Every finding on record at Chapel Hill Nursing Center

Based on observation and interview it was determined the facility failed to ensure professional standards for food service safety was followed. This was evident for 1 of 1 facility kitchen, and 2 of 2 units observed during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility on 3/23/26 at 7:43 AM the surveyor observed an open cart sitting in the Unit 1 nursing hallway which contained a glass ice water dispenser with a rope handle sitting on the top tier of the cart. The second tier of the cart was observed to have a dirty food tray with dirty dishes and wilted lettuce with orange liquid present on it protruding out of the cart sitting directly next to an open sleeve of unused cup lids. On the bottom tier of the cart, another dirty food tray was observed with an open container with yellow food matter and a plastic cup holding cream colored liquid.On 3/23 at 7:43 AM the surveyor observed a tray of snacks sitting on top of a nursing treatment cart located in the Unit 1 hallway with snacks on it. The snacks were felt by the surveyor to be warm to the touch. The surveyor observed an unclean fork, crusty food debris, and an empty opened snack package on the snack tray with the snacks. Upon further inspection of the snacks located on that tray, two out of 9 snacks had a label present, a sandwich had a label which read: Diabetic 3/22/26 7pm, and a shake had a label which read: Resident #, 7pm unit 1, 3/22/26.On 3/23/26 at 7:46 AM the surveyor observed an ice water pitcher with a sticky substance and dark areas of matter present on the exterior surface which was sitting on a medication cart in the Unit 1 hallway labeled with a date of 3/23/26 which contained ice and clear liquid.On 3/23/26 at 7:52AM the surveyor observed a trash can in the Unit 1 main dining area with brown matter present on the exterior surface. A tray of snacks located in the refrigerator of the Unit 1 main dining area was observed by the surveyor to be labeled with the following: Diabetic 7pm 3/19/26.On 3/23/26 beginning at 7:58AM the surveyor conducted an initial tour of the facility's kitchen.On 3/23/26 at 7:59 AM the surveyor observed a two compartment sink with a counter area which held dirty items including knives in a plastic pitcher in which the pitcher had a brown appearance, and a plastic container filled 1/4 of the way with red liquid with clean dessert style bowls stored underneath and next to the area. A plastic crate was observed situated on a metal cart holding several clean plastic mugs directly next to a plastic pitcher which contained light brown liquid in the bottom.On 3/23/26 at 8:00 AM the surveyor observed the exterior surface of the food service line steam table with an unclean appearance with cloudy areas on the glass material, light brown drip stains on the front surface, papers attached with tape to the glass material on the front, stickers and with areas of sticky residue present on the top surface which held open plated food.On 3/23/26 at 8:00AM the surveyor observed a warming plate base in the warmer with food debris present on the surface.On 3/23/26 at 8:00 AM the surveyor observed the storage rack for clean items located next to the food serving line. The rack was observed by the surveyor to be holding various plates, utensils, cookware, and an unlabeled lidded plastic container holding white powder which had a dirty exterior surface with dark green food matter and white powder present sitting next to an open bag of unlabeled bread and next to a stack of plates located above a mixing bowl, and open container of utensils.On 3/23/26 at 8:01AM the surveyor observed food cooking equipment with a layer of food debris and clear liquid present on it, which was located on the storage rack for clean items. On 3/23/26 at 8:02 AM the surveyor observed the kitchen's ice cooler machine which was located immediately next to the dirty dishwashing line which had spray ware washing equipment, and also located next to several open trash cans observed to have trash present within them. The exterior surface of the ice machine was observed to be unclean in appearance with areas of light colored matter and drip marks down the side of the machine. A visibly dirty trash can lid was observed by the surveyor on the floor located between the wall and the ice cooler machine. A broom was observed resting against the side of the ice machine. On the floor located next to the ice machine an area of pooling water was observed next to dirty plumbing pipes which descended down into the kitchen floor. On 3/23/26 at 8:04 AM the surveyor observed a metal cart holding a bag of bread slices with visible droplets of moisture within it sitting directly next to the stove which was observed to be on.On 3/23/26 at 8:05 AM the surveyor observed a cart next to the food serving line which had visible chunks of food matter present on it. A visibly dirty and broken spatula was observed sitting on top of the cart. A green scoop plate was observed with food matter present on it sitting on top of a stack of plates on the rack utilized for clean wares. The electrical area of the steam table was observed to have food matter present on it. The lower storage area of the food steam table was observed to be unclean in appearance with food matter and debris present. Food service saran wrap was observed uncovered located on the lower level of the food prep area with food crumbs and debris present.On 3/23/26 at 8:07AM onions were observed by the surveyor to be held in a plastic container with areas of brown and black debris present along the rim of one side of the container with gnats present. Concerns were shared by the surveyor with [NAME] #4.On 3/23/26 at 8:07 AM the surveyor observed a container of noodle soup located on the food prep table with a label that read: 3/18/26. Damaged disposable food service gloves were observed by the surveyor sitting on the food prep table's surface.On 3/23/26 at 8:08AM the surveyor noted that the hand soap dispenser was detached and laying on the windowsill underneath a broken blind. The metal surrounding the handwashing sink handle was observed to be in unclean and damaged condition with open and cracked areas present.On 3/23/26 at 8:09AM the surveyor observed a rolling metal cart located in the kitchen which had an area of duct tape wrapped on it with areas of fraying and unclean brown material.On 3/23/26 at 8:11AM the surveyor observed the exterior surface of the paper hand towel dispenser to be unclean with orange food debris present on the surface.On 3/23/26 at 8:12AM the surveyor observed and noted that the ceiling vent above the food serving line was surrounded by dark brown matter. Further observation of the wall vent located near the food cart area revealed dark brown matter was present on the vent and extended onto the ceiling in several directions.On 3/23/26 at 8:12AM the surveyor observed the holding rack utilized for clean/drying storage of lid covers. Lid covers were observed stored on the rack which had food debris and pieces of trash present within it.On 3/23/26 at 8:13AM the surveyor observed the food mixer which was being utilized for storage of hairnets and various other items.On 3/23/26 at 8:29AM the surveyor observed on compartment of the three-compartment sink which was labeled sanitize with a rag stuffed within the drain to keep water within the sink. The chemical used for this sink was observed with the line curled up and sticking up above the level of the chemical. During the observation, an interview of Dietary Aide #6 was conducted by the surveyor. Dietary Aide #6 informed the surveyor that the rag was present because the drain was unable to hold the water within the sink without it.On 3/23/26 at 8:32AM the surveyor observed a pool of pink liquid running across the floor extending from underneath the two-compartment sink, stretching several feet in length across the flooring in the food preparation area and under the food prep table. The surveyor observed pink liquid present in one of two of the compartments of the sink.On 3/23/26 at 8:33AM the surveyor observed pink liquid surrounding the plumbing where it met the flooring and observed function of the two-compartment sink with the water on, at which time the area where the plumbing pipe met the flooring was observed backflowing onto the kitchen floor. Visible separation was observed to be present between the plumbing piping extending from the sink which was draining water visibly into a pipe observed to be catching the flow beneath it. Plumbing pipes were observed to be in visibly dirty condition with dark matter observed within the open area of piping.On 3/23/26 at 8:39AM the previously observed visibly dirty food cooking equipment was observed in the trash can. On 3/23/26 at 8:40AM the surveyor conducted a dual observation of concerns with Food Protection Manager (FPM) #5 who observed, acknowledged, and confirmed understanding of the surveyor's concerns. On 3/23/26 at 8:56AM the surveyor requested to review 3/23/26 breakfast food temperature logs at which time the surveyor was provided with a food temperature log dated: Week of 3-17-3/23. Review of the log revealed the log began on Sunday and ended on Saturday and the entire log of 7 days was completely filled out for all three meals. Another log sheet was provided dated: 3-23-29 in which four days of dinner temperatures were recorded. No further documentation of breakfast food temperatures for the meal served to Residents on 3/23/26 was observed to be present.On 3/23/26 at 9:02AM the surveyor conducted an interview of the FPM #5 who reported to the surveyor regarding the overflow of liquid wastewater from the plumbing pipe: This has been ongoing, maintenance knows, we try to keep the water off the floor. Regarding the metal cart with duct tape, FPM #5 reported the cart was used for transport back and forth.On 3/23/26 at 9:03AM the surveyor observed dry food storage with FPM #5 at which time a bin of thickener powder was observed with powder present in the bottom of the bin, a plastic bag within the bin, and a handled scoop with the handle lying directly within the powder. A nickel sized ball of paper was observed laying within the powder and a brown discolored area was observed within the powder.On 3/23/26 at 9:04AM the surveyor observed a bin of flour holding a bag of flour within it, and upon further inspection of the bag, a handled scoop was observed contained within the flour in the bag. Regarding the scoop handles located within food, FPM #5 inquired to the surveyor as to if they were not supposed to keep the handles in the flour and thickener.On 3/23/26 at 9:06AM the surveyor observed with FPM #5, various sealed chemical containers of rinse additive and other chemicals sitting directly in front of dry food supply of various cereals and other food items. A plastic jug filled 3/4 of the way with clear liquid was observed sitting on top of boxes of chemicals. Concerns were shared by the surveyor with FPM #5.On 3/23/26 at 9:12AM the surveyor shared concerns with the facility Administrator and Director of Nursing. On 3/27/26 at 9:47AM the surveyor observed the Unit 1 medication cart which held a pitcher of clear liquid and ice which was labeled 3/27/26. The exterior surface of the pitcher was observed to be unclean with a sticky residue and areas of brown and black matter present. The surveyor shared and observed the concern with Nurse #27.On 3/27/26 at 9:50 AM after surveyor intervention, the Administrator was observed removing the pitcher from the cart and reported to the surveyor that it was being removed in order to get cleaned.On 3/27/26 at 11:20AM the surveyor observed the Unit 2 dining area with several dirty food trays with dishes and dirty cups present on the countertop sitting next to the cold water dispenser cart.On 3/27/26 at 11:30AM the surveyor shared the dirty food tray concern with the facility's Administrator who acknowledged the concern.On 3/30/26 at 10:58AM the surveyor shared concerns with Director of Maintenance #22 who acknowledged and confirmed understanding of the concerns.On 3/30/26 at 11:27AM concerns were again shared with FPM #5 at which time an interview was conducted by the surveyor. FPM #5 reported to the surveyor during the interview: They are fixing the sinks; they stopped the water coming onto the floor after you pointed it out. FPM #5 reported an issue with a rubber ring located within the sink which was repaired by maintenance the day after the surveyor shared the concern. FPM #5 reported that the metal cart had been replaced.On 3/30/26 at 11:44AM the surveyor observed the exterior thermometer on Freezer #3 displaying 114. The internal thermometer was not able to be easily located within the freezer and kitchen staff continued to search for it until it was found at 11:47AM.On 3/30/26 at 11:49AM the surveyor observed the rack utilized for storage of clean dishes at which time a plate was observed to be unclean with food matter present on the surface sitting on top of an unclean plastic lidded container observed to have food matter present within it.On 3/30/26 at 11:56AM the surveyor observed [NAME] #7 plating food with their artificial nail observed protruding out of a broken thumb area of their glove at which time the surveyor shared the concern with FPM #5 who after surveyor intervention, instructed [NAME] #7 to remove their gloves, wash their hands, and apply clean gloves.On 3/30/26 at 11:57AM the food test tray previously requested by the surveyor was unable to be made due to their being no available quantity of main foods served left. A test tray was prepared with the alternative items. [NAME] #7 stated that the alternative items were the foods served to Residents who did not eat spaghetti sauce.On 3/30/26 at 12:01PM the surveyor observed unserved resident meal trays on an open cart parked outside of the Unit 1 main dining area with a plate of food in which the cover left half of the meal food exposed and uncovered. Carrots were observed by surveyors on the plate open to air in the hallway designated for Resident #33. Beverages were observed to be open and uncovered on 4 out of 5 meal trays present on the open cart.On 3/30/26 at 12:02PM the surveyor shared the observation and concerns with FPM #5 who acknowledged and confirmed understanding of the concern.On 3/30/26 at 12:03PM the surveyor observed another open cart with unserved resident food trays present sitting in the Unit 1 Resident hallway. Open, uncovered beverages were observed on four out of six trays with two food trays containing uncovered beverages located on the lowest tier of the cart approximately four inches from the floor's surface. The surveyor shared the concern with FPM #5 and GNA #37 who acknowledged the concerns.On 3/30/26 at 12:07PM FPM #5 was observed removing the uncovered Resident meal from the cart.On 3/30/26 at 12:12PM the surveyor observed GNA #37 wheel the cart with uncovered drinks down the hallway. This surveyor shared the concern again, and after surveyor intervention, the drinks and cups were replaced.On 3/30/26 at 12:13PM FPM #5 informed the surveyor that a new tray will be made from scratch for the Resident whose food was left exposed in the hallway. FPM #5 reported that because there was no more lasagna, the Resident would receive something different.On 3/30/26 at approximately 12:19PM the surveyor observed Geriatric Nursing Assistant #40 place a dirty breakfast tray containing opened used items on it onto the clean food cart next to the surveyor's clean food lunch test tray. One Resident lunch meal waiting to be served was observed on the second tier of the cart. On 3/30/26 at 12:20PM the surveyor shared the concern with FPM #5 who informed GNA #18 and GNA #40 that dirty breakfast trays should not go on clean food carts.On 3/30/26 at 12:31PM the surveyor conducted temperature testing of the test tray with FPM #5 at which time the following temperatures of food was observed: 1.) Chicken breast: 115F, 2.) Mashed potatoes: 129F, and 3.) Carrots: 118F.On 3/30/26 at 12:45PM the surveyor observed the dry food storage area at which time a scooped handle was observed laying in the thickener powder, a scoop bowl and handled ladle was observed laying in the rice container, and a handled scooper was observed laying within the flour.On 3/30/26 at 1:41PM the surveyor observed a Kitchen Dietary Aide obtain and bring an Arizona sweet tea container from under the dishwashing area which was filled with a blue liquid the consistency of dish soap over to the wash compartment of the three-compartment sink.On 3/30/26 at 1:44PM the surveyor shared concerns with FPM #5 who acknowledged and confirmed understanding of the concerns. All Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on observation and interview it was determined the facility failed to ensure handrails were firmly affixed. This was evident for 2 out of 2 nursing units during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility on 3/23/26 at 7:43AM handrails were observed on Unit 1 of the facility to be in worn condition with chips, splintering, holes, and with areas present where the wood's surface finish had worn off.On 3/30/26 at 2:55PM the surveyor conducted rounding of the nursing units and observations of all handrails of the facility. Three handrails were observed and felt by this surveyor to be loose and movable, with one being located on the Main Unit 1 hallway, one being located in the hallway connecting Units 1 and 2, and one located in the Unit 2 hallway. The surveyor shared concerns and conducted rounding with Director of Maintenance #22 who observed and acknowledged the surveyor's concerns.Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on observations, interviews, and record reviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment in good repair. This was evident for 2 of 2 Nursing units and 1 out of 1 dining area reviewed during the annual recertification survey and investigation of complaints; #2713655, #320969, and #320969.The findings include: 1. During the surveyor's initial tour of the facility on 3/23/26 at 7:43AM the surveyor observed that the supply of linens present on the nursing unit 1 hallway was low in quantity. On 3/23/26 at 2:06PM the surveyor conducted a review of Complaint #320969 which included a concern for delays in Resident incontinence care. On 3/23/26 at 3:29PM the surveyor reviewed Complaint # 2713655 which included a concern that bed linens were not changed regularly, and Residents of the facility were left without clean bedding. At this time, the surveyor conducted an interview of the complainant who reported a concern that the facility did not have enough supply of clean linen available to the Residents. On 3/24/26 at 1:02PM the surveyor conducted an interview of Staff #16 who reported to the surveyor that staff utilized towels, sheets, and washcloths to wipe Residents for incontinence care and stated: That is the problem, we don't have no wipes, we are throwing away a lot of towels and washcloths because of it. Staff #16 additionally stated to the surveyor: Yes, there is a shortage of linen. Staff #16 reported having told Director of Housekeeping (DH) #19 about the issue, however, the linen shortage was not being addressed by them and the facility did not have enough linen to bring to the nursing units at 7:30AM. On 3/24/26 at 1:14PM the surveyor conducted an interview with GNA #17 who stated to the surveyor: Linen might be coming up late. On 3/24/26 at 1:14PM the surveyor conducted an interview of GNA #18 who reported to the surveyor that the linens come up late to the nursing units and Residents like to get up before breakfast, however, if linen is late they have to wait. GNA #18 confirmed that there were delays in care provided due to the issues with linen supply. On 3/24/26 at 3:31PM surveyors conducted observations of the clean supply room at which time there was no disposable wipes or cloths for incontinence care found to be present. On 3/25/2026 at 9:48AM Resident #28 reported to the surveyor that facility staff does not use wipes, they had to purchase their own, and that if the washcloth or towel has too much excrement on it, staff just throws them away. On 3/27/26 at 7:52AM the surveyor conducted a tour of all nursing unit linen carts and linen closets at which time only 6 clean washcloths were observed to be present, and limited supplies of other items such as towels, gowns, and bed linens was observed to be present. On 3/27/26 at 7:56AM the surveyor requested and conducted a dual observation of concerns with the facility's Director of Nursing (DON) at which time the surveyor shared the concerns. The DON observed and acknowledged and confirmed understanding of this surveyor's concerns. The DON stated to the surveyor: Maybe laundry has not brought it up yet. On 3/27/26 at 8:02AM the surveyor conducted an observation of the clean laundry room at which time only three washcloths were observed to be present, in addition to other linens. On 3/27/26 at 8:02AM the surveyor conducted an interview with Laundry Assistant (LA) #20 at which time the DON was present. LA #20 reported to this surveyor and to the DON that this morning they had only had 3 wash cloths for each nursing unit and that they were short on the linen supply. LA #20 confirmed with the surveyor and DON that they only had 3 washcloths total at present to send to the nursing floor, and had repeatedly informed DH #19 of the issue one month ago, one week ago, and also this morning. LA #20 confirmed at this time, that there was not other additional laundry present in the process of being washed or dried. The DON was observed leaving the laundry room as LA #20 was continuing to express their concerns relating to the shortage of linen. On 3/27/26 at 8:10AM surveyors conducted an interview of the DON at which time they stated to the surveyors that wipe squares should be used, not linen for hygiene relating to incontinence care of Residents. At this time, surveyors offered for DH #19 and the DON to show surveyors all available linens including the emergency supply and par levels, and any stock of available disposable wipes or similar wipe type products. No supply of wipes relating to incontinence care were present during tour of the facility's clean medical supply room and no additional washcloths were observed to be present in the emergency back up supply of linen located in DH #19's office. DH #19 confirmed with surveyors that there was no back up supply of wash cloths. On 3/27/26 at 9:41AM the surveyor observed Administrator in Training (AIT) #10 wheeling a dolly with boxes of pre-moistened wash cloths and personal cleansing cloths. The surveyor conducted an interview of AIT #10 who reported to the surveyor that they had been asked by the Administrator to bring supplies in. On 3/27/26 at 9:41AM the surveyor observed DH #19 holding a stack of washcloths. The surveyor conducted an interview of DH #19 and inquired as to if more washcloths had been obtained, at which time they reported that wash cloths were brought in from another facility now, and they wanted to go put enough washcloths on the units. On 3/27/26 at 1:01PM the surveyor shared concerns and conducted an interview with DH #19 who confirmed with the survey team that the linen levels were short and reported that they had spoken with their Regional supervisor and that they needed to have more emergency linen supply available, and conduct weekly instead of monthly room rounding for linen sweeps for the supply, and order more linens needed so they can pull from supply and still have more emergency supply on hand. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 2. During the surveyor's initial tour of the facility on 3/23/26 at 7:52AM the surveyor observed a recliner chair situated directly in front of the handwashing sink located in the main dining area of the facility on unit 1. On 3/23/26 at 9:12AM the surveyor shared the concern with the facility's Administrator who acknowledged the concern. On 3/23/26 at 10:00AM the surveyor again observed the recliner chair situated directly in front of the handwashing sink located in the main dining area of the facility on unit 1 continued to be present. Additionally, the surveyor observed two recliner chairs stored in front of the main dining room's nutrition area kitchenette on unit 1. On 3/23/26 at 10:07AM the facility Administrator reported to the surveyor that they had moved the reclining chairs and acknowledged and confirmed understanding of the concerns. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 3a.) On 3/23/26 at 2:06PM the surveyor conducted a review of Complaint #320969 involving a shared Resident bathroom. On 3/27/26 at 9:47AM the surveyor conducted an observation of the shared bathroom between Rooms # 31 and #33 on nursing unit 1 which revealed: -Unfinished areas of spackling present on the bathroom wall below the paper hand towel dispenser -Grey areas of wear on the bottom of the bathroom mirror -Broken areas of metal baseboard -Dark brown and rust colored areas of wear present on the metal baseboard -Areas of flooring felt and observed to be lifting and sticky upon walking on it. On 3/30/26 at 10:58AM the surveyor shared concerns with Director of Maintenance #22 who acknowledged and confirmed understanding of the concerns. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 3b. On 03/23/26 at 8:17 AM, during the screening process, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door that needs to be resurfaced and painted. On 03/23/26 at 8:29 AM, during the screening process, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door and toilet paper holder that needs to be resurfaced and painted, chipped paint around the bathroom sink, and a section of uneven, white boards nailed to the bathroom wall underneath the sink that appears to be partially covering a hole in the wall. On 03/24/26 at 11:23 AM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door that needs to be resurfaced and painted. On 03/24/26 at 11:32 AM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door and toilet paper holder that needs to be resurfaced and painted, chipped paint around the bathroom sink, and a section of uneven, white boards nailed to the bathroom wall underneath the sink that appears to be partially covering a hole in the wall. On 03/27/26 at 1:04 PM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door that needs to be resurfaced and painted. On 03/27/26 at 1:11 PM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door and toilet paper holder that needs to be resurfaced and painted, chipped paint around the bathroom sink, and a section of uneven, white boards nailed to the bathroom wall underneath the sink that appears to be partially covering a hole in the wall. On 03/30/26 at 4:13 PM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door that needs to be resurfaced and painted. On 03/30/26 at 4:17 PM, during observation rounds, the resident bathroom in room [ROOM NUMBER] was observed with a white, spackle-like substance on the wall near the bathroom door and toilet paper holder that needs to be resurfaced and painted, chipped paint around the bathroom sink, and a section of uneven, white boards nailed to the bathroom wall underneath the sink that appears to be partially covering a hole in the wall. On 03/30/26 at 4:21 PM, the Director of Nursing staff #2 was made aware of the surveyor's observations of a white, spackle-like substance on the wall near the bathroom door that needs to be resurfaced and painted in the residents' bathroom in room [ROOM NUMBER], and a white, spackle-like substance on the wall near the bathroom door and toilet paper holder that needs to be resurfaced and painted, chipped paint around the bathroom sink, and a section of uneven, white boards nailed to the bathroom wall underneath the sink that appears to be partially covering a hole in the wall in the residents' bathroom in room [ROOM NUMBER]. Staff #2 indicated that he will check into the surveyor's concerns. On 03/30/26 at 4:26 PM, the surveyor interviewed the Maintenance Director staff #22. The surveyor made staff #22 aware of the above maintenance issues. Staff #22 indicated that resident bathrooms are in the process of being renovated. Staff #22 also indicated that some renovations have been completed; however, there are still some resident bathrooms that need renovations and that maintenance will have those renovations completed soon. 4. During the surveyor's initial tour of the facility on 3/23/26 at 7:43AM handrails were observed on Unit 1 of the facility to be in worn condition with chips, splintering, holes, and with areas present where the wood's surface finish had worn off. On 3/23/26 at 10:01AM the surveyor conducted observations of the facility's handrails which revealed damage was present to hallway handrails on both Unit 1 and Unit 2. On 3/30/26 at 10:58AM the surveyor shared concerns with Director of Maintenance #22 who acknowledged and confirmed understanding of the concerns. On 3/30/26 at 2:55PM the surveyor conducted rounding of the nursing units and observations of all handrails of the facility, and after surveyor intervention, wood filling material was observed to be present on various areas of wooden handrails. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 5. On 3/23/2026 at 8:17AM, during an observation of the shared bathroom for residents staying in room [ROOM NUMBER] and room [ROOM NUMBER], the Surveyor observed the following environmental concerns: -Baseboard heater, surrounding the sink and the toilet area, with cream colored eroded and chipped paint, exposed cracks and dark brown metal, and covered with areas of orange/brown rust-like material. -Bathroom smelled of a musty odor -Spotty black substance noted between the shower base pan and shower wall at the front of the shower stall. -Threshold wood transition moulding missing between room [ROOM NUMBER] and the bathroom entrance exposing cracks between transition of flooring, missing tile, and a nail. On 3/23/2026 at 8:21AM, during an observation of the shared bathroom for residents staying in room [ROOM NUMBER] and room [ROOM NUMBER], the Surveyor observed the following environmental concerns: -Baseboard heater, surrounding the sink and the toilet area, with cream colored eroded and chipped paint, exposed dark brown metal and cracks, and covered with areas of orange/brown rust-like material. -Green colored wall with a large patch of a white compound above the back shower wall; a large patch of a white compound on the wall near the top of the doorway and a hole in the wall above that, exposing a black substance underneath; and a hole in the wall near the window. During an interview with the Director of Maintenance (DOM) #22 on 3/26/2026 at 1:34PM, the Surveyor expressed the environmental concerns and reviewed pictures of the shared bathrooms for rooms [ROOM NUMBERS], and rooms [ROOM NUMBERS]. DOM #22 acknowledged the Surveyor's concerns and was aware of the conditions of those bathrooms and the maintenance department is currently working on repairs and have ordered materials to resurface the baseboard heater. 6. On 3/23/2026 at 2:30PM, the Surveyor conducted an observation of shower rooms on Unit 1 and Unit 2. During an observation of the shower room on Unit 2, in the administrative hallway, the Surveyor observed the following environmental concerns: -A foul smell of feces and dried, brown stains covering the back of the toilet seat and brown stains in the toilet bowl. -Baseboard heater along the wall with white colored eroded and chipped paint, exposed dark brown metal and covered with areas of orange/brown rust-like material. -Chipped paint area along the handrail on the wall, exposing another layer of cream paint underneath. On 3/23/2026 at 2:37PM, the Surveyor informed the former Nursing Home Administrator, Staff #21, of the findings. Staff #21 acknowledged the condition of the shower room and stated he would inform environmental services and the maintenance department immediately.

Based on record review and interview with staff, it was determined that the facility failed to maintain discharge documentation, ensure the local Ombudsman was notified of the facility's discharges and transfers, and provide the resident/representative with written notification of transfers to the hospital and written notification of the facility's completed bed hold policy upon transfer to the hospital. This was evident for 4 (#42, #8, #50, #52) of 5 residents reviewed for transfers and discharges during the annual recertification survey.The findings include: 1. On 03/25/26 at 6:52 AM, Resident #11's medical record was reviewed. During the medical record review, the surveyor could not locate documentation indicating that the local Ombudsman's office was notified about Resident #42 being transferred to the hospital on [DATE]. On 03/25/26 at 9:37 AM, the Nursing Home Administrator Staff #1 was interviewed. During the interview, the surveyor asked Staff #1 whether the facility notifies the local Ombudsman's office about residents being transferred/discharged to the hospital. Staff #1 stated that the Social Services Director Staff #11 provides notification to the local Ombudsman's office about residents being transferred/discharged to the hospital. The surveyor asked Staff #1 how does staff #11 notify the local Ombudsman's office about residents being transferred/discharged to the hospital. Staff #1 indicated that staff #11 notifies the local ombudsman's office about residents being transferred/discharged to the hospital via email either weekly or monthly. On 03/25/26 at 10:13 AM, Staff #11 was interviewed. During the interview, the surveyor asked Staff #11 if she notifies the local Ombudsman's office about residents being transferred/discharged to the hospital. Staff #11 indicated that she did not know that she had to notify the local ombudsman's office about residents being transferred/discharged to the hospital. On 03/25/26 at 10:30 AM, Staff #1 was interviewed. During the interview, Staff #1 indicated that Staff #11 did not start notifying the local Ombudsman's office about residents being transferred/discharged to the hospital until Staff #1 started working at the facility around the end of February 2026. 2. On 3/24/2026 at 1:15PM, a review of Resident #52's electronic medical record revealed a social services note, dated 1/9/2026, which stated that [he/she] has chosen to proceed with discharge against medical advice [AMA]. On 3/24/2026 at 3:02 PM, during an interview with the Social Service Director (SSD) #11, in the presence of the Nursing Home Administrator (NHA, #1), the Surveyor was informed that Resident #52 left the facility AMA and the signed AMA document was placed in the resident's chart. The Surveyor requested a copy of the document. A review of Resident #52's electronic medical record on 3/25/2026 at 12:55PM failed to reveal documentation of a signed Resident-Initiated Release of Responsibility for Discharge Against Medical Advice form. The Surveyor again requested a copy of the document this time from the Nursing Home Administrator in Training (AIT) #10. During an interview with the NHA on 3/26/2026 at 8:50AM, the Surveyor expressed the concern that the signed Resident-Initiated Release of Responsibility for Discharge Against Medical Advice form for Resident #52 had been requested on multiple occasions and had not been provided. The NHA stated that the facility was still looking for the document. The facility failed to provide AMA documentation for Resident #52 as of the exit conference on 3/30/2026 at 5:45 PM. 3. On 3/25/2025 at 8:00AM, a review of Resident #50's electronic medical record revealed that the resident was transferred to the hospital on 4/7/2025, 5/31/2025, 6/24/2025, 8/5/2025, 9/8/2025, 9/26/2025, 10/20/2025, and 2/17/2026. Further review failed to reveal documentation that the resident was provided with written notification of the transfers to the hospital and the facility's bed hold policy upon transfer to the hospital on 4/7/2025, 5/31/2025, 6/24/2025, 9/8/2025, 9/26/2025, 10/20/2025, and 2/17/2026. On 3/25/2026 at 8:20AM, a review of Resident #8's electronic medical record revealed that the resident was transferred to the hospital on 3/6/2026 and 3/21/2026. Further review failed to reveal documentation that the resident was provided with written notification of the transfers to the hospital and the facility's bed hold policy upon transfer to the hospital on those dates. On 3/25/2026 at 8:37 AM, during an interview with the NHA, the Surveyor requested documentation to verify the facility provided Resident #50/representative and Resident #8/representative with written notification of their transfers to the hospital and written notification of the facility's completed bed hold policy upon transfer to the hospital. On 3/25/2025 at 10:08AM, during an interview with the Director of Admissions #32, the Surveyor was informed that she does not send written notification of transfer and bed hold to the resident representative when a resident is transferred to the hospital. On 3/25/2025 at 10:13AM, during an interview conducted with SSD #11, the Surveyor was informed that she does not send written notification of transfer and bed hold to the resident representative when a resident is transferred to the hospital. On 3/25/2026 at 3:00PM, a review of Resident #50's transfer and bed hold documents provided failed to confirm the resident/representative was provided with written notification of his/her transfers to the hospital on 4/7/2025, 5/31/2025, 6/24/2025, 9/8/2025, 9/26/2025, 10/20/2025, and 2/17/2026, and written notification of the facility's bed hold policy upon transfer to the hospital on 4/7/2025, 5/31/2025, 6/24/2025, and 10/20/2025. Additional review of the Request for Temporary Leave Bed-Holds indicated that the form should be signed and returned to the facility to properly effectuate a bed-hold request and included the statement: By my signature below, I hereby state that I have read, understand, and agree to the Facility's Policy and State Requirements for a temporary leave bed-hold. The form failed to include the resident's actual signature on the following dates: 4/7/2025, 5/31/2025, 6/24/2025, and 10/20/2025. On 3/25/2026 at 3:30PM, a review of Resident #8's transfer and bed hold documents provided failed to confirm the resident/representative was provided with written notification of his/her transfers to the hospital on 3/6/2026 and 3/21/2026. Additional review of the Request for Temporary Leave Bed-Holds indicated that the form should be signed and returned to the facility to properly effectuate a bed-hold request and included the statement: By my signature below, I hereby state that I have read, understand, and agree to the Facility's Policy and State Requirements for a temporary leave bed-hold. The form failed to include the resident's actual signature on 3/6/2026. During an interview with the NHA on 3/26/2026 at 8:50AM, the Surveyor expressed the concern that the facility was inconsistent with providing residents with written notification of the transfers to the hospital and the facility's bed hold policy upon transfer to the hospital. The Surveyor asked if residents representatives are provided with written notification of the transfers to the hospital and the facility's bed hold policy upon transfer to the hospital and the NHA responded that they are not provided with written notification. 4. On 3/24/2026 at 1:15PM, a review of Resident #52's electronic medical record revealed that the resident discharged against medical advice [AMA] on 1/9/2026. On 3/25/2025 at 8:00AM, a review of Resident #50's electronic medical record revealed that the resident was transferred to the hospital on 4/7/2025, 5/31/2025, 6/24/2025, 8/5/2025, 9/8/2025, 9/26/2025, 10/20/2025, and 2/17/2026. On 3/25/2026 at 8:20AM, a review of Resident #8's electronic medical record revealed that the resident was transferred to the hospital on 3/6/2026 and 3/21/2026. Investigation of these Resident's (#52, #50, #8) discharge and transfers revealed that no notification was made to the Ombudsman's office: On 3/25/2026 at 8:37AM, a Surveyor's interview with the NHA revealed that SSD #11 notifies the local Ombudsman of the facility's transfers and discharges via email either weekly or monthly. The Surveyor requested that the NHA provide documentation to verify that the facility notifies the local Ombudsman of the discharges and transfers, specifically for the months of April 2025, May 2025, June 2025, August 2025, September 2025, October 2025, January 2026, and February 2026. On 3/25/2025 at 10:13AM, during an interview conducted with SSD #11, the Surveyor was informed that she was unaware that she was responsible for notifying the local Ombudsman of the facility's transfers and discharges until recently. During an interview conducted with the NHA on 3/25/2026 at 10:30 AM, the Surveyors were informed that SSD #11 began to notify the local Ombudsman of the facility's transfers and discharges via weekly or monthly emails when he started employment at the facility at the end of February 2026. No other department was sending the local Ombudsman transfer and discharge notification at that time.

Based on record review and interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (Resident #18) out of 2 residents reviewed for communication/sensory during the annual recertification survey.The findings include:On 3/26/2026 at 2:15PM, a review of Resident #18's electronic medical record failed to reveal a personal inventory sheet.On 3/26/2026 at 2:20PM, a review of Resident #18's paper chart failed to reveal a personal inventory sheet.On 3/26/2026 at 2:23PM, during an interview with Registered Nurse #34, the Surveyor was informed that if a resident has personal belongings, they should be logged on a personal inventory sheet located in the resident's paper chart.A review of the facility's Personal Property policy on 3/27/2026 at 2:50PM, #10, revealed that The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. A copy of the personal inventory sheet should be maintained in the residents' medical records.During an interview with the Director of Nursing (DON) on 3/27/2026 at 3:00PM, the Surveyor expressed the concern that the facility failed to complete and maintain a comprehensive personal inventory sheet for Resident #18. The DON acknowledged the Surveyor concerns.

Based on record review and staff interviews, it was determined that the facility failed to ensure the assessments were accurately completed. This was determined for 1 (#14) out of 6 residents reviewed for Minimum Data Set (MDS) assessments during this annual recertification survey.The findings include:The Minimum Data Set (MDS) 3.0 is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate residents' functional capabilities, health needs, and preferences. It drives care planning, monitors quality, and determines reimbursement rates. Assessments are required at admission, quarterly, annually, and upon significant changes.On 3/27/2026 at 3:11 PM, during record review, it was revealed that Resident #14 had an error on the MDS assessment. Resident #14 has an ostomy, but it wasn't checked on the assessment that the resident had one. The Nursing Home Administrator (NHA #1) was asked for a copy of the MDS - Section H for Resident #14. On 3/27/2026 at 3:30 PM, the surveyor asked the NHA #1 for an interview with the MDS Coordinator. The MDS Coordinator (MDS #30) came to the conference room and was asked if she was familiar with Resident #14. MDS #30 responded that she was familiar with the resident. MDS #30 was asked how often she makes changes to the MDS assessment for a resident. MDS #30 responded that it is completed within 72 hours of admission, quarterly, annually, and within 14 days of a significant change. MDS #30 was shown the current MDS-Section H 100, where it showed that the resident had an indwelling catheter only. And in section H 400, it indicated that the resident was not rated for bowel continence because they have an ostomy. MDS #30 was not sure what happened or why it didn't carry over from the previous MDS assessment. MDS #30 made the necessary corrections and returned with a copy of the printed correction.

Based on observation and interview with staff, it was determined that the facility failed to ensure clean linen was handled, transported, and stored in a safe and sanitary manner. This was evident for 2 of 2 clean linen transports, and 1 of 1 main supply room observed during the annual recertification survey.The findings include: 1. On 3/25/2026 at approximately 9:30 AM, the Surveyor observed Laundry Staff #33 carrying clean, uncovered resident garments on hangers while walking up the facility steps. The garments draped over the laundry staff member's arm. On 3/27/2026 at approximately 8:30AM, the Surveyor observed Laundry Staff #20 transporting an uncovered, yellow clean linen cart with folded facility linen on Unit 1 and then down the freight elevator. On 3/27/2026 at 12:55PM, during an interview conducted with Environmental Services/ Laundry Manager #19, the Surveyor expressed the concern that a laundry staff member was observed carrying clean, uncovered Resident garments on hangers and in their arms as they walked up the facility steps and another laundry staff member was observed transporting an uncovered, yellow clean linen cart with folded facility linen on Unit 1 and then down the freight elevator. The Surveyor was informed that clean linen and resident personal linen and laundry should be fully covered while being transported through the facility. 2. On 3/24/26 at 3:31PM surveyors conducted observations of the supply room utilized for storage of clean supplies at which time several cracks in the ceiling were noted to be several feet long in length with damaged open areas present with dust, debris, and light brown discoloration present. Pieces of white crumbled debris was observed present on the flooring and white colored dust was observed on stored supplies. On 3/30/26 at 10:58AM the surveyor shared concerns with Director of Maintenance #22 and requested and conducted a dual observation of the concerns with them at which time they observed, acknowledged, and confirmed understanding of the concerns. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 3. During surveyor observation of the facility laundry areas on 3/24/26 at 1:00PM the surveyor observed a rolling cloth type laundry container with areas of soiling and discoloration present on it holding two Resident's personal laundry, each in mesh bags. The surveyor noted that the mesh bags had open spaces within the material. On 3/27/26 at 1:01PM the surveyor shared concerns and conducted an interview of Director of Housekeeping #19 who confirmed with the survey team that mesh bags were used for Resident personal laundry and acknowledged and confirmed understanding of the surveyor's concerns. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure effective pest control to ensure the environment was free from gnats. This was evident in 1 of 2 units, and 1 of 1 kitchen reviewed for effective pest control during the annual recertification survey.The findings include: 1. On 3/23/2026 at 8:17AM, during an initial tour of Unit 2, the Surveyor observed the shared bathroom of Resident #19 and Resident #45. The bathroom had a musty odor and there were flying gnats observed in the shower area. On 3/24/2026 at 8:30AM during a tour of Unit 2, the Surveyor observed flying gnats at the nurses' station and in the hallway. On 3/25/2026 at 9:30AM, during an interview conducted with Resident #28, the Surveyor observed flying gnats in the room. The resident mentioned the facility had an issue with gnats. On 3/26/2026 at 1:34PM, during an interview conducted with the Director of Maintenance (DOM) #22, the Surveyor was informed that the facility utilizes [Pest Control Company] and an employee was in the building on 3/23/2026 for treatments. [Pest Control Company] comes monthly and as needed. Staff verbally informs DOM #22 of pest sightings and will also log them in the maintenance log at the nurses' station. The Surveyor expressed the concern of gnats in the building, particularly in the shared bathroom of Resident #19 and Resident #45, Resident #28's room, and at the nurses' station and hallways of Unit 2. 2. On 3/23/26 beginning at 7:58AM the surveyor conducted an initial tour of the facility's kitchen. On 3/23/26 at 8:07AM the surveyor observed gnats flying around and in the open plastic onion container. Concerns were shared by the surveyor with [NAME] #4. On 3/23/26 at 8:40AM the surveyor conducted a dual observation of concerns with Food Protection Manager (FPM) #5 who observed, acknowledged, and confirmed understanding of the surveyor's concerns. On 3/30/26 at 11:26AM the surveyor observed gnats on the onions and flying around the onions within the open plastic onion container. On 3/30/26 at 11:27AM The surveyor shared the concern and conducted a dual observation of the concern with FPM #5 who observed the gnats and after surveyor intervention, the onions were observed being removed and thrown away by them. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on review of an employee file, online sources, and interview with staff, it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) staff had an active, current certification. This was evident for 1 (GNA #15) out of 5 GNAs reviewed for staff qualifications during the annual recertification survey.The findings include: On [DATE] at 11:30AM, a review of staffing sheets from [DATE] through [DATE] revealed that GNA #15 worked on a resident care assignment on the following days:[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM [DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AM[DATE]: 3:00PM-11:00PM[DATE]: 3:00PM-11:00PM[DATE]: 3:00PM-11:00PM and 11:00PM-7:00AMGNA #15 was scheduled to work 3:00PM-11:00PM and 11:00PM-7:00AM on [DATE]. On [DATE] at 1:15PM, during a review of GNA #15's employee file, the Surveyor discovered a copy of the Maryland Board of Nursing (MBON) Licensee Details sheet which stated GNA #15's license expiration date was on [DATE]. On [DATE] at 1:30PM, the Surveyor requested a copy of GNA #15's current GNA license. On [DATE] at 2:00PM, a review of the Look UP A License feature on MBON website showed the certification status for GNA #15 as non-renewed and the expiration date was [DATE]. On [DATE] at 2:20PM, during a review of GNA #15's employee file with the Director of Nursing and the MBON's website Look Up A License feature, the Surveyor confirmed that GNA #15's license expired on [DATE]. On [DATE] at 2:28PM, during an interview with the NHA in the presence of former NHA #21, the Surveyor expressed the concern that GNA #15's license had been expired since [DATE] and a review of staffing sheets from [DATE] through [DATE] revealed that he has been recently providing resident care. The NHA acknowledged the Surveyor's concern and informed the Surveyor that GNA #15 will be taken off the schedule until his license becomes active.

Based on observation, interview and record review it was determined the facility failed to ensure the menu was followed. This was evident for 1 out of 1 lunch meal tray pass observation conducted by the surveyor during the facility's recertification survey. The findings include: On 3/30/26 at 12:13PM Food Protection Manager (FPM, Staff #5) informed the surveyor that a new tray will be made from scratch for Resident #33 whose food was left exposed in the hallway. FPM #5 reported that because there was no more lasagna, Resident #33 would receive something different.On 3/30/26 at 12:14PM the surveyor conducted an interview of FPM #5 and inquired as to why the menu of lasagna being served for the lunch meal did not follow the facility's posted menu reviewed by the surveyor. During the interview FPM #5 reported that the prime rib posted on the menu was not served because it was not available for order when they went to order the food on Thursday. FPM #5 confirmed that Residents were not notified of the menu substitutions prior to the meal being served.On 3/30/26 at 12:43PM the surveyor conducted an interview of Resident #33 who indicated to the surveyor that they had received a replacement meal tray and reported that they had been served a sandwich and carrots for the meal. Review of the facility's menu by the surveyor revealed that the posted menu was not followed for the lunch time meal.On 3/30/26 at 1:44PM the surveyor shared concerns with FPM #5 who acknowledged and confirmed understanding of the concerns. All Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on observation and interview it was determined the facility failed to ensure:1. Medications were securely stored, this was evident in 1 out of 2 medication carts observed on the Unit 1 hallway during the facilities recertification survey.2. Nutritional supplements were not expired. This was evident in 2 of 2 storage areas for Nepro nutritional supplements observed during the facility's recertification survey. The findings include:1. During the surveyor's initial tour of the facility on [DATE] at 7:43AM the surveyor observed an unattended and unlocked medication cart on the Unit 1 hallway in which all drawers were found to be accessible containing various Resident medication pill packs, bottled medications and medical supplies.On [DATE] at 7:47AM the surveyor requested and conducted a dual observation of the concern with Nurse #26 who after surveyor intervention, was observed locking the medication cart. The surveyor conducted an interview at this time with Nurse #26 and inquired as to what staff was assigned to the medication cart at which time they reported to the surveyor that it was assigned to a nurse who had not yet showed up for their shift. When the surveyor inquired as to what staff was currently assigned to the medication cart at this time, they indicated that it was theirs. On [DATE] at 9:12AM the surveyor shared the concern with the facility's Administrator and Director of Nursing who acknowledged and confirmed understanding of the concern. 2.During the surveyor's initial tour of the facility on [DATE] at 10:03AM the Unit 1 nursing supply closet was observed with a box of Nepro nutritional supplements dated with expiration of [DATE]. On [DATE] at 10:07AM the surveyor shared the concern with the facility's Administrator who stated We'll trash that. Subsequently, the Director of Nursing was observed by the surveyor removing the box of expired nutritional supplements from the Unit 1 nursing supply closet.During a dual surveyor tour of the facility's clean supply room on [DATE] at 3:26PM surveyors observed a box of Nepro nutritional supplements dated with expiration of [DATE]. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on [DATE].

Based on review of employee personnel files and interviews with staff, it was determined that the facility failed to ensure required Geriatric Nursing Assistant (GNA) performance reviews were completed every 12 months. This was evident for 2 (GNA #15 and GNA #37) out of 5 employees reviewed for sufficient staffing during the annual recertification survey.The findings include:On 3/30/2026 at 12:15PM, a review of GNA #15's personnel file failed to reveal that the facility conducted a yearly performance review at least every 12 months.On 3/30/2026 at 12:30PM, a review of GNA #37's personnel file failed to reveal that the facility conducted a yearly performance review at least every 12 months.During an interview with the Director of Nursing (DON) on 3/30/2026 at 2:20PM, the Surveyor the Surveyor expressed the concern that the facility failed to complete yearly performance reviews for GNA #15 and GNA#37. During a review of GNA #15's and GNA #37's personnel files, the DON confirmed that no yearly performance review was conducted at least every 12 months. The DON did not conduct any performance reviews.During an interview with the Director of Human Resources (DHR) #39 on 3/30/2026 at 2:40PM, the Surveyor was informed that GNA #15 and GNA #37 employee personnel files are complete; therefore, yearly performance reviews should be in the files if they were conducted. DHR #39 does not conduct performance reviews for staff.On 3/30/2026 at 2:45PM, the Surveyor expressed their concerns to the Nursing Home Administrator (NHA) in the presence of the former NHA #21 . The former NHA #21 and the NHA did not conduct performance reviews.

Based on record review and interviews with a resident and staff, it was determined that the facility failed to ensure a resident attended a scheduled medical appointment and the missed appointment was rescheduled timely. This was evident for 1(Resident #45) out of 2 residents investigated for communication/sensory during the annual recertification survey.The findings include:On 3/23/2026 at 12:24PM, during an interview with Resident #45, the Surveyor was informed that the resident missed a scheduled follow-up eye appointment on 2/27/2026 because the facility did not schedule transportation. The resident stated that the Appointment Scheduler (AS) #31stated that she would ensure that his/her appointment is rescheduled immediately, but he/she had not received any information regarding the rescheduled appointment.On 3/24/2026 at 1:00PM, a review of Resident #45 electronic medical record failed to reveal an order for a follow-up eye appointment.On 3/24/2026 at 1:54PM, during an interview with AS #31, the Surveyor was informed that she was unaware of Resident #45's follow-up eye appointment on 2/27/2026. Nursing staff usually informs AS #31 of a resident's appointment. AS #31 stated she was in the process of rescheduling the Resident #45's appointment.On 3/25/2026 at 8:34AM, the Surveyor requested the Nursing Home Administrator to provide documentation of Resident #45's rescheduled appointment.On 3/25/2026 at 10:15AM, the Surveyor conducted an interview with Resident #45. During the interview, the resident reported that he/she has not received any information regarding his/her follow-up eye appointment. The resident stated that the appointment on 2/27/2026 was important because he/she was receiving eye injections for a medical condition and currently his/her eyes feel uncomfortable while watching television. The resident stated that during his/her admission to the facility on 1/23/2026, he/she informed the admitting nursing staff of his/her appointment on 2/27/2026. At this time, the resident has not been updated on the status of his/her appointment.During an interview with the Director of Nursing (DON) on 3/25/2026 at 10:35AM, the Surveyor expressed the concern that Resident #45 missed a scheduled follow-up appointment on 2/27/2026 and AS #31 informed the resident that she would reschedule the appointment; however, the resident has not been provided with information on the status of the follow-up eye appointment. The appointment should have been rescheduled immediately after the missed appointment due to the reason for the appointment. The DON stated that he would call [eye company] himself to reschedule Resident #45's follow-up appointment.On 3/25/2026 at 2:00PM, the Surveyor reviewed a Physician's order, dated 3/25/2026 at 10:57AM, for Resident #45's eye appointment on 4/22/2026 at 1:30PM, confirmed by the DON.

Based on record review and interview with staff, it was determined that the facility failed to ensure a person-centered care plan was updated and revised. This was evident: for 2 (#50, #63) out of 3 residents reviewed for care plan revisions during the annual recertification survey and investigation of complaint #320972.A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted. The findings include: 1. On [DATE] at 12:21PM, a review of Resident #50's electronic medical record revealed a social services note, dated [DATE], which stated that the resident's MOLST was reviewed and updated from Full Code to DNR-B. Further review revealed a care plan with a focus, [Resident's] FULL CODE MOLST will remain in place through review date, created on [DATE]. On [DATE] at 12:30PM, a review of Resident #50's paper chart revealed a MOLST completed on [DATE] with orders for No CPR, Option B, Palliative and Supportive Care. On [DATE] at 12:41PM, during an interview and review of resident records with the Nursing Home Administrator (NHA), the Surveyor expressed the concern that Resident #50's MOLST was updated on [DATE] from Full Code to DNR-B; however, the care plan was not revised to reflect the updated code status. After a review of Resident #50's current MOLST dated [DATE] and current care plan for code status, the NHA confirmed the Surveyor's findings. 2. On [DATE] at 2:18PM the surveyor conducted a review of Complaint #320972 and conducted a phone interview of the complainant who reported concern regarding Resident #63 having a fall while residing at the facility. On [DATE] at 10:16AM the surveyor conducted a review of Resident #63's medical record which revealed a progress note written by Licensed Practical Nurse #23 dated [DATE] which documented Resident #63's fall, assessment of several injuries sustained, and transfer to the emergency room. On [DATE] at 10:31AM the surveyor reviewed Resident #63's care plan and noted that no revisions relating to the Resident's fall were made to the fall interventions in place prior to the fall. The surveyor observed that the care plan was not documented as reviewed and revised until [DATE]. On [DATE] at 11:10AM the surveyor conducted an interview of Director of Rehabilitation #13 who reported to the survey team that the therapy department makes necessary recommendations and sees Residents after falls occur, but does not revise the care plan, and stated: I would have to check if nursing is responsible for care plan revisions. On [DATE] at 1:31PM the surveyor shared the concern and conducted an interview of the Director of Nursing (DON) who reviewed Resident #63's care plan with the surveyor and confirmed that no revisions had been made to the Resident's care plan in response to the fall and reported to the surveyor that revision to the care plan is the first thing they do as soon as they find out about a Resident fall. The surveyor inquired to both the DON and Regional Administrator (RA) #21 as to if a fall investigation had been performed and documented, at which time RA #21 indicated they had no recollection or documentation to provide and the DON indicated that they were not yet in the DON role at the time of the fall and indicated they did not have any documentation to provide. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on [DATE].

Based on observation and interview it was determined the facility failed to ensure maintenance of essential kitchen equipment. This was evident during the surveyors review of the kitchen task during the facility's recertification survey. The findings include: On 3/23/26 at 7:58AM the surveyor conducted an initial tour of the facility's kitchen.On 3/23/26 at 7:59AM the surveyor observed the digital exterior thermometer on Freezer #3 to be reading: 110. On 3/23/26 at 8:00AM the surveyor observed the warming plate base in the warmer was observed to have food debris present on the surface.On 3/23/26 at 8:01AM the surveyor observed food cooking equipment located on the clean cooking utensil rack with a layer of food debris and clear liquid present on it. On 3/23/26 at 8:02AM the surveyor observed a rectangular bucket of cloudy liquid sitting beneath the dishwasher's filter container and drain. The drain stopper used for containing water used for washing of dishes was observed to be disconnected from the machine. On 3/23/26 at 8:04AM the surveyor observed the three compartment sink located next to the dishwashing area at which time the chemical line for the wash compartment of the sink was draped over the middle rinse compartment of the sink which was observed dripping into the rinse compartment from a cracked area in the line which had a small pad affixed near it, held to the line with a metal piece. On 3/23/26 at 8:18AM the surveyor opened the reach in refrigerator located nearest to the food serving line at which time the refrigerator was observed to not be in working order with no refrigeration occurring and refrigerator parts was observed sitting within the unit. On 3/23/26 at 8:19AM the surveyor conducted an interview of [NAME] #4 who stated regarding the dishwasher: They have to repair this part. When the surveyor inquired as to how long the dishwasher had been leaking they stated: A week, maintenance knows they are supposed to be doing something about it, they are waiting for the part. On 3/23/26 at 8:43AM the surveyor inquired to FPM #5 as to what type of dish machine was present, if it was a low or high temperature machine at which time FPM #5 stated: I'm not sure. FPM #5 confirmed that no monitoring logs were kept of any temperatures relating to the dish machine. On 3/23/26 at 8:45AM the surveyor conducted an interview of [NAME] #4 who reported that the machine was hot water and chemical. [NAME] #4 confirmed with the surveyor that no temperature logs were maintained. On 3/23/26 at 8:47AM the surveyor observed a temperature dial located on the machine which had an unclean film present on it which was not readable. On 3/23/26 at 8:55AM the surveyor conducted an interview of FPM #5 and inquired as to how long the reach in refrigerator had been out of operation at which time they reported that the facility had the wrong part for it.On 3/23/26 at 9:12AM the surveyor shared concerns with the facility Administrator and Director of Nursing. On 3/23/26 at 1:54PM the surveyor requested the last six months of documentation for dishwashing maintenance and repairs and any TELS/Maintenance requests from the facility's Administrator. On 3/24/26 at 10:34AM the surveyor conducted a review of documentation provided by the Administrator and noted that one kitchen service report was provided regarding the dishwasher dated 2/25/26 which documented the following information: Electrical connections: Needs review (see notes) however, the notes were not observed to be provided. On 3/30/26 at 2:47PM the surveyor shared concerns and conducted an interview with the facility's Director of Maintenance who reported regarding the dishwasher, that If food service staff don't empty out the bucket, which has a screen in it and clean it out, it will overflow with the water. Concerns were shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26.

Based on interviews and record reviews, it was determined that the facility failed to develop and implement comprehensive care plans. This was evident for 2 (#50, #2) of 6 residents reviewed for care planning during an annual recertification survey and investigation of Complaint #2784382.The findings include: 1. On 3/23/26 at 2:39PM the surveyor conducted a review of Complaint #2784382 and conducted an interview of the complainant relating to an injury sustained by Resident #50. On 3/26/26 at 11:46AM the surveyor conducted an interview of the facility's Director of Nursing (DON) at which time the surveyor inquired as to how Resident #50's injury occurred at which time the DON responded: (Resident #50) ran into his/her bed with his/her wheelchair and got a skin tear or laceration on his/her leg, there was no issues with the bed, it was him/her running into the bed, s/he had a motorized wheelchair assessed by therapy at that time. On 3/26/26 at 12:01PM the surveyor reviewed Resident #50's medical record with the DON which revealed an Emergency Department Physician note which included documentation of the Resident's report that they were in their motorized wheelchair when the injury occurred. On 3/26/26 at 1:31PM the surveyor conducted a review of Resident #50's care plan which revealed no documentation was present regarding the Resident's use of a motorized wheel chair. On 3/26/26 at 2:06PM the surveyor conducted an interview of the facility Administrator who reported to surveyors that safety assessment had been conducted by the Resident's therapist for their use of the motorized wheel chair. On 3/26/26 at 2:07PM the surveyor conducted an interview of the facility's DON who reported to surveyors that they update Resident care plans based on information received from utilization review meetings, obtaining of information from the Director of Rehabilitation, the Resident's discharge summary, and their assessment. On 3/26/26 at 2:14PM the surveyor conducted an interview of Resident #50's Occupational Therapist #24 who confirmed the Resident's use and safety assessment for their motorized wheelchair. On 3/30/26 at 3:25PM the surveyor reviewed the Resident's medical record which revealed they were initially admitted to the facility on [DATE] and were discharged from the facility on 2/17/26. The surveyor additionally reviewed a power mobility indoor driving assessment documented as performed with Resident #50 dated 4/29/25 provided by the facility's Administrator. Concerns were again shared with the facility's Administrator, Director of Nursing, Administrator in Training #10, and Regional Administrator #21 during the facility's exit conference on 3/30/26. 2. On 03/23/26 at 2:43 PM, facility's records were reviewed. The facility record review revealed that it is documented in the facility's matrix that resident #2 has PTSD/Trauma. On 03/24/26 at 11:03 AM, the resident's medical record was reviewed. The resident record review revealed that Resident #2's care plan focus indicates that resident #2 has a history of trauma related to childhood sexual abuse; however, the care plan's interventions only lists trauma as the intervention for the aforementioned care plan's focus. There are no interventions listed for that care plan focus. On 03/24/26 at 11:14 AM, The resident's medical record was reviewed. The resident's medical record review revealed that it is documented in resident #2's Quarterly MDS, dated [DATE], that resident #2 has a medical diagnosis of post-traumatic stress disorder. On 03/26/26 at 12:11 PM, the Nursing Home Administrator staff #1 was interviewed. During the interview, the surveyor made staff #1 aware that Resident #2 has a medical diagnosis of post-traumatic stress disorder; however, the surveyor could not locate interventions for the diagnosis in the resident's care plan other than trauma. Staff #1 indicated that he will check into the surveyor's concerns.

Based on observations, record review, and staff interviews, it was determined that the facility failed to ensure the promotion of resident's dignity and residents' rights. It was evident for 2 (#14, #61) out of 4 residents reviewed for Resident Rights during this annual recertification survey.The findings include:1.On 3/23/2026 at 8:30 AM, during the initial observation of Resident #14, an observation was made that the urinary catheter bag was hanging from the bed without a bag cover.On 3/24/2026 at 12:35 PM, an observation was made by the surveyor, and it was noted that Resident #14 had a bag cover over the urinary catheter bag.On 3/26/2026 at 2:43 PM, the surveyor observed that while Resident #14 was lying in bed, once again the resident's urinary catheter bag was not covered. The cover for the bag was lying on the floor next to where the urinary catheter bag was hanging.The facility failed to maintain Resident #14's dignity by not covering the urinary catheter bag.2. On 3/26/26 at 11:30 AM, a review of the facility-reported incident revealed that the facility failed to ensure that resident rights were being upheld. The facility conducted a thorough investigation into the alleged neglect claim that the facility was not feeding Resident #61. However, the facility denied the resident's right to remain on the phone with his family while being fed.On 3/26/26 at 2 PM, the Nursing Home Administrator (NHA #1) and Director of Nursing (DON #2) were interviewed in reference to a complaint from the resident's family about the incident that had occurred. When asked what had happened, the DON #2 responded that the resident was on the phone with their sister (Resident Representative/ RP) and mother when it was their lunch time. A staff member had come to the resident's room to assist them with eating and noted that the resident was on the phone with their mother and sister. The DON #2 continued to reply that the staff member had made a statement to the resident that she would feed them once they had finished their conversation and were off the phone. Resident #61's sister (their RP) was on the phone and stated to the staff member that it was okay to feed them because they weren't really saying anything on the phone. The staff member continued to refuse to feed Resident #61 while they were on the phone, and replied that she would be back once they were off the phone. The family did not like the answer, so they called the police to report the facility for neglect for not feeding the resident. However, the police were told by the resident that they were not being abused or neglected and that they had received their lunch. The DON #2 was asked if the resident had the right to be fed while on the phone. The DON #2 replied yes, but we can't make staff do something that they do not feel comfortable doing. The nurse at that time did not feel comfortable about feeding the resident while the family was on the phone. The DON #2 was then asked if the resident's rights had been denied. The DON #2 stated no. The surveyor explained that the resident's rights had been denied and that it was against the resident's wishes that they had to get off the phone in order to be fed.

Based on record review and staff interviews, it was determined that the facility failed to ensure that the resident's representative's rights were being upheld. This was evident for 1 (#61's representative) out of 1 resident representative reviewed during this annual recertification survey.The findings include:On 3/26/26 at 11:30 AM, a review of the facility-reported incident revealed that the facility failed to ensure that resident rights were being upheld. The facility conducted a thorough investigation into the alleged neglect claim that the facility was not feeding Resident #61. However, the facility denied the resident's right and the resident representative's right to remain on the phone with the resident while being fed. On 3/26/26 at 2 PM, the Nursing Home Administrator (NHA #1) and Director of Nursing (DON #2) were interviewed in reference to a complaint from the resident's family about the incident that had occurred. When asked what had happened, the DON responded that the Resident #61 was on the phone with his sister (Resident #61 Representative) and mother when it was lunch time. A staff member had come to the resident's room to assist them with eating and noted that the resident was on the phone with their mother and sister. The DON #2 continued to reply that the staff member had made a statement to Resident #61 that she would feed them once they had finished their conversation and were off the phone. Resident #61's sister (their RP) was on the phone and stated to the staff member that it was okay to feed them because they weren't really saying anything on the phone. The staff member continued to refuse to feed Resident #61 while they were on the phone, and replied that she would be back once they were off the phone. The family did not like the answer, so they called the police to report the facility for neglect for not feeding the resident. However, the police were told by Resident #61 that they were not being abused or neglected and that they had received their lunch. The DON #2 was asked if the resident had the right to be fed while on the phone. The DON #2 replied yes, but we can't make staff do something that they do not feel comfortable doing. The nurse at that time did not feel comfortable about feeding the resident while the family was on the phone. The DON #2 was then asked if the resident's rights had been denied. The DON #2 stated no. The surveyor explained that the resident's rights and the resident representative's rights had been denied and that it was against the resident's wishes that they had to get off the phone in order to be fed.

Based on observations, record review, and resident and staff interviews, it was determined that the facility failed to ensure that the recommendations and suggestions of residents were addressed and reported back to the residents. This was evident for 6 out of 6 concerns sent to the facility from the resident council. The findings include: On 3/25/2026 at 2:04 PM, the surveyor observed a resident council meeting in the main dining hall area. The meeting was initially scheduled for 2 PM; however, the Activities Aide who facilitates the meeting needed to change the time from 2 PM to 4 PM. Residents had been notified by word of mouth from facility staff that it was going to be at 4 PM. The surveyor spoke with the Resident Council President (Resident #9), who stated that they prefer their meeting earlier in the day, like around 11 AM, before lunch. Resident #9 did not know the reason that the meeting had been changed to 4. After the surveyor was finishing up speaking with the Resident #9, the Activities Aide (AA, Staff # 28) came into the room and stated they had changed the meeting time back to 2 PM, and residents were being told of the change for those who wanted to attend.-As the meeting began, the AA (Staff #28) started with an introduction of the President (Resident #9) and then began to conduct the meeting, dividing the concerns into departmental sections. The administrative department was addressed with an introduction to the new Administrator (NHA, Staff #1), who had started at the facility the month prior. Many of the residents did not know who the NHA was and made a statement about the fact that he had not introduced himself to them individually. The NHA commented briefly and stated that he would be getting around to speaking with each individual real soon.-The next department was nursing. Residents stated that staff were always on their phones and even wore their earbuds while doing resident care. Some residents thought that this was a violation of their HIPAA rights. And that some nights are full of noise from the staff talking loudly or listening to music loudly while the residents are trying to sleep. Residents commented that the Housekeeping Department fails to clean the resident room floors unless requested.-The residents would also like for the Maintenance department to be available on the weekends for when something needs fixing, and they don't have to wait until Monday. -Finally, there were concerns about communication within the facility. The residents stated that they would like better communication from the facility on what is being done about their previous concerns.On 3/26/2026 at 12:31 PM, the surveyor interviewed with the Nursing Home Administrator (Staff #1) and the social worker (SW, Staff #11), and asked what the process of resident grievances was after receiving the minutes from the activities aide. SW #11 explained that when she receives the minutes, she writes up any grievances to be addressed. She would speak with the resident involved and reconcile the issues, if possible. And then it is documented on the grievance. When asked how recommendations are addressed, she was unsure. The NHA #1 stated that the responses should be readdressed at the next meeting. The surveyor requested copies of the resident council meeting minutes for the past 2 months.On 3/26/26 at 2 PM, the surveyor met with the NHA #1 and the Activities Aide (AA, Staff #28), who facilitates the resident council meeting. When asked what do you do with the meeting minutes once you type them up? The AA #28 stated that she gives them to SW #11. When asked if the prior month's minutes were discussed at each resident council meeting or how they were resolved, the AA #28 stated no, we don't do that. The NHA was asked how they will be addressing the nighttime interruptions from staff. The NHA was unsure at this time. The surveyor then asked if the residents could have condiments placed in the kitchenette or somewhere that staff could get to them quickly. The NHA #1 stated that this is something that they could look into for the residents and staff.On 3/27/26 at 10 AM, review of the Resident Council meeting minutes for January 28, 2026, revealed that the residents would like 1) a suggestion box placed in an accessible area, 2) nighttime interruptions were affecting their sleep and that something needed to be done about it, and a 3) request for condiments to be more readily available during meals are examples of some of their concerns. Review of February 26th, 2026, resident council meeting minutes revealed that the residents would like 4) to speak with the dietary manager, 5) about the food being served cold, and they would like 6) snacks throughout the day. The meeting minutes did not include revisiting any past concerns or how they were addressed.On 3/27/26 at 1:30 PM, the surveyor revisited the president of the resident council for another interview. When asked if the AA# 28 goes over the minutes from the previous meeting, the president, Resident #9, stated no. When asked, does the facility notify them of the responses or changes made from the resident council meeting minutes, Resident #9 stated, No. They never receive any responses back ever.On 3/27/26 at 1:45 PM, the surveyor interviewed an activities aide (AA #29) working in the main dining area with the residents and asked whether she knew where the suggestion box was for the resident to place their recommendations. The AA# 29 said yes and walked over to the small kitchenette, opened the top left cabinet door, and pulled down a small rectangular box. No writing was on the box to identify it as the suggestion box. When she opened the box, there were several pieces of paper inside with writing on them. When asked how the residents know where the suggestion box is, if it's not visible to them. AA# 29 stated that she was still learning about the facility and that she had recently started working there.

Based on record reviews and staff interviews, it was determined that the facility failed to indicate the facility's per diem rate for services no longer covered under Medicare/Medicaid as well as the reason why Medicare/Medicare is no longer covering those services on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (CMS-10055) form. This was evident for 3 (#3, #5, #64) of 3 residents reviewed during the annual recertification survey for beneficiary notification.The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (CMS-10055) form is a required document used by Medicare-certified skilled nursing facilities to notify Medicare beneficiaries that their Part A services may not be covered because they are not considered medically reasonable/necessary or are deemed custodial. The notice provides an estimate of costs for the services and the reasons why Medicare is not expected to pay.The findings include:On 03/27/26 at 1:18 PM, the surveyor reviewed the CMS-10055 forms provided by the facility for Residents #3, #5, and #64. Review of the CMS-10055 forms for these residents revealed that the facility did not indicate, on the CMS-10055 form, the facility's per diem rate for services no longer covered under Medicare/Medicaid as well as the reason why Medicare/Medicare is no longer covering those services.On 03/27/26 at 1:48 PM, the Social Services Director (Staff #11) was interviewed. During the interview, the surveyor informed Staff #11 that the CMS-10055 forms for residents #3, #5, and #64 did not indicate the facility's per diem rate for services no longer covered under Medicare/Medicaid as well as the reason why Medicare/Medicare is no longer covering those services. Staff #11 mentioned that she was told it was optional to list that information on the CMS-10025. The surveyor asked Staff #11 how the residents are informed about the facility's per diem rate for services no longer covered under Medicare/Medicaid. Staff #11 mentioned that the Business Office Manager Staff #25 verbally informs the residents about the facility's per diem rate for services no longer covered under Medicare/Medicaid. On 03/30/26 at 8:55 AM, the surveyor informed the Nursing Home Administrator Staff #1 that the CMS-10055 forms for residents #3, #5, and #64 did not indicate the facility's per diem rate for services no longer covered under Medicare/Medicaid as well as the reason why Medicare/Medicare is no longer covering those services. Staff #1 indicated that he would check into the surveyor's concerns.

Based on the investigation of the facility reported incident, review of medical records and interview with facility staff, it was determined that the facility failed to follow the specified number of staff support needed when providing care for residents. This resulted in the resident falling out of the bed and suffering a left acute frontal subdural hematoma, which required surgery. This was evident for 1 (Resident #264) out of 9 residents reviewed for accidents during the Medicare/Medicaid recertification survey. The findings include: The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment. The Minimum Data Set (MDS) is administered to all residents upon admission, quarterly, yearly, and whenever a significant change in an individual's condition occurs. It is a standardized assessment tool to comprehensively evaluate a resident's health status, functional abilities, and needs. It is the foundation for creating a personalized care plan that drives care rendered by the healthcare team within a nursing facility. On 1/09/24 at 09:00 AM, a review of the facility self-reported incident, MD00210423, revealed that Resident #264 had a fall when Geriatric Nursing Assistant (GNA #10) provided morning care on 9/28/24 around 5AM. The report indicated that the fall incident resulted in Resident #264 having an intracranial hemorrhage (also known as brain bleed, is bleeding within the skull or in the brain tissue. It's a life-threatening condition that requires immediate medical attention). Further review of the facility's investigation revealed that: - The facility obtained GNA #10's statement on 09/28/2024. The statement stated that on 9/28/24 around 5 AM GNA #10 admitted to leaving the bed high at her own waist level when she went to perform Activity of Daily Living care(ADL) on Resident #264 and ran out to the bathroom to wet and warm the towel. When she was in the bathroom, GNA #10 heard thud, she came back out and saw Resident #264 was on the floor and she called the nurse. GNA #10 also stated that before she went to the bathroom, the resident was squirming in bed but was able to calm him/her down. - Registered Nurse (RN #11) who was called by GNA #10 for the incident assessed the resident and wrote a progress note on 09/28/2024 at 05:30 AM which stated that assigned GNA reported to nurse that while she was in the room getting ready to provide care to Resident #264 when she heard a loud noise and observed Resident #264 on the floor. On assessment, the resident was noted face down on the floor mat beside his/her bed with a large bleeding. Hematoma noted on the left forehead and the nurse got an order to transfer the resident to the hospital. On 09/28/2024 at 11:36 AM, a note signed by License Practical Nurse (LPN #7) showed that [hospital 1] was contacted for an update on Resident #264's status. The resident was transferred from [hospital 1] to [hospital 2] emergency room and admitted to [hospital 2] Surgical Center at 11 am. No other updates at this time. Per statement by the DON on 09/30/2024, GNA #10's appointment was terminated, and she was reported to the board of nursing. On the initial self-incident report dated 10/01/24 at 1:30 PM, it was documented that [hospital 2] informed the facility that Resident #264 had an Intracranial Hemorrhage. On 1/09/25 at 10:20 AM, the surveyor reviewed Resident #264's medical record. The review revealed that the resident was admitted to the facility in August 2024 with a past medical history that included but was not limited to unspecified dementia with behavioral disturbance, other epilepsy, and seizure disorder. The residents' brief interview for mental status (BIMS) score was 10 out of 15 on 08/07/2024. The Minimum Data Set (MDS) assessment on 08/04/2024 revealed that the resident was dependent on activities of daily living (ADL). Also, a care plan initiated on 08/03/2024 indicated that the resident must have 2 persons assist at all times. On 01/10/2025 at 9:47 AM, an interview was conducted with GNA #16, to inquire how ADL care was performed for residents and how she knew the number of required staff for the residents. She stated that usually when they had a new admission, the resident was first assessed by the rehabilitation team before the GNAs provided any care. She added that the rehabilitation team told them the type of assistance the resident would need, and they took over from there. When she was also asked how she set the beds for the residents during ADL care, she stated that she raised the bed to her waist level. When she was asked how she ensured resident's safety while doing ADL care, she stated that she turned the patients towards her if it was a one person assist or towards another GNA if it was a two-person assistance to prevent rolling onto the floor. On 01/10/25 at 09:58 AM, in an Interview with GNA #17, when she was asked how ADL care was provided for residents, she stated that she washed the residents, cleaned their mouths and got them dressed up. When she was asked how she knew the number of required staff for the residents, she stated that it was attached to the wall on the top of the resident's bed. When she was also asked how she set the beds for the residents' ADL care, she stated that she raised the beds to a comfortable level for her. When she was asked how she ensured residents safety while doing ADL care, she stated that she turned the patients towards her if it was a one-person assist and called another GNA if it was a two-person assistance. She also added that she kept the bed low if she needed to step away from the resident. On 01/10/2025 at 11:05 AM during a tour to B wing of Unit 1 with RN #19, When she was asked how staff would know the type of assistance the resident needed, she stated that it was in the resident's electronic record and that she gave them orientation and reminded them at the beginning of the shifts of the type of assistance the residents needed. On 01/10/2025 at 11:14 AM In an interview with Certified Occupational Therapist Assistant (COTA), staff #18, when she was asked how staff members know the type of assistance a resident needed, she stated that upon admission, the Physical Therapist/Occupational Therapist assessed the residents and communicated the assistance with the PTA/COTA. Then the PT/OT developed a care plan stating the type of assistance and communicated it with the nursing staff. On 01/10/25 at 11:30 AM, in an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), when they were asked how many people were in-serviced after the incident, the DON stated that all licensed nurses and GNA's were in serviced, she added that those who were not around in person were giving the education via the phone. She added that the new hires were educated to know that the Physical Therapist/Occupational Therapist needed to see the residents before they took care of the residents. The administrator was asked to provide a copy of the list of nursing employees during that incident. Additionally, on 1/10/25 around 3 PM, a review of the facility's investigation packet revealed that nursing staff, including 19 GNAs and 17 licensed nurses, received education on 10/01/2024 about resident safety and transfer mobility. However, reviewing the entire nursing staff list revealed that 4 staff (GNA #21, #23, #24,, and Assistant Director of Nursing #1) were not listed on their in-service training records. On 1/13/25 at 7:59 AM, in an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), when the DON was asked how staff members identify the assistance each resident needed, she stated that the assistance level was indicated in the task in the electronic health record, and that GNAs received reports from the nurses concerning the type of assistance needed by each resident. The NHA added that they stopped posting signs due to HIPPA. The NHA also stated that GNAs could verify care via GNA task in the electronic health record & during shift handover. The surveyors requested a document to support that all GNAs had the same procedure of taking reports from the licensed nurses regarding the required resident assistance levels, but none was provided. On 1/13/25 at 7:50 AM, the Nursing Home Administrator(NHA) and the Director of Nursing (DON) were also informed that the in-service education done did not match the list of nurses employed during that time which included the Assistant Director of Nursing as well. The survey team informed DON and NHA that since the training was not completed and the nursing staff were not aware of the same procedure of taking report from the licensed nurses regarding the required resident assistance levels, this was considered as active harm. On the same day at 08:20 AM, the facility was also asked for a copy of documentation of what the facility did to prevent a similar incident in the future. On 01/14/2025 at 08:30 AM, the NHA submitted copies of interviews with the residents on 10/18/2024 regarding their transfers (the questions included, how do the staff transfer you? Is this the usual way that they transfer you? Do you feel safe?). However, it did not address care received by the residents with accurate numbers of assistance. On the same day at 11:53 AM, the surveyor informed NHA about the findings.

Based on observation, interview and medical record review, it was determined that the facility failed to administer medication according to professional standards of nursing, monitor the administration of medication to residents and crush medications according to standards of nursing practice. This was evident during the observation of staff putting medication in resident food and not monitoring when the resident gets the medication, who gives the medication and how much of the medication the resident receives and if the appropriate staff administered the medication. Resident #11's ten medications were left unattended on his/her tray and Resident #13's five medications were left unattended. Both medications were administered by a geriatric nursing assistant (GNA) and incorrectly crushed. This was found during the observation of medication pass for 2 of 2 residents observed (Residents #11 and #13). The observations of the medication pass with LPN #4, interviews with staff and their failure to verbalize and identify the safe and proper way to ensure medications were administered to residents by the correct licensed staff resulted in an Immediate Jeopardy (IJ) identified by the survey team and the Office of Health Care Quality (OHCQ) on 2/12/2020 at 3:20 PM. The facility submitted an initial plan to remove the immediacy on 2/12/2020 at 6:28 PM and again at 7:31 PM that was not accepted. The facility submitted another plan to remove the immediacy on 2/12/2020 at 8:05 PM that was accepted. The implementation of the facility plan of removal was confirmed by the survey team on 2/14/2020 at 2:28 PM and the IJ was removed. After removal of the immediacy, the deficient practice remained at a scope and severity of D. The findings include: Review of the medical record of Resident #11 on 2/21/2020 at 9:00 AM revealed [DIAGNOSES REDACTED]. Resident #11's last Brief Interview for Mental Status (BIMS) in November of 2019 revealed a score of '00 indicating severe cognitive impairment. BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively. Review of Resident #13's medical record on 2/12/2020 at 9:00 AM revealed [DIAGNOSES REDACTED]. Resident #13's last BIMS in December of 2019, revealed a score of 6 indicating severe impairment. During observation of medication pass on 2/12/2020 at 7:48 AM, LPN #4 was observed preparing medication for Resident #11. LPN #4 pulled the medication from the medication cart and reviewed the medication with the surveyor. According to the physician orders, the resident was scheduled for 10 medications, including, [MEDICATION NAME] ordered as delayed release (for depression). Delayed release tablets are [MEDICATION NAME]-coated to delay release so that the medications do not immediately disintegrate and release the active ingredient(s) into the body. Crushing the medication destroys the medications' functional purpose. LPN #4 stated that she was crushing all the resident's medication and that a certain GNA would give the medication with Resident #11's breakfast as the resident would not take the medication from her. She was asked for a do not crush list and for any medications that should not be crushed. Although a do not crush list was not on the medication cart, she stated what medications should not be crushed. LPN #4 placed the [MEDICATION NAME] into a bag to crush the medication and into the pill crusher. Surveyor asked LPN #4 at 7:53 AM to look at the order again and she realized and stated that the medication was delayed release and that I've been giving it like this (crushed) the entire time. LPN #4 proceeded to take the other medications that were crushed for Resident #11 and the [MEDICATION NAME] pill to Resident #11's breakfast tray that was on top of the tray cart at the top of the hall by the dining hall. The tray was identified by Resident #11's meal ticket. According to LPN #4 she put the medication into Resident #11's food, she was then observed going back down the hall to her medication cart. Surveyor clarified with LPN #4 where the medications for Resident #11 were and she stated that she put the [MEDICATION NAME] pill in Resident #11's food along with the other pills that were crushed and when the GNA gets to it she will feed him/her. During the continued observation surveyor observed LPN #4 come up to another tray cart at 8:10 AM, open the lid to a cup and sprinkle medications that were crushed. The meal ticket identified the meal tray was for Resident #13. The tray cart carrying the meal tray for Resident #13 was then wheeled down the hall by GNA staff. Neither tray for Resident #11 nor Resident #13 remained in contact with nursing staff after the medication was placed into the residents' food. A review of the medical record for Resident #13 at 8:15 AM on 2/12/2020 revealed that per the physician orders, medications could be crushed; however, there was an order for [REDACTED]. LPN #4 was interviewed at 8:34 AM and was asked if Resident #11 and #13 received all their medications and she said, yes. The tray of Resident #11 was observed at 8:35 AM on 2/12/2020 and noted to be empty of all food and drink. Surveyor went to Resident #13's room and noted that the cup that had medication sprinkled in it was empty. GNA #7 was interviewed at 8:37 AM on 2/12/2020 and stated that she took the tray down to Resident #13's room and noted that he/she was anxious so made sure that she gave him/her the milk that contained all the medication that was put in there by LPN #4. A review of the Medication Administration Record [REDACTED]. LPN #4 was interviewed at 10:08 AM and stated that she gave all the medications scheduled for Resident #13 but was pulled by the Administrator to give out trays so was not able to sign off the medications for a few residents. According to Resident #13's MAR, [MEDICATION NAME] was scheduled for 9:00 AM. The Acting Director of Nursing (ADON) was interviewed on 2/12/2020 at 1:22 PM and stated that GNA's are not to give medications to residents. Review of the facility medication administration policy dated 2016 and reviewed on 2/12/2020, also demonstrated that the facility staff failed to follow the procedures outlined in their policy. The policy stated that staff are to follow the 8 rights of medication administration and follow the physician order. Furthermore, medications can only be administered by licensed staff and medications are to be prepared, recorded and administered by the same licensed staff. All the concerns identified were reviewed with the Administrator,Director of Nursing (DON) and ADON throughout the survey process and again during exit from the facility. Failures to administer medications appropriately places residents at risk for sub or super therapeutic doses of medication. Leaving medications on meal trays also places residents at risk for receiving incorrect medications. Immediate action was needed to ensure medications are administered according to professional standards of practice, medications are monitored during the time of administration, medications are directly administered by licensed staff, and that appropriate medications are crushed when necessary. As a result of these findings, an Immediate Jeopardy situation was identified on 2/12/2020 at 3:20 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 2/12/2020 at 6:28 PM and again at 7:31 PM that was not accepted. The facility submitted another plan to remove the immediacy at 8:05 PM on 2/12/2020 that was accepted by the survey team and OHCQ. The implementation of the facility plan of removal was confirmed by the survey team on 2/14/2020 at 2:28 PM and the IJ was removed. The facility removal plan included the following: They determined that the facility failed to administer medications according to professional standards of nursing, monitor administration of medication to residents and crushed medications according to standards of nursing practice. Steps put in place included: The facility policy on medication administration was reviewed by the ADON and Administrator on 2/12/2020. No changes made to the policy at that time. LPN #4 was immediately educated on medications administration by the Regional Clinical Director on the facility policy as it relates to: Medication administration 8 Rights of medication pass Ensuring medications are being administered following physician orders Crush/no crush guidelines The facility also reviewed with LPN #4 the scope and practice and understanding that only the nurse assigned to the resident will administer the medications unless the resident has been previously assessed safe to self-administer medications by the facility interdisciplinary team (IDT). Additional licensed nurses were questioned on the facility policy and were deemed to be [MEDICATION NAME] the proper policy and procedure for medication administration. The facility ensured that the pharmacy crush/no crush medication list as well as the 8 rights of the medication administration are placed on the medication carts and in the medication rooms. Licensed nursing staff will be in-serviced regarding mediation policy and procedures as it relates to medication administration, crushable mediation, Scope and practice, using the education method LPN #4 has been received by the ADON/designee. Licensed nursing staff who have not received the in-services mentioned will be removed from the schedule. The ADON/designee will conduct medication administration observation audits on four medication passes with forty medications on 2/13/2020 with licensed nurses and then five weekly audits on mediation passes alternating shifts for three months. The DON/designee will present the results of the audits at an Ad-hoc Quality Assurance/QAPI meeting on 2/13/2020 and will continue to review results of these audits at the monthly committee meetings for a period of three months or until the committee determines compliance resolution. The survey team confirmed the facility completed in-service education on all staff and observed the ADON/designee completing audits on medication passes on 2/13/2020 prior to removing the Immediate Jeopardy. Cross Reference F759

Based on medical and administrative record review and staff interview it was determined the facility failed to:1a) provide ongoing supervision of Resident #5 who had a history of [REDACTED].#1) was free of abuse by Resident #5 who engaged in inappropriate touching of Resident #1; 1c) ensure a cognitively impaired resident (Resident #6) was free of abuse by Resident #5 who was found fondling Resident #6 in his/her room; 2) thoroughly investigate incidents of sexually inappropriate behavior by Resident #5 to prevent future occurrences of the behavior; and 3) to protect a cognitively impaired resident (Resident #3) from abuse by GNA (Geriatric Nursing Assistant) #4. This was evident for 3 of 4 residents reviewed for abuse during this complaint survey. The facility's failure to provide adequate supervision for Resident #5 and promptly investigate and initiate corrective actions for repeated expressions of sexually inappropriate behavior by Resident #5, posed an immediate threat to the health and safety of other vulnerable residents. Therefore, an immediate jeopardy situation was identified on (MONTH) 28, 2019 at 1:49 PM. The facility submitted an acceptable plan of action at 7:22 PM on (MONTH) 28, 2019 that was reviewed and accepted by the surveyor and the Office of Health Care Quality. The immediate jeopardy was removed on (MONTH) 1, 2019 at 5:30 PM while the surveyor was on-site. After removal of the immediate jeopardy, the deficient practice remained for potential for more than minimal harm and at a scope and severity of D. The findings include: Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1a) The facility failed to provide adequate supervision to Resident #5 to ensure Residents #1 and #6 were free from abuse by Resident #5. Medical record review on 6/26/19, revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A Physician's Certification Related to Substitute Decision Making form dated 7/31/18 indicated the resident was unable to make medical and financial decisions due to having [MEDICAL CONDITION] Disorder. Decision Making Capacity and Treatment Limitations forms dated 6/21/11 and 6/20/18 also indicated the resident was not capable of making and communicating decisions regarding medical care. Due to the resident's cognitive impairment a Guardian of Person and property was appointed in (YEAR). Review of facility reported incident #MD 477 revealed that on 12/6/18 Residents #5 was found in Resident #6's room, with the door closed, and was observed by staff rubbing Resident #6's buttocks. Facility staff reported in incident #MD 813 that on 6/18/19 Resident #5 had inappropriate contact with Resident #1 in the dining room at approximately 9:00 AM. The report indicated Resident #5 was on top of Resident #1 in the dining room attempting to remove Resident #1's pants. Review of the quarterly MDS assessment dated [DATE] revealed facility staff entered a BIMS score for Resident #5 of 6 out of 15, indicating moderate cognitive impairement. Medical record review on 6/26/19, revealed a care plan for Resident #5, with an initiation date of 12/31/18 and a review date of 4/25/19, that addressed the resident's fondness for females/males. Interventions included but were not limited to maintain a calm approach to the resident if s/he is found in a female/male resident's room and redirect, obtain a psychiatric evaluation, and move the resident to a calm environment when s/he becomes physically aggressive. The interventions were initiated on 12/31/18 with no indication that staff reviewed and updated the interventions after incidents subsequent to the initiation or review date. A care plan initiated on 4/22/19 addressed Resident #5's physically and verbally abusive behaviors and impulsiveness. Interventions included but were not limited to assess whether the behavior endangers the resident and others, divert the resident's behavior by providing activities, maintain a calm environment, seat resident where constant/near constant observation is possible. A Progress note dated 6/7/19 at 12:15 PM written by RN #1 noted the resident had a fondness of male/female residents, approaches with impulsiveness and aggressiveness. RN #1 documented the resident had an episode of holding a male/female resident from behind and the residents were separated. RN #1 noted Resident #5 stated I like him/her. It was further noted that staff would continue to redirect the resident every shift. RN #1 took a telephone order dated 6/7/19 from the resident's physician directing staff to obtain a psychiatric consult to address the resident's fondness for female/male residents and impulsive behavior. A physician's note dated 6/11/19 reported the resident had behavior issues with inappropriate behavior towards females/males and was referred for a psychiatric evaluation. The physician also noted that the resident was receiving 3 psychiatric medications and [MEDICATION NAME] (mood stabilizer) was increased. The psychiatric Nurse Practitioner wrote an order on 6/11/19 to discontinue [MEDICATION NAME] 50 milligrams three times a day and start 75 milligrams three times a day. On 6/13/19 the physician wrote an order to transfer the resident to the hospital for evaluation of a change in mental status. An observation note written on 6/13/19 at 4:43 PM by RN #2 reported the resident was transferred to the hospital for a change in mental status. Further medical record review failed to reveal details about the resident's condition. A hospital physician's progress note, dated 6/13/19 at 6:16 PM, reported Resident #5 was sent to the emergency room because s/he was acting out sexually towards residents and staff. It is further noted that nursing home staff were requesting new placement for the resident. The resident returned to the facility with no recommendations. In a progress note dated 6/18/18 at 1:14 PM, the Director of Nursing reported Resident #5 had inappropriate contact with Resident #1. It was noted that Resident #5 was fully clothed when s/he was found with Resident #1. The residents were separated and Resident #5 was placed on one-to-one observation. Further review of the medical record revealed a psychiatric progress note dated 6/18/19 at which time the psychiatric nurse practitioner recommended that staff discontinue [MEDICATION NAME] (antipsychotic), start [MEDICATION NAME] (antipsychotic) and Klonopin (anti-anxiety) and decrease [MEDICATION NAME] (antidepressant). The Social Services designee documented on 6/19/19 at 9:02 AM that s/he was made aware by a kitchen staff member that Resident #5 was lying on top of Resident #1 trying to pull Resident #1's pants down (on 6/18/19). The resident verbalized that s/he raped Resident #1 and did not know why s/he did it. It was further noted that Residents #1 and #5 were placed on one-to-one monitoring. The medical record contained a telephone order dated 6/24/19 at 3:30 PM that directed staff to send Resident #5 to the hospital for evaluation of inappropriate sexual behavior and endangering self and others. During an interview with the Director of Nursing (DON), on 6/27/19 at 7:58 AM, the surveyor inquired about the reason the care plan regarding Resident #5's fondness for female/male residents was initiated. The DON stated Resident #5 had a female/male friend, identified as Resident #6, in the facility and they spent time together. The DON stated it was necessary to supervise the time they spent together in common areas. During an interview with the surveyor on, 6/27/19 at 7:58 AM, the Director of Nursing (DON) was asked about the incident s/he documented in the medical record on 6/7/19 that noted Resident #5 grabbed a female/male from behind. The DON stated this incident involved a staff member, not a resident but was unable to identify the staff member. The DON stated that s/he discussed this incident with the psychiatric Nurse Practitioner. The DON stated the resident had a history of [REDACTED]. Regarding the change in condition that prompted a transfer to the hospital for an evaluation on 6/13/19 the DON stated Resident #5 was pacing more as though s/he was looking for something and making sexual comments to female/male staff and residents. The surveyor asked the DON about the sequence of events that occurred on 6/18/19 and s/he stated Dietary Aide #1 reported to the nurse (unsure which nurse) that Resident #1 screamed, and staff rushed in to address the incident. During an interview with the surveyor, on 6/27/19 at 9:40 AM, the Administrator stated s/he had no knowledge of an incident of inappropriate touching by Resident #5 on 6/7/19 and has not received reports of other incidents. The Administrator reported the resident is currently hospitalized and will return to the facility when s/he is stable. The Administrator stated Resident #5 remained on one-to-one observation after the incident on 6/18/19 until his/her transfer to the hospital on [DATE]. In interview with the surveyor on 7/1/19 at 11:19 AM Activities Assistant # 1 (AA #1) stated the supervisor asked him/her to watch Resident #5 because an incident occurred. AA #1 stated he watched the resident from 11:00 AM- 4:00 PM on 6/18/19. AA #1 confirmed during this interview that s/he was referencing the abuse of Resident #1 by Resident #5. During an interview with the surveyor on 7/2/19 at 12:19 PM Resident #5's attending physician stated Resident #5 periodically makes advances towards females. The physician stated the resident had been evaluated by behavioral health services and adjustments have been made to Resident #5's medications. The physician noted Resident #5's sexually inappropriate behavior began to escalate, and s/he was sent to the hospital for an evaluation on 6/13/19 but was sent back to the facility without recommendations. After the 6/18/19 incident the resident was placed on one-to-one observation until s/he was transferred to another hospital for evaluation. Medical record review and staff interview revealed staff failed to make prompt adjustments to Resident #5's care plans that addressed aggressive and sexually inappropriate behaviors to include adjusting the level of supervision, despite ongoing expressions of sexually inappropriate behavior. During interviews with the surveyor the Administrator, Director of Nursing and physician stated the resident was placed on one-to-one observation after the incident that occurred on 6/18/19 but did not present physician's orders [REDACTED].#5. 1b) The facility failed to ensure that a cognitively impaired resident (Resident #1) was free from abuse by Resident #5. Medical record review, on 6/26/19, revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the facility coded the resident as severely cognitively impaired. A Progress note dated 6/7/19 at 12:15 PM written by the Director of Nursing (DON) noted Resident #5 had a fondness of male/female residents, approaches with impulsiveness and aggressiveness. The DON documented the resident had an episode of holding a male/female resident from behind and the residents were separated. RN #1 noted Resident #5 stated I like him/her. It was further noted that staff would continue to redirect the resident every shift. Review of a complaint #MD 712, on 6/26/19, revealed an allegation that on 6/18/19 Resident #1 was assaulted in the dining room and a concern that Resident #1 did not receive a physical examination. Facility report, #MD 813 noted that on 6/18/19 Resident #5 was observed lying on top of Resident #1 in the dining room attempting to take Resident #1's pants off. The report noted the nurse practitioner was in the building and staff planned to send Resident #5 out for a psychiatric evaluation. A progress note dated 6/18/19 at 2:16 PM written by the Director of Nursing (DON) reported that at 9:00 AM dietary staff reported Resident #1 had inappropriate contact with another resident. The DON documented that s/he and the assigned nurse assessed the resident and there were no injuries. In a written statement, dated 6/18/19, Dietary Aide #1 noted s/he went into the dining room to clean up and noted Resident #1 on the floor with Resident #5 on top of him/her. Dietary Aide #1 reported that when s/he got closer s/he observed Resident #1 crying and Resident #5 was trying to remove Resident #1's pants. The dietary aide noted s/he called for help and intervened to separate the residents. The surveyor observed Resident #1 on 6/26/19 at 2:10 PM in the hallway at an exit repeatedly trying to open the door. The resident was whispering and then began pacing. During an interview with the surveyor, on 6/27/19 at 7:58 AM, the Director of Nursing, stated residents had just finished breakfast and staff were taking residents back to their rooms. S/he stated Residents #1 and #5 were in the hallway shortly before the dietary aide reported Resident #5 was discovered on top of Resident #1. The DON noted the dietary aide reported Resident #5 was trying to pull Resident #1's pants down. S/he stated that when s/he entered the dining room both residents were fully clothed. The DON stated s/he noted Resident #1 was shaky and was hugging herself/himself. The DON reported s/he and the assigned nurse took the resident to her/his room, asked what happened and removed Resident #1's clothes to ensure s/he had no injuries. The DON stated that the facility concluded there was no actual sexual contact and therefore no need to send the resident to the hospital for an evaluation. During an interview with the surveyor on 6/27/19 at 10:14 AM the Nurse Practitioner (NP) stated she was not in the facility on the date the incident occurred. The NP stated s/he did not examine the resident after the incident occurred. The NP stated s/he was told the residents were in a vertical position and had their clothes on, therefore no need for further examination. In interview with the surveyor on 6/27/19 at 1:35 PM, LPN #1 reported that on 6/18/19 staff from another unit called for him/her to go to the cafeteria. LPN #1 reported Resident #1's pants were partially down but Resident #5 was fully clothed. Upon redirecting Resident #5 back to his/her room s/he stated, I was trying to rape him/her. In interview with the surveyor, on 6/27/19 at 1:38 PM, GNA #2 stated that approximately one month ago s/he was providing care to Resident #5's roommate when s/he heard a commotion in the hallway. GNA #2 reported that upon investigation s/he observed Resident #5 on the floor attempting to hold Resident #1. GNA #2 stated that Resident #1 was attempting to get up and Resident #5 tried to pull her/him back down. GNA #2 stated Resident #5 said I love her/him. GNA #2 stated s/he reported this incident to the Director of Nursing and was asked to write a statement. This statement was not presented to the surveyor during the survey. During an interview with the surveyor, on 6/27/19 at 7:58 AM, the Director of Nursing was asked about the incident s/he documented in the medical record on 6/7/19 that noted Resident #5 grabbed a female/male from behind. The DON stated this incident involved a staff member, not a resident but was unable to identify the staff member. During an interview with the surveyor on 6/27/19 at 9:40 AM the Administrator stated he had no knowledge of an incident of inappropriate touching by Resident #5 on 6/7/19 and had not received reports of other incidents. The Administrator reported the Resident #5 is currently hospitalized and will return to the facility when s/he is stable. During an interview with the surveyor, on 6/27/19 at 10:02 AM, Dietary Aide #1 confirmed what was written in her/his statement dated 6/18/19. S/he stated the Resident #1 was screaming but probably not loud enough to alert other staff. The dietary aide stated there were no other staff present when s/he initially discovered Resident #1 and Resident #5 on the floor. In interview with the surveyor on 7/1/19 at 11:06 AM, GNA #5 stated s/he was assigned to and provided care for Resident #5 on Station 2 on 6/18/19. GNA #5 stated s/he then went to Station 1 to assist with care of other residents. GNA #5 stated another staff member told her/him that Resident #5 went to Station 1 and he did something to Resident #1 after which s/he was escorted back to Station 2. GNA #5 stated that it was after this incident that s/he was told to stay with Resident #5 at all times. GNA #5 also noted s/he was not a full-time staff member and was not aware of other incidents of Resident #5's inappropriate behavior towards females. During an interview with the surveyor, on 6/28/19 at 9:55 AM, RN #2 stated Resident #1 was the resident referenced in the incident that occurred on 6/7/19. RN #2 stated that although Resident #5 touched other female/male residents inappropriately s/he was fixated on Resident #1. RN #2 stated Resident #5 told her/him that Resident #5 admitted s/he could not control his/her impulses towards Resident #1. RN #2 stated that even with supervision it was difficult to stop Resident #5 from pursuing Resident #1. The surveyor noted that 1 GNA and 1 Nurse were usually assigned to the unit and that was the case on 6/18/19. The surveyor inquired if Station 2, RN #2's assigned unit, received help from the other unit to ensure there was adequate monitoring of Resident #5. RN #2 stated they did not receive additional assistance. The facility failed to provide adequate supervision for Resident #5 after s/he demonstrated sexually inappropriate behavior/intent towards Resident #1 which resulted in continued sexual aggression towards Resident #1 creating the potential for psychosocial harm for Resident #1 and other cognitively impaired residents who were unable to give consent for sexual activities. 1c) The facility failed to ensure that a cognitively impaired resident (Resident #6) was free from abuse by Resident #5. Medical record review, on 6/26/19, revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed facility staff entered a BIMS score of 5 out of 15, indicating severe cognitive impairement. Review of facility reported incident #MD 477 revealed that on 12/6/18 Resident #5 was found in Resident #6's room, with the door closed, and was observed by staff rubbing Resident #6's buttocks. The medical record contained a care plan with an initiation date of 7/20/18 that addressed impaired daily decision making related to [MEDICAL CONDITION]. Interventions included but were not limited to praising the resident for making appropriate decisions, structure/limit the resident's choices and encourage small groups like one-to-one. A Progress note dated 12/6/18 at 4:46 PM written by LPN #2 reported Resident #6 wandered to another unit and was found in Resident #6's room hugging and feeling on him/her. Resident # 5 was rubbing Resident #6's buttocks. The residents were separated, and Resident #6 was taken back to her/his room. A care plan with an initiation date of 12/31/18 addressed Resident #6's fond feelings for a male/female resident and the desire to spend time with that resident. Interventions included removing the resident from the female/male residents' room and from her/his room, common area visitation only, and obtain a psychiatric consult and psychosocial therapy. During an interview with the Director of Nursing (DON), on 6/27/19 at 7:58 AM, the surveyor inquired about the reason the care plan regarding Resident #5's fondness for female/male residents was initiated. The DON stated Resident #5 had a female/male friend, identified as Resident #6, in the facility and they spent time together. The DON stated it was necessary to supervise the time they spent together in common areas. 2) The facility failed to conduct a thorough investigation of incidents of inappropriate sexual expressions by Resident #5 towards Residents #1 and #6 Review of facility reported incident #MD 477 revealed that on 12/6/18 Residents #5 was found in Resident #6's room, with the door closed, and was observed by staff rubbing Resident #6's buttocks. The investigation did not reflect interviews with staff and residents to determine if other residents were affected. Review of Resident #5's and #6's medical records failed to reveal evidence that care plans were promptly reviewed and revised to ensure both residents were adequately supervised. Medical record review on 6/26/19, revealed a care plan for Resident #5, with an initiation date of 12/31/18 and a review date of 4/25/19, that addressed the resident's fondness for females/males. The interventions were initiated on 12/31/18, twenty-five days after the incident that occurred on 12/6/18. A care plan with an initiation date of 12/31/18 addressed Resident #6's fond feelings for a male/female resident and the desire to spend time with that resident. This care plan was initiated twenty-five days after the incident that occurred on 12/6/18. Review of facility reported incident #MD 813 on 6/26/19, revealed an allegation that on 6/18/19 Resident #5 was observed lying on top of Resident #1 in the dining room attempting to remove his/her pants. Review of the facility's investigation of this incident on 6/26/19 revealed the investigation packet consisted of a statement from Dietary Staff #1, a blank incident form, the responding police officers contact information and the self-report. There was no evidence that other employees or staff were interviewed. There was no information that the facility investigated possible contributing factors such as inadequate staffing and no education was provided following this incident or previous incidents. Review of the medical record failed to reveal ongoing documentation of the resident's inappropriate sexual expressions, investigations of the incidents and implementation of interventions to maintain the safety of vulnerable residents placing them and future residents at risk for harm. Because of these findings, an immediate jeopardy situation was identified on (MONTH) 28, 2019 at 1:49 PM. The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 3:57 PM. This initial plan was not accepted. Revised plans were submitted at 5:43 PM and 6:46 PM which were not accepted. The facility submitted a revised plan of action at 7:06 PM that was reviewed by the survey team and the Office of Health Care Quality. The plan was accepted but the immediate jeopardy was not removed until 7/1/19 at 5:30 PM. The plan included: *Resident #5 was transferred and admitted to [NAME] County hospital on [DATE]. Resident #5 was transferred from [NAME] County Hospital to Levindale on 6/27/19. Resident #5 was admitted to Levindale on 6/27/19. *Interviewable residents in the facility were interviewed by the Social Worker on 6/28/19 to validate they feel safe in the facility and they have not had any inappropriate interactions with other residents. *DON and Social Worker to review the care plans of vulnerable females and update those plans. *The Director of Nursing has reviewed incident reports and 24 hour reports of the past 14 days to validate no other incidents of inappropriate resident interaction has occurred. Any residents involved in an abuse incident will be provided support systems coordinated by the Social Worker including but not limited to psych services, the medical team, and community resources. *The Administrator, Social Worker, and Director of Nursing will have re-educated the facility staff on: --identifying behaviors that could lead to incidents of inappropriate touching of cognitively impaired residents: the components of the investigation process of these types of incidents including but not limited to collecting resident and employee statements, communication with responsible parties, reviewing of staffing assignments, review of resident care plans, physician orders, staff education: --immediate actions to take when a resident exhibits sexually inappropriate/aggressive behavior to include a review of staffing patterns, and education staff regarding accurate documentation and reporting of incidents, along with prevention of abuse or neglect --the levels of supervision provided by nursing staff so that all facility staff understand what one-to-one supervision entails. *This re-education will be completed by 6/30/19. Any facility staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. *Director of Nursing or Nurse Supervisor will review incident reports and progress notes daily to identify residents exhibiting inappropriate sexual behaviors / aggressive behaviors or residents with new onset of inappropriate sexual behaviors to ensure a thorough investigation was completed and a plan to address concerns was developed in a timely manner, to validate a safe environment was maintained, and to ensure care plans are updated and revised as warranted. This will occur daily for two weeks, then Monday through Friday for three months. *An Ad Hoc Quality Assurance & Performance Improvement meeting was conducted on 6/28/19 to address this occurrence. Results of the monitoring will be presented to the QAPI committee for recommendations monthly for 3 months. All concerns will be addressed at time of discovery. 3) The facility failed to ensure a cognitively impaired resident (resident #3) was free from abuse. Medical record review on 6/27/19 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The medical record contained a care plan with an initiation date of 7/18/18 that addressed verbally threatening, screaming and cursing at others. Interventions included maintaining a calm environment and avoiding power struggles with the resident. A care plan evaluation note reported the care plan was reviewed but the interventions were not updated. A care plan initiated on 10/9/18 that addressed behavioral symptoms that included spitting on staff and refusing care. Interventions included maintaining a calm environment. An evaluation note dated 4/9/19 reported the resident continued to have behavioral symptoms. There was no indication the interventions were reviewed or revised. A care plan with an initiation date of 11/9/18 addressed aggressive behaviors, spitting and cursing due to Dementia with behaviors. Interventions included the administration of medication (antipsychotic), following familiar routines, maintain a calm environment and approach to the resident. Provide reassurance and comfort during episodes of aggression. An evaluation note dated 4/10/19 reported the resident continued to demonstrate aggressive behaviors. There was no indication the interventions were reviewed and updated. Review of the quarterly MDS assessment dated [DATE] revealed facility staff coded the resident in Section C Cognitive Patterns as severely cognitively impaired. Surveyor review of a facility reported incident #MD 890 and complaint #MD 209 on 6/27/19, revealed an allegation that on 2/14/19 a therapy aide observed GNA #4 strike Resident #3 on the arm while providing care. In a written statement dated 2/14/19 the therapy aide reported s/he heard and observed GNA #4 smack Resident #3 after the resident placed her/his nails on the GNA's arm. The therapy aide also reported s/he observed GNA #4 slam Resident #3 into the wheelchair while performing a transfer. GNA #4 signed a Suspension Pending Investigation form, dated 2/14/19, that noted while s/he was taking care of Resident #3 the resident scratched her/him and s/he told the resident to stop. During an interview with the surveyor on 6/27/19 at 9:21 AM the Administrator confirmed the allegation of abuse was substantiated and the employee was terminated. During an interview with the surveyor on 7/3/19 at 3:05 PM the therapy aide stated s/he was working with a resident in bed #2 when s/he heard someone say ouch. The therapy aide stated s/he observed Resident #3 scratch GNA #4, then GNA #4 hit the resident on the forearm. The therapy aide stated s/he also observed GNA#4 aggressively place Resident #3 in the wheelchair. Review of the investigation and staff interview failed to reveal that care plans that addressed the resident's aggressive behaviors were reviewed and revised to ensure the interventions were based on a comprehensive assessment of the resident's needs.

Based on investigation, and facility staff interviews, it is determined that the facility staff failed to promptly intervene when Resident #9 was noted with ants crawling on his/her body and the nurse failed to document an assessment on the Resident or notify the physician after the Resident had been found with the ants crawling over the Resident's body. In addition, the facility staff failed to ensure that a treatment was administered to Resident #9 as ordered by the physician. This was evident for 1 out of 33 Residents observed in stage II of the survey process. The findings include: 1. The facility staff failed to promptly intervene when Resident #9 was noted with ants crawling on his/her body and the nurse failed to document an assessment on the Resident or notify the physician after the Resident had been found with the ants crawling over the Resident's body. On 5/2/17, a complaint was issued to the Office of Health Care Quality, the complaint contained a video recording of ants crawling on Resident #9's legs (near wounds) and on resident's bed; complainant stated that video was taken on morning of 5/2/17. Allegations included that ants were observed crawling all over the resident and the resident's bed, ants were reported to be crawling from the resident's ear. Surveyor observation on 5/4/17 confirmed the video was of Resident # 9. An investigation was initiated on 5/4/17. Resident #9 is assessed with [REDACTED]. Additionally, the resident is dependent on staff for most activities of daily living. The resident was unable to move away from the ants, or brush ants from her skin due to her physical limitations. Interview of GNA #6, (Geriatric Nursing Assistant) on 5/4/17 at 12:50 p.m. revealed that on the morning of 5/1/17, the Resident was out of bed in the Geri chair when the GNA arrived at the facility. The GNA further stated that the Resident was not usually up when the 7 - 3 shift came in, the GNA was not aware of any issue and thought the previous shift was just helping the day shift out. The GNA revealed that on the morning of 5/1/17, the ants were found crawling on the Resident. On 5/1/17, GNA #6 went in to the room to provide care to the Resident's roommate at approximately 11:00 a.m. The nurse was performing wound care on Resident #9 when the GNA went into the room. The GNA stated to the nurse are you ready to do him/her? The GNA further stated I just happened to look and I saw ants. They were all over him/her .they were everywhere. On his/her feet, legs, face, in the wounds. They were in open wounds. I immediately panicked and said let me get him/her up. The Licensed Practical Nurse # 1(LPN) said no, no let me finish. I said let me get him/her up. When the nurse was doing the dressing, the nurse was wiping the ants off. The GNA went on to say that when the GNA turned the Resident over, the bed was covered in dead ants like he/she was lying on them. When the survey team asked the GNA what the Resident's skin looked like, the GNA stated that the skin was red, like they (ants) had been biting the Resident. You could see he/she had been bitten up. On 5/5/17 at 1:20 PM, GNA #7, who cared for Resident #9 the morning of 5/1/17, was interviewed. The GNA was asked if there was anything unusual when the GNA changed Resident #9's bed. The GNA stated that there were a few live ants. The GNA was asked if the sighting of the ants was reported. The GNA stated no, but that this GNA reported that there were ants in the Resident's room prior to 5/1/17. When GNA #7 was asked if there were ants on the Resident the morning of 5/2/17, the GNA confirmed that he/she observed ants crawling on Resident #9's legs and in the bed. The GNA further stated there were a lot of ants that day. GNA #9 confirmed that on the night of 4/30/17, the Resident was taken out of the bed before day shift because ants were observed in the Resident's bed. That was why the Resident was observed in the chair on 5/1/17 by day shift. During an interview with the DON on 5/5/17 at 1:40 p.m., the DON acknowledged that GNA #5 reported that there were ants on the Resident's feet on 5/2/17. Despite knowing ants were observed in the Resident's bed as early as before 4/30/17, the staff failed to notify supervisory personnel and/or maintenance staff, and to promptly intervene. The nurse failed to assess the Resident and notify the administrator, director of nursing and the physician. Based on the findings, it was determined that harm was done to resident #9 as staff neglected to promptly remove the ants from the resident's body and bed, and to take steps to ensure the pest problem was alleviated immediately. 2. The facility staff failed to ensure that a treatment was administered to Resident #9 as ordered by the physician. The findings include: Resident #9 has resided at the facility since January of 2017. Review of the Minimum Data Set (MDS), an assessment tool, dated 4/18/17 revealed that the resident is assessed with [REDACTED]. Observation of the resident on 5/9/17 at 11:05 a.m. revealed that the resident was noted with a wound on the right bunion. The wound was not covered with a dressing. Review of the resident's medical record on 5/9/17 revealed that the resident has a physician's orders [REDACTED]. The nurse caring for the resident on 5/9/17, Staff #5, was interviewed on 5/9/17. The nurse was asked by the surveyor what treatment was administered to the resident's right bunion wound. The nurse replied that a treatment of [REDACTED]. bunion wound was [MEDICATION NAME] and a dry dressing.