practitioners assigned to the facility, will have education ongoing until 100% of staff receive the education, including agency staffing. Staff will be educated prior to their next scheduled shift. This will be the responsibility of the Center Nurse Executive. The Clinical Quality Specialist will educate the Center Nurse Executive on honoring patient's wishes regarding MOLST choices and immediate termination of CPR if initiated against the patient's wishes. - The results of the QAPI Plan of [DATE] will be reported by the Center Nurse Executive to the Quality Assurance Performance Improvement Committee monthly to track compliance for at least the next six months or until 100% compliance is achieved. The Center Executive Director oversees the QAPI meetings.

Based on review of the medical record, review of the facility's policy and interviews with facility staff, it was determined that the facility failed to maintain accurate documentation of a resident's code status. In addition, the facility failed to ensure that nursing staff were able to demonstrate an understanding of a resident's orders for code status and their individualized orders on the physician sheet, placing residents at risk for receiving CPR (cardio [MEDICAL CONDITION] resuscitation) against their wishes in the event of an arrest. Due to this failure, on [DATE], at 6:10 PM an immediate jeopardy was identified by the Office of Health Care Quality related to the facility's failure to have a system in place to ensure the desired code status of the resident was correctly articulated in the resident's chart and to ensure that facility staff was able to understand and carry out said wishes. The immediacy was removed while the survey team remained on site on [DATE] at 9:45 PM. After removal of the immediacy, the deficient practice remained with potential for more than minimal harm at level D.The findings include:On [DATE] at 1:15 PM, review of Resident #267's [MEDICAL TREATMENT] binder revealed a MOLST (Medical Orders for Life-Sustaining Treatment) form dated [DATE] with a decision made by the resident for no CPR option A-2 Do Not Intubate (DNI). Review of the resident's paper chart that was stored at the nurse's station revealed an order for [REDACTED]. Both conflicting orders were documented on the same form. Review of the resident's medical record in the facility failed to reveal any documentation that the medical order form regarding code status had been reviewed with the resident or the family since the admission on [DATE]. Review on [DATE] of the resident's hospital discharge records from [DATE] revealed that the resident and family did not want CPR performed in the case of a [MEDICAL CONDITION]. Review on [DATE] of the resident's hospital records that accompanied him/her from the hospital to the facility on [DATE] revealed a MOLST dated [DATE] documenting: No CPR option A-2 DNI. The same copy of this MOLST was found in the resident's [MEDICAL TREATMENT] book. Meanwhile, there was also an active MOLST form dated [DATE] in the resident's chart at the nursing station that indicated to initiate CPR and also to not initiate CPR option A-2 DNI all on the same form. Review of the facility policy on Health Care Decision Making, on [DATE], revealed that the MOLST form is accepted and respected as a resident's health care instructions and desires regarding resuscitation status including the level of medical interventions and future hospitalization s. This code status form was what the staff are trained to use to determine whether to perform CPR or any other life sustaining treatments on a resident.Interview with 3 out of 3 nurses failed to reveal that facility staff were aware of how to read and execute the orders documented on the MOLST for code status. Two of the three nurses admitted the resident to the facility on [DATE] and both had reviewed the medical orders for code status form and did not observe a concern. The third nurse was the he resident's assigned nurse for the ,[DATE] shift on [DATE].On [DATE] at 1:13 PM Staff RN #19 was asked if Resident #267 coded and was in a situation that required CPR, what would she do. Staff RN #19 stated that she would stay with the resident, have someone check his/her chart at the nurse's station, and call the doctor. He/she was then asked: According to the resident's MOLST in the chart at the nurse's station what would you do? She proceeded to read off of the medical orders form and said that she would attempt CPR and not intubate the resident. She was further asked if that was feasible. She stated that, 'it's clearly 2 different answers,' and that, 'she would get the social worker.' The nurse was asked again, if there was a code situation at this moment what would she do, and she stated, 'I would do full CPR, but yes its conflicting orders.'Interview with staff RN #20 on [DATE] at 5:10 PM revealed that he was one of the admitting nurses the night Resident #267 came to the facility. He stated that for that admission, he was responsible for the assessment of the resident and his co-worker, staff RN #21, did all of the paperwork. He was further asked what paperwork was reviewed. He reported the POS (physician order sheet), c-2 form (narcotic order form), getting the orders from the discharge papers and the PAR (pre-admission review) that comes with the patient, review of the discharge summary, lab values and the MOLST regarding code status. Staff RN #20 was asked specifically if he reviews the MOLST regarding code status form and he stated, 'yes we check them.' Staff RN #20 was asked to interpret Resident #267's MOLST regarding code status form that came from the resident's chart. He stated that s/he was a DNR, (do not resuscitate). Then he stated CPR, no intubation. The survey team asked for clarification as to what Staff #20 would do according to the MOLST form that was currently on the resident's chart. He stated CPR with no intubation, as CPR was checked, and do not intubate, as No CPR option A-2 DNI (do not intubate) was checked.Interview with Staff RN #21 on [DATE] at 5:42 PM revealed that she always works the ,[DATE] shift and that is when most of the admissions come. She was asked what she reviews when she does the admission paperwork. She stated: MOLST (Medical Orders for Life-Sustaining Treatment), and the discharge summary from the sending facility with medications and orders, and if there is a PICC (A peripherally inserted central catheter) he/she looks for x-rays or some form of documentation related to the placement of the PICC line. She agreed with staff RN #20 that there are times she will do the physical assessment and he does the paperwork and vice versa and times when they are each responsible for the entire admission.Staff RN #21 was asked what her understanding of the medical orders regarding code status form was. She stated that, it explains how the patient wants to be handled when in distress, can't breathe etc., if they want CPR or don't and you have to look to make sure that it's for the right resident. Staff RN #21 was asked to review the MOLST regarding code status identified for Resident #267's [MEDICAL TREATMENT] chart, and asked what she would do for that resident. She stated, no CPR. She was asked if she felt that it was filled out correctly and she said yes. She was also asked to review the MOLST from the resident's chart at the nursing station and stated that they are different but that she did not see an error with the way it was filled out. She reported, yes she would do CPR but not intubate. She was asked if she reviews the hospital records for new admissions, and she stated yes. Staff RN #21 was shown the hospital records documenting that the resident wanted to be DNR/DNI.Review of the residents care plan revealed that s/he had a care plan in place for his/her desire for palliative comfort care related to terminal illness initiated on admission. A review of the resident's hospital discharge records revealed documentation of conversations with the resident and the family in regards to hospice care versus the residents ongoing need for [MEDICAL TREATMENT].Surveyor interviewed the facility Director of Nursing (DON) on [DATE] at 1:44 PM regarding the interview with Staff RN #19 and asked if she or the social worker were notified of the concerns identified regarding the medical orders regarding code status for Resident #267 at 1:14 PM. The DON stated, 'no,' and was asked to review the MOLST forms from the chart and the [MEDICAL TREATMENT] book. After reviewing the MOLST regarding code status form the DON stated that the medical order had to be from the hospital, that one of the facility doctors usually sees new admissions and the physician that signed the order was not one with privileges at the facility. However, if they (a resident) are admitted late on a Friday or the weekend (as was Resident #267) the resident would be seen on Monday. As of Tuesday [DATE], no discipline had reviewed the resident's medical orders for code status form. The DON stated that they would have to find out what happened as it should have been reviewed by social services and/or the physician's group.On [DATE] 6:28 PM, the survey team informed the Administrator and DON that based on concerns regarding Resident #267's code status, staff interpretation of the medical orders regarding code status form and in consultation with management at the State Agency, an immediate jeopardy had been determined.The Administrator reported that they already started the audits and the nurse educator had started education on the concerns that were identified.An initial plan to remove the immediacy was given to the survey team at 7:45 PM. This plan was not accepted by the survey team and the Office of Health Care Quality. At 8:45 PM another plan to remove the immediacy was given to the survey team and reviewed by the Office of Health Care Quality. The plan included: to educate the Social Service employees on the process for maintaining accurate documentation in the resident's medical record, and education of all licensed staff regarding reading and application of the advanced directive prior to returning to work. Additionally, the medical chart as well as any [MEDICAL TREATMENT] communication books of facility residents, including new admission and any changes with a medical order regarding code status form, would be brought to the morning meeting within 72 hours of the change for review. An audit of all other resident's medical orders regarding code status forms also occurred. This plan was accepted. The immediate jeopardy was removed at 9:15 PM on [DATE].All findings were discussed with the Director of Nursing and the Administrator during the Immediate Jeopardy and the exit.

Based on review of medical records, facility reported incident investigation, employee files and maintenance books; interviews with residents and staff; and observations it was determined that the facility: 1) failed to appropriately transfer a resident in accordance with the resident's written plan of care resulting in an injury to the resident, this was evident for one out of one resident (Resident #88) reviewed in relation to facility report MD 118; and 2) failed to have a system in place to ensure potential environmental hazards were reported to maintenance in a timely fashion as evidenced by observation of a non-functioning bathroom light that was not reported to maintenance for more than 5 days. The findings include: 1. An interview with the resident #88, on 4/19/2016, revealed that Staff #27 (a geriatric nursing assistant) used a Sit to Stand lift instead of a Hoyer lift when getting the resident up and dropped the resident causing the resident to hurt his/her right knee. The resident stated that the staff is supposed to use the Hoyer lift and not the Sit to Stand when getting the resident out of the bed. A review of the medical record on 4/20/16 revealed a nurses note created on 4/11/16 stating that the resident was heard saying, My knees hurt because I was dropped on the floor. Staff #27, who was assigned to Resident #88, stated the patient was not dropped as stated. Her knees touched the bed during transfer as per protocol. The resident was given scheduled pain medications. The NP (nurse practitioner) was notified and an order for [REDACTED]. The X-ray completed on 4/11/16 revealed a fracture involving the right supracondylar femur (knee) with mild displacement. A review of the facility investigation on 4/20/16 revealed that Staff #27 stated that he/she used the Sit to Stand lift because the Hoyer lift was being used to get weights. The facility investigation also stated that Staff #27 admitted to utilizing the wrong technique in transferring Resident #88 which resulted in a fracture to Resident #88's right knee. According to the facility investigation into the incident, it was determined that Staff #27 did not use the proper transfer equipment as defined in the assessments and care plan. An interview on 4/20/16 with Staff #14, a GNA that worked with the resident, revealed that the staff are to use a Hoyer lift when transferring the resident. Staff #14 stated that two persons are needed to use the Hoyer lift with the resident. An interview on 4/20/16 with Staff #13, a GNA that worked with the resident, revealed that the staff are to use a Hoyer lift when transferring the resident. Staff #13 also stated that two persons are needed to use the Hoyer lift with the resident. An interview on 4/20/16 with Staff #10, the RN Unit Manager that works with the resident, revealed that the staff are to use a Hoyer lift when transferring Resident #88. Staff # 10 stated that two persons are needed to use the Hoyer lift with the resident. A review of the care plan on 4/21/16 with the last review completed date of 4/5/2016 revealed the following: Focus: Resident dependent on staff for ADL, care in (bathing, grooming, dressing, bed mobility and requires assist with transfers, locomotion, toileting) and is at risk for skin breakdown related to incontinence and to functional deterioration. Goal: Resident's ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and physical well-being x 90 days. Interventions: Resident requires 2 person assistance with transfers with Hoyer total lift (equipment). A review on 4/21/16 of the facility's policy of the Safe Resident Handling Program Policy and Procedures, revealed the following statement: training on the safe resident handling policy and procedures will be conducted upon orientation, annually and as needed for corrective action for all Center staff. This surveyor requested copies of any and all documentation of training provided to Staff #27 that was involved in the incident on the use of the equipment required when transferring this resident. The facility provided copies of training's provided to Staff #27. The training documentation provided did not include documentation of training in safe resident handling. This surveyor asked Staff #15, the RN Nurse Educator, if the facility had any documentation of training provided to the Staff #27 on the use of the equipment required by Resident #88. Staff #15 stated that the facility was not able to provide the requested documentation of training provided to the staff person. A review of the employee file for Staff #27 revealed that Staff #27 had been disciplined for not using an appropriate lift to transfer a resident in 9/2012 which resulted in a fall. An action plan was developed, for Staff #27 on 9/1/2012 which stated that the staff person would be in serviced about the importance of using proper lifts to maintain resident safety. There was no documentation in the employee file that the training had been completed after the incident in 2012 for the staff person involved in this incident. 2. The survey team toured the facility on 4/19/16 and 4/20/16. The bathroom for room 421 was observed to have a malfunctioning light during these tours. The Maintenance Director (Staff #16) confirmed on 4/25/16 at 11:12 AM during a tour of the facility with this surveyor that the light was malfunctioning. This surveyor and Staff #16 checked the maintenance request book at the nurses station for any request to have the light fixed. This surveyor and Staff #16 reviewed requests dating back to March 23, 2016 and could not find a request. Staff #16 said he would take care of it. The Administrator and Director of Nursing were interviewed on 4/26/16 at 1:28 PM. They said they understood the findings and did not offer additional information prior to exit.

Based on reviews of the medical and administrative records and interviews of the facility staff, the following was determined. The facility staff failed to prevent a resident to resident altercation resulting in resident injury. This deficiency is cited as a result of the investigation of facility reported incident, intake MD 895. The findings include: The surveyor's review of the medical and administrative records for resident #6 and #7 on January 31, 2011 revealed the following. On September 26, 2010 during the 11p.m-7 a.m. shift resident # 6 reported to the nurse assigned to his room that resident # 7 hit him with his cane. Further reviews of the records revealed that at approximately 8 a.m. resident # 6 left his room via his wheelchair to go to the nurses' station. The resident requested to contact his sister because resident # 7 continued to threaten to hit him. Resident # 7 followed resident # 6 to the nurse's station and began to strike resident # 6. Resident #7 had to be restrained by the staff. Resident # 6 was noted to be bleeding and was transported to an acute care hospital for evaluation and treatment. The surveyor's review of the incident report revealed that resident #6 was "shaky but conscious." Further review of the residents' medical records revealed that resident # 6 sustained a laceration to his lip as a result of the assault. The surveyor interviewed the Director of Nursing and the Nursing Home Administrator on January 31, 2010 about the incident. The interview disclosed that the facility staff failed to implement interventions to protect Resident # 6 from being abused by Resident # 7. Neither resident currently resides in the facility.