Every finding on record at Charlestown Community Inc

Based on interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (Resident #1) of 4 sampled residents reviewed for abuse/neglect. Findings included: A facility policy titled, Abuse Prevention, dated 05/2021, indicated, 5. Investigation a. The community will investigate all suspected or alleged incidents of resident abuse, mistreatment, neglect, exploitation, involuntary seclusion, including injuries of unknown source and misappropriation of property. A Face Sheet revealed the facility admitted Resident #1 on 12/23/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of Alzheimer's disease, dementia with psychotic disturbances, and delusional disorders. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident #1's Clinical Notes Report, electronically signed by Registered Nurse #10 and dated 12/26/2025 at 12:48 PM, indicated Resident #1 reported to an Occupational Therapist that someone was touching [him/her], and gestured toward their private area. Per the Clinical Notes Report, a head-to-toe skin assessment was completed, and the resident was found not to have any visible injuries, redness, bruising, or signs of trauma and denied pain or discomfort. A review of the facility investigation file revealed no evidence to indicate that all staff that had access to Resident #1's room were interviewed. Per the facility investigation file, only two residents who had intact cognition were interviewed; the facility did not include assessments of resident who were cognitively impaired. During an interview on 05/04/2026 at 10:40 AM, the Assistant Administrator stated the facility did interview two alert and oriented residents who resided in the general area of Resident #1's room after the incident and those residents had no concerns. Per the Assistant Administrator, the remainder of the residents were cognitively impaired. When asked if the facility had done any assessment of residents who were cognitively impaired, the Assistant Administrator stated the facility did not do any type of assessments on the residents who were cognitively impaired and he could see why that would be a good idea. During an interview on 05/04/2026 at 12:45 PM, the Director stated usually the facility would interview residents who were cognitively intact and residents who were cognitively impaired would be assessed. During a follow-up interview on 05/06/2026 at 1:00 PM, the Assistant Administrator stated the facility did not assess cognitively impaired residents when the allegation of abuse was made but interviewed cognitively intact residents since they could tell them if they experienced anything related to abuse/neglect. The Assistant Administrator stated only nursing and dietary staff were interviewed; however, the facility should have interviewed all staff that had access to the resident to include housekeeping and therapy staff.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of sexual abuse and an allegation of neglect to the state survey agency for 2 (Resident #1 and Resident #2) of 4 sampled residents reviewed for abuse/neglect. Findings included: A facility policy titled, Abuse Prevention, dated 05/2021, indicated, ii. Timing 1. Alleged allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). 1. A Face Sheet revealed the facility admitted Resident #1 on 12/23/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of Alzheimer's disease, dementia with psychotic disturbances, and delusional disorders. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. During an interview on 05/05/2026 at 3:47 PM, the Occupational Therapist (OT) stated as she evaluated Resident #1 on 12/26/2026, the resident told her that someone touched them inappropriately. The OT stated she immediately informed Registered Nurse (RN) #10. Resident #1's Clinical Notes Report, electronically signed by RN #10 and dated 12/26/2025 at 12:48 PM, indicated Resident #1 reported to an OT that someone was touching [him/her], and gestured toward their private area. Per the Clinical Notes Report, a head-to-toe skin assessment was completed, and the resident was found not to have any visible injuries, redness, bruising, or signs of trauma and denied pain or discomfort. During an interview on 05/05/2026 at 10:25 AM, RN #10 stated an OT came to her on 12/26/2025 and informed her that Resident #1 stated someone touched their private parts. RN #10 stated she informed the administration immediately and was told to assess the resident. During an interview on 05/05/2026 at 3:47 PM, the Director of Nursing (DON) stated it was his expectation that any allegation of abuse be submitted in a timely manner. The DON stated the allegation should have been reported to the state survey agency on 12/26/2025 when the nurse was informed of the alleged incident; however, the allegation was not reported until 01/05/2026. During an interview on 05/05/2026 at 3:50 PM, the Director stated he would have expected the allegation of abuse to be reported in a timely manner. The Facility Reported Incident [FRI] Initial Report Form, indicated the facility reported an allegation of sexual abuse to the state survey agency on 01/05/2026. Per the FRI Initial Report, Resident #1 alleged on 12/26/2025, a female staff member entered their room and began to touch them inappropriately. 2. A Face Sheet revealed the facility admitted Resident #2 on 11/12/2024. According to the Face Sheet, the resident had a medical history that included a diagnosis of senile degeneration of the brain, palliative care, type 2 diabetes mellitus, chronic kidney disease, and urinary tract infection. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/21/2026, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Email correspondence from Resident #2's Power of Attorney (POA) addressed to the Director and dated 03/23/2026 at 6:33 PM, indicated the POA had concerns of neglect. The Facility Reported Incident [FRI] Initial Report Form, indicated on 03/23/2026 at 9:00 AM, the Director was made aware of an incident/allegation. Per the FRI Initial Report Form, Resident #2's POA made the Director aware of the allegation of neglect, specifically an allegation of inattentive care that led to the resident being hospitalized . Email correspondence indicated that the Assistant Administrator reported the allegation of neglect to the state survey agency on 03/24/2026 at 7:09 PM. During an interview on 05/06/2026 at 1:00 PM, the Assistant Administrator stated his expectation would be that any allegation of neglect be reported in a timely manner.

Based on observation, staff interviews and surveyor record review it was determined that the facility failed to ensure sanitary and safe food service practices. This was found to be evident in 1 out of 2 nourishment refrigerators on the nursing units and in the kitchen. The findings include:On the initial tour of the kitchen at 8:35 AM on 9/15/2025 with the Food Services Director (FSD) in attendance, the surveyor reviewed the dish machine temperature log for the month of September 2025. The surveyor observed that the dish machine temperature log did not have wash temperatures recorded for 9/12 PM, 9/13 PM, and 9/14 PM, and did not have rinse temperatures recorded for 9/2 PM, 9/12 PM, 9/13 midday, 9/13 PM, and 9/14 PM. Additionally, the surveyor reviewed the pot sink sanitizer log for the month of September 2025 and observed that the wash temperature for 9/2 was not recorded for PM, and that the wash and rinse temperatures for 9/4 were not recorded for PM. In an interview with the Food Services Director (FSD) during the initial tour, the surveyor asked what the expectation was for recording the wash and rinse temperatures for the dish machine and the pot sink sanitizer on the log. The FSD stated that the expectation was for the wash and rinse temperatures to be taken AM, midday and PM and recorded on the logs by the dietary staff.At 9:15 AM on 9/15/2025 the surveyor observed the 1st floor nourishment refrigerator with the Food Services Director (FSD) in attendance. The surveyor reviewed the refrigerator and freezer log that was posted for the month of September 2025. The surveyor observed that the log did not have temperatures recorded for 9/2, 9/3, 9/6, 9/7, 9/9 and 9/12 for the refrigerator and freezer. In an interview with the Food Services Director (FSD) at 9:20 AM on 9/15/2025 the surveyor asked what the expectation was for recording the temperatures for the nourishment refrigerator and freezer on the log. The FSD stated that the nursing staff was responsible for monitoring the nourishment refrigerators and freezers on the units and recording the temperatures daily on the log. Additionally, the FSD stated that the nourishment refrigerators and freezers on the nursing units were for the storage of food and beverages for Residents brought in from the outside by family and visitors.

Based on record review and interviews it was determined that the facility failed to appropriately prescribe a psychotropic medication for a resident without a documented need for one and monitor for behaviors and side effects. This was found evident in 3 (Resident #11, #67, & #84) out of 6 residents reviewed for unnecessary medications.The findings include:Chemical restraint is the use of drugs to restrict a person's freedom of movement or control their behavior, and it is not a standard treatment for their medical or psychiatric condition. It is a controversial practice that is heavily regulated and can be considered a form of abuse when misused. A chemical restraint is a form of medical restraint in which a drug (medication) is used to restrict the freedom of movement of a person or in some cases to sedate the person. An example of a chemical restraint includes benzodiazepines (such as Ativan and Xanax) which are fast-acting sedatives used for anxiety and agitation. These drugs are used primarily to control or restrict a person's behavior rather than treat an underlying condition. These medications, when used with the main intent of reducing agitation or movement, function as chemical restraints, even if they also have other therapeutic purposes. A drug used for chemical restraint may also be referred to as a psychotropic drug or therapeutic restraint. Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers.1a) On 9/16/25 at 9:12 AM, the surveyor reviewed Resident #11's medical record. The review revealed that Resident #11 was prescribed Seroquel (also known as Quetiapine, an antipsychotic medication that treats several kinds of mental health conditions) for destressing delusional thoughts on 4/6/24 and Remeron (also known as Mirtazapine, an antidepressant) for adjustment disorder starting 11/2/23. The surveyor next reviewed Resident #11's psychiatric notes written by Clinical Nurse Specialist Staff #21. In a note dated 12/20/24 Staff #21 wrote, a Gradual Dose Reduction (GDR) is contraindicated as Resident # 11 continues to have distressing delusional thoughts and Quetiapine is at the lowest dose possible that has helped to decrease some of the distress. Staff #21 assessed Resident #11 on 2/21/25, 4/18/25, and 7/11/25. In both note on 2/21/25 and 4/18/25 Staff #11 documented that Resident #11 did not express delusional thoughts that day however continued to have episodes. On 7/11/25 Staff #21 wrote that Resident # 11 was tolerating Quetiapine as prescribed suggesting continuing the dose and that the Resident was continuing to have distressing delusional thoughts. The surveyor reviewed the Minimum Data Set (MDS) assessments for Resident #11 during the assessments with an Assessment Reference Dates (ARD) of 10/4/24, 1/4/25, 4/4/25 and 7/8/25. No, was marked for hallucinations and No, was marked for delusions in all of the assessments noted above. On 9/16/25 the surveyor interviewed Minimum Data Set Coordinators #18 & #19 along with the Director of Nursing (DON). Staff #18 stated that behaviors are coded on the assessment when the behaviors are noted in the medical records, in both nursing and/or provider notes within the look back period. The surveyor expressed the concern that the rationale given by Staff #21 for the continuation and contraindication for reduction of Quetiapine was noted delusional behaviors. The surveyor requested any documented behaviors noted for Resident #11. On 9/16/25 at 12:10 PM, the surveyor conducted an interview with Staff #21. During the interview Staff #21 stated that when a Resident is on a psychotropic medication it would be her expectations that behaviors are monitored. She further stated that when she evaluates if behaviors are happening, she would look through notes and speak to the staff about behaviors. The surveyor relayed the concern that the only behaviors noted in the medical record were from the ones written in her evaluation. She confirmed that she did not document the behaviors described by staff when asked. At the time of exit no evidence that Resident #11 was having behaviors was provided even though it was the rationale for continuing to prescribe a psychotropic medication and rationale for not titrating a gradual dose reduction. 1b) The surveyor conducted a record review of Resident #67's medical record on 9/17/2025 at 9:30 AM. Review of the medical record revealed that Resident #67 had a physician order since 8/11/2025 for Alprazolam (Xanax) 0.25 mg oral tablet one time daily as needed (PRN) for agitation and anxiety. Further review of the medical record revealed that Resident #67 was administered Xanax daily for 6 days in August on 8/14/2025, 8/19/2025, 8/22/2025, 8/24/2025, 8/28/2025 and 8/29/2025 and for 5 days in September on 9/4/2025, 9/5/2025, 9/6/2025, 9/7/2025 and 9/12/2025. Also, the physician order for Alprazolam (Xanax) did not include the duration/time frame for the usage of this psychotropic medication that was prescribed as needed (PRN). At 12:05 PM on 9/18/2025 the surveyor interviewed the Director of Nursing (DON) regarding the physician order for Alprazolam (Xanax) daily as needed (PRN) for Resident #67 that did not include the duration/time frame for the usage. The surveyor reviewed the PRN Xanax order with the DON. The surveyor confirmed with the DON that Xanax was ordered originally on 8/11/2025 and that Resident #67 had not received this medication prior to this date in the facility. The surveyor conveyed to the DON that the PRN Alprazolam (Xanax) order did not have a duration/time frame for usage. The DON acknowledged the surveyor. The surveyor asked the DON what the expectation was for duration/time frame for usage of PRN (as needed) psychotropic medications, such as Xanax. The DON stated that there should be a duration/time frame included in the physician order for usage of PRN Xanax. The surveyor clarified that psychotropic medications such as Alprazolam (Xanax) which were ordered as needed (PRN) were to be limited to 14 days, unless the prescribing practitioner documented a rationale to extend the medication. Additionally, the surveyor conveyed to the DON that there was insufficient documentation of ongoing monitoring of behaviors and symptoms for the usage of Alprazolam (Xanax). The DON acknowledged the surveyor and stated that the facility was in the process of educating the licensed nurses on the monitoring and documentation of behaviors and symptoms for the usage of psychotropic medications. At the time of survey exit, no additional information was provided by the facility regarding psychotropic medications. 1c) On 09/17/25 at 11:30 AM a review of Resident #84 medication administration record revealed the resident was prescribed Seroquel 12.5 mg by mouth (PO) every hour of sleep related to Dementia with Psychotic Disturbance. On 12/10/24 the medication was increased to Seroquel 25 mg PO every hour of sleep R/T the resident had visual hallucinations. The surveyor was unable to locate documentation to verify the nurses were monitoring the resident for extrapyramidal side effects of the medication or documenting when the resident had behaviors that would indicate the dose of the medication may need to be adjusted. Further review of the electronic medical record revealed the psychotropic medication was increased on 01/30/25 to Seroquel 37.5 mg PO every hour of sleep. There was no documentation to indicate why the medication was increased and if the staff was monitoring behaviors or side effects. On 09/17/2025 at 2:03 PM during an interview with the Director of Nursing (DON) #2, he/she verbalized they have a behavioral monitoring system where the Geriatric Nursing Assistants use a touch system where they document what they see. If there was any negative action or expression displayed the system would prompt them to answer more questions. The surveyor made DON #2 aware that if a nurse is assigned a resident who is prescribed psychotropic medication they are required to monitor the resident for behaviors and extrapyramidal side effect. The prescribing clinician should have that information available to determine if the medication is working or needs to be adjusted. On 09/17/2025 at 3:37 PM the surveyor reported to Administrator #1 the nurses are not monitoring residents prescribed psychotropic medications for extrapyramidal side effects and not monitoring the resident for behaviors. Administrator #1 verbalized they have high risk rounds weekly which include residents who are prescribed psychotropic medications. They are going to work on having more precise documentation instead of generic documentation. On 09/18/2025 at 11:05 AM DON #2 verbalized the resident goes to see a Neurologist at John Hopkins Hospital for Huntington's Disease and the Neurologist made the recommendation to increase the medication to Seroquel 37.5 mg R/T moderate Dementia with psychotic disturbance. The surveyor asked what warranted the increase of the medication. DON #2 verbalized the resident was having hallucinations; they don't have documentation specific to that nature. Yes, they could have had documentation. They meet on a weekly basis and talk about the residents who are prescribed psychotropic medications.

Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of facility reported incidents as evidenced by not including statements from all staff who worked during the time the alleged incidents occurred. This deficient practice was evidenced in 2 (#36, #98) of 5 facility reported incident investigations reviewed during the recertification survey. The findings include: On 09/16/2025 at 2:44 PM a review of the facility's investigation of the facility reported incident #325365 related to an allegation of abuse associated with Resident #36 revealed there were no statements from all staff who worked during the time of the alleged incident. On 09/16/25 at 11:15 AM during an interview with Assistant Nursing Home Administrator #3 the surveyor asked how did they determine who should be interviewed concerning the allegation? He/she verbalized after the alleged perpetrator was interviewed, the nursing supervisor, and the assigned nurse were interviewed. Also, statements were taken from people who worked on 03/10/25. The surveyor requested a copy of the staffing sheets for the date and shift when the alleged incident occurred. At 12:00 PM a review of the staffing sheet for [NAME] Overlook 2 dated 03/10/25 3:00 pm - 11:00 pm revealed Geriatric Nursing Assistants #8, #9, #10, and #11 were included on the staffing sheet but a statement from the GNA's were not included with the investigation. On 09/16/25 at 2:48 PM the surveyor reported to Assistant Nursing Home Administrator #3 there were not statements from all the staff who worked on 03/10/25 during the 3:00 pm - 11:00 pm shift when the alleged allegation of abuse was reported. Assistant Nursing Home Administrator #3 verbalized statements are taken on a case-by-case basis & they use a clinical rationale for everything. Often the staff may not have a statement, and they were more concerned about getting a summarization of interviews. The surveyor verbalized there were no statements from four GNA's and 1 nurse who worked in the neighborhood when the alleged incident occurred. There were interviews from seven other staff who were not included on the assignment sheet. On 09/18/25 at 10:31 AM a review of the facility's investigation related to the Facility Reported Incident (FRI) #325310 related to an allegation of abuse concerning Resident #98 revealed, a statement from all the staff who worked on [NAME] Overlook 2 on 07/13/23 during 7:00 am - 3:30 pm was not included in the investigation. There was not a statement from Licensed Practical Nurse (LPN) #30 who was assigned to the resident nor was there a statement from GNA #31 who worked when the alleged incident occurred. On 09/18/25 at 11:46 am the surveyor reported to Administrator #1 a thorough investigation was not completed because all the staff who worked during the alleged incident were not interviewed.

Based on record review, and interview, it was determined the facility failed to provide the resident's representative with a written notice of reason for transfer. This was found evident of 1 (Resident #92) of 4 residents reviewed for hospitalization during the survey. The findings include: On 9/18/25 at 12:10 AM, the surveyor reviewed Resident #92's medical record. The review revealed that Resident #92 went to the hospital in mid June of 2025. Next the surveyor requested the notice for bed hold and reason for transfer notifications. On 9/19/25 the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA provided the bed hold notice give to Resident #92's Representative however, stated that he was not able to find the written notice with reason for transfer. He further stated that the facility had a form for this notice but was not able to explain why it was not utilized

Based on staff interviews and surveyor record review, it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment accurately for a Resident. This was found to be evident in 1 (Resident #27) out of 36 Residents reviewed for accuracy of MDS assessments. The findings include: Minimum Data Set (MDS) assessment is a standardized, comprehensive collection of demographic and clinical information about a person's condition, used to facilitate individualized care planning, monitor quality, and support reimbursement in healthcare. The MDS assessment is a federally mandated process by the Centers for Medicare and Medicaid Services (CMS) for clinical assessment of all Residents in Medicare and Medicaid certified nursing homes. The core principle is to gather essential information about patient needs and care. The surveyor conducted a record review of Resident #27's medical record on 9/17/2025 at 9:15 AM. Resident #27 was admitted to the facility on [DATE]. Review of the medical record revealed that Resident #27 had a diagnosis of major depressive disorder as noted in the admitting diagnoses section of the Resident's chart and had an active physician order for Fluoxetine 40 mg capsule oral one time daily for depression as of 5/22/2025. Fluoxetine is an antidepressant drug by pharmacological classification. Further review of Resident #27's medical record revealed that Resident had an active physician order for gabapentin 100 mg capsule oral hour of sleep for neuropathy pain as of 5/22/2025. Gabapentin is an anticonvulsant drug by pharmacological classification. Review of Resident #27's admission MDS assessment dated [DATE] did not indicate that Resident had a diagnosis of depression as this diagnosis was not coded under Section I (Active Diagnoses) of the MDS. Also, under Section N (Medications) of the MDS an antidepressant drug was coded as is taking and indication noted. Also, under Section N (Medications) an anticonvulsant drug was not coded as is taking and indication noted. Additionally, review of Resident #27's quarterly MDS assessment dated [DATE] did not indicate that Resident had a diagnosis of depression as this diagnosis was not coded under Section I (Active Diagnoses) of the MDS. However, Section N (Medications) of the MDS was coded as is taking and indication noted for antidepressant drug and anticonvulsant drug. On 9/17/2025 at 2:30 PM the surveyor interviewed the RN (Registered Nurse) MDS Coordinators with the Director of Nursing (DON) in attendance regarding Resident #27's inaccurate admission and quarterly MDS assessments. The surveyor reviewed the admission [DATE]) and quarterly (8/28/2025) MDS assessments with the MDS Coordinators and the DON. The surveyor conveyed that major depressive disorder was not coded in Section I (Active Diagnoses) on both MDS assessments, but Resident #27 had an active physician order for an antidepressant medication (Fluoxetine) since admission on [DATE]. Additionally, Resident had an active physician order for an anticonvulsant medication (gabapentin) since admission on [DATE] and this drug was not coded on Section N (Medications) of the admission MDS dated [DATE] but was coded on the quarterly MDS dated [DATE]. The MDS Coordinators reviewed the admission and quarterly MDS assessments for Resident #27 and acknowledged the surveyor. The MDS Coordinators stated that a modification/correction would be made to the admission MDS and the quarterly MDS assessments for Resident #27. At the time of survey exit, no additional information was provided by the facility regarding MDS assessments.

Based on interviews, and record review, it was determined that the facility failed to review and revise a Resident's care plan after a Resident's situation changed and a Minimum Data Set assessment was completed. This was found evident of 1 (Resident #51) out of 1 Residents reviewed for change of condition during the survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. On 9/16/25 at 10:35 AM, the surveyor reviewed Resident #51's medical record. The review revealed that Resident #51 has a Minimum Data Set (MDS) assessment with an Assessment Reference date of 7/28/25, that indicated Resident #51 had a change of condition. In the special treatments section Hospice care was not indicated. On further review a note written by Licensed Practical Nurse (LPN) #28 on 7/22/25 stated, Resident discharged today from hospice services and will continue the plan of care. Next the surveyor reviewed the Resident's active care plans. One of Resident #51's care plans was; Resident is on hospice care. On 9/17/25 at 9 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that Resident #51 had a change of condition MDS assessment where it was identified that Resident #51 no longer required hospice services and that the care plan was not updated to reflect the actual needs of the Resident. The DON confirmed that the hospice care plan should have been removed.

Based on observations and interviews it was determined that the facility failed to provide necessary adaptive equipment to a Resident based on his/her needs. This was found evident in 1 (Resident #86) of 1 resident reviewed for communication. The findings include: On 9/15/25 at 10:30 AM, the surveyor observed Resident #86 in the common dining area. Resident #86 was not wearing hearing aids and asked for questions to be repeated. On 9/15/25 at 2:16 PM, the surveyor observed Resident #86 in his/her room. The surveyor asked Resident #86 if he/she had hearing aids and Resident #86 responded that he/she did but didn't know why they didn't work. The surveyor next observed a sign on the wall that stated, Please take out his/her hearing aids each evening prior to bed and place them in the charger, make sure the light is on and they are seeded correctly. On 9/15/25 at 2:23 PM, the surveyor interviewed the Geriatric Nursing Assistant (GNA) assigned to Resident #86. GNA #6 stated that she normally did not work on the floor and had not seen any hearing aids for Resident #86. On 9/17/25 at 8:02 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #7 assigned to Resident #86. During the interview LPN #7 stated that Resident #86 had hearing aids and would have them placed after getting dressed for the morning. When asked where the hearing aids were located, LPN #7 went over to a table and opened a charging case. Inside were two hearing aids that appeared to be charged. The surveyor next reviewed Resident #86's care plan. A hearing care plan stated Resident #86 required hearing aids in both ears and require assistance to apply, remove, and/or store hearing aids. On 9/17/25 at 8:17 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the Surveyor reviewed the concerns that on 9/15/25 Resident # 86 was observed without his/her hearing aids and when the GNA was asked about the hearing aids she was not aware if the resident required them. The DON confirmed that the GNA should have known about the hearing aids through a report and the resource binder.

Based on observations, staff interviews and surveyor record review, it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 2 (Resident #1 and #50) out of 3 Residents reviewed for respiratory care and services. The findings include: On the initial tour of the 2nd floor nursing unit on 9/15/2025 at 10:25 AM the surveyor observed in Resident #1's room two emergency tanks of oxygen secured in carts. There was not an oxygen signage posted on the Resident #1's room door upon entry to the room. In an interview with the Licensed Practical Nurse (LPN) #20 on 9/15/2025 at 10:33 AM the surveyor asked what the expectation was for oxygen signage to be posted on the Resident room doors when oxygen tanks were in Resident rooms. LPN #20 stated that an oxygen signage should be posted on the Resident room doors when oxygen was in use and the LPN placed an oxygen signage on Resident #1's room door. At 11:00 AM on 9/16/2025 the surveyor conducted a record review of Resident #1's medical record. Review of the medical record revealed that Resident #1 had a physician order for oxygen 2Liters/minute via nasal cannula as needed (PRN) for hypoxia (absence of enough oxygen in the tissues) dated 4/2/2025. The surveyor interviewed the Director of Nursing (DON) at 8:30 AM on 9/17/2025 and asked what the expectation was for the oxygen signage to be posted on Resident room doors when oxygen tanks were in Resident rooms. The DON stated that the expectation was oxygen signage to be posted on the Resident room doors when oxygen tanks were in Resident rooms. The surveyor conveyed to the DON that two emergency oxygen tanks were observed in Resident #1's room and that there was not an oxygen signage posted on the Resident room door, and that LPN #20 was notified and placed an oxygen signage on the Resident room door. A respiratory nebulizer machine is a medical device that turns liquid medications into a fine mist, allowing the patient to inhale the fine mist directly into their lungs for respiratory conditions. It allows for direct delivery of medication to the lungs. At 4:11 PM on 9/15/2025 the surveyor observed Resident #50 in bed with oxygen in use via nasal cannula. The nasal cannula oxygen tubing was attached to the oxygen concentrator that was delivering oxygen to Resident #50's nostrils. The oxygen tubing was not labeled with date, but the oxygen humidifier bottle was labeled with date 9/12/2025. Additionally, the surveyor observed a respiratory nebulizer machine on Resident #50's bedside table. The mask to the nebulizer machine was stored in a plastic bag and labeled with date 9/12/2025, but the nebulizer tubing was not labeled with date. At 12:55 PM on 9/16/2025 the surveyor conducted a record review of Resident #50's medical record. Review of the medical record revealed that Resident #50 had physician orders for oxygen via nasal cannula every shift for SOB (shortness of breath), DuoNeb solution for nebulization inhalation for wheezing, and date and change oxygen tubing / humidification bottle weekly. The surveyor reviewed at 1:15 PM on 9/16/2025 the facility's policy for respiratory equipment dated 5/2003 and revised 1/2025. The policy indicated that the nebulizer tubing and the oxygen tubing/nasal cannula tubing would be changed every week and labeled with date of change and would be kept in a plastic bag when not in use. The surveyor observed Resident #50 again on 9/17/2025 at 7:30 AM. The oxygen tubing and nebulizer tubing were not labeled with a date. In an interview with the Director of Nursing (DON) at 8:30 AM on 9/17/2025 the surveyor asked what the expectation was for labeling/dating oxygen tubing and nebulizer tubing. The DON stated that the oxygen tubing and nebulizer tubing were to be labeled/dated and changed weekly and stored in a plastic bag when not in use. The surveyor conveyed to the DON that the oxygen tubing and the nebulizer tubing for Resident #50 was not labeled with date. At the time of survey exit, no additional information was provided by the facility regarding respiratory care.

Based on medical record review and interviews it was determined that the facility failed to implement physician instructions for behaviors health needs. This was evident for 1 (Residents #51) out of 5 residents reviewed for unnecessary medications. The findings include: On 9/16/25 at 10:35 AM, the surveyor reviewed Resident #51's medical record. The review revealed that Resident #51 has a Minimum Data Set (MDS) assessment with an Assessment Reference date of 7/28/25 that indicated Resident #51 had a change of condition. In the special treatments section Hospice care was not indicated. On further review a note written by Physician #29 on 8/6/25 stated Resident #51 was recently discharged from hospice. It also stated that Resident #51's mood disorder, that was due to a medical condition, would be treated with Seroquel and Sertraline along with mental health follow up. On 9/16/25 at 12:17 PM, the surveyor interviewed Clinical Nurse Specialist Staff #21. During the interview Staff #21 stated that she had stopped seeing Resident #51 when he/she became a hospice resident. The surveyor confirmed that Staff #21 was not aware that Resident #51 was no longer receiving hospice services. On 9/16/25 at 12:49 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor reviewed the concern that Resident 51's provider wrote that resident should be seen by psychiatric services however Staff # 21 was not aware that resident #51 was off of hospice services and should have been seen, The DON stated that an order should have been written to communicate that Resident #51 should have been seen by psychiatric services.

44440 Based on observation, staff interviews, medical records review, review of facility reports, and facility's policy and procedures it was determined that the facility failed to: 1) ensure appropriate processes were followed and adequate supervision was in place to prevent a cognitively impaired resident with exit seeking behaviors and a history of a previous elopement from leaving the building. This was evident for 1 Resident (#55) out of 3 Residents reviewed for actual elopements reviewed during an annual and complaint survey. 2) ensure fall prevention interventions were in place for a resident with a history of falls. This was found evident of 1 (#49) of 7 residents reviewed for falls during an annual and complaint survey. The Findings Include: 1. On 7/11/23 6:56 AM, the surveyor reviewed Resident #55's medical record. Resident #55 was admitted to the facility in September of 2019. Resident #55's past medical history includes dementia, adjustment disorder, acquired absence of left leg (amputation), and repeated falls. Further review of the medical record revealed a quarterly assessment and care plan dated 7/6/22. In the Safety and Exploring section the questions were asked, I have attempted to leave my residence or other places unescorted which potentially placed me in danger, and was answered yes. Additionally, Yes was answered to, I have poor decision-making skills and I have actively exhibited exit-seeking actions. Following the assessment, the care plan stated,Roam alert to my [wheel chair] for safety due to seeking exit. The section titled My Cognitive Function, documented Resident #55 consciousness level as confused and constantly Requires assistance and some direction in specific situations or consistently requires low stimulus environment due to distractibility. The surveyor next reviewed the comprehensive annual assessment and care plan following the 8/14/22 elopement. The assessment was completed on 9/29/22. In section Safety and Exploring the assessment had a section labeled, approximate dates of elopement and this section was left blank. On 7/11/23 at 7:57 AM, the surveyor reviewed the facility investigation following an elopement of Resident #55 that occurred on 8/14/22. The report states Resident #55 was alert and oriented times 1-2, indicating he/she was aware of 1-2 of the standard orientation questions. These questions assess a person's knowledge of person, place, time or situation. The report also stated that Resident #55 has episodes of confusion and a Brief Interview for Mental Status (BIMS) score, or brief interview to understand mental status, of 7. A score from 0-7 indicates severe impairment in mental status. Resident #55's mobility was documented as needing assistance with transfers but able to self-propel in a wheelchair. The report stated that Resident #55 asked the front desk staff about activities on the lower level. The front staff (located on lower level, across from the main entrance) instructed Resident #55 that the activities were located on the first floor and second floor. The front desk staff continued to help others and Resident #55 wheeled further down the hallway on the lower level. Resident #55 wheeled to an employee exit door and the Roam alert (safety device alarm) alarmed at 1:44 PM. The report indicated the alarm was canceled within 14 seconds. The report did not reveal who canceled the alarm. The report stated Resident #55 was seen leaving the back door by an employee that was eating lunch in her car. The employee then wheeled the Resident to the front door where the Roam alert went off again at 1:45 PM. The report indicated that the doors and alarms were checked and were functioning properly. On 7/11/23 at 7:57 AM, the surveyor reviewed the facility investigation following an additional elopement of Resident #55 that occurred on 2/4/23. The investigation indicated that Resident #55 came down to the lower level with a group of visitors. The communication specialist was on a call with another Resident when the Roam alert went off at the front doors at 11:21 AM. During this time, a housekeeping assistant reset the Roam alarm without investigating the reason for the alarm activation. Resident #55 was able to leave out the front doors and make it to the curb. An employee brought Resident #55 back in and the Roam alarm activated upon entrance at 11:23 AM. The report indicated that the facility's corrective action was to re-educate the employees involved to not resetting the Roam alert without verifying the resident involved. The surveyor reviewed Resident #55's quarterly assessment and care plan following the 2/4/23 elopement. This assessment was conducted on 3/23/23. In section, Safety and Exploring the approximate dates of elopement were again blank. In section, My Cognitive Function the daily decision making skills documented, Moderately impaired-decisions poor; cues/supervision required. On 7/12/23 at 2:30 PM, the surveyor observed the back parking lot, just outside the door where Resident #55 had eloped on 8/14/22. The surveyor observed a car drive from the road adjacent to the employee door and make a 90 degree left turn. The car then drove on the black paved area alongside the sidewalk to the employee entrance. The surveyor observed no stop sign when turning left from the adjacent road. When exiting the back employee entrance, both the paved area along the sidewalk and the road adjacent had a downward slope. When leaving from the employee door, if the right turn to exit was not made, there was a tall metal fence located at the bottom of the slope. Also located outside the employee exit were electric boxes and dumpsters. On 7/11/23 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON) regarding the elopement of Resident #55 from 8/14/22. The DON states she was unaware of who had silenced the Roam alarm and that the Assistant Director of Nursing (ADON) who had completed the investigation was no longer employed at the facility. The DON stated the alarm was canceled in 15 seconds and whoever canceled the alarm should have determined why the alarm went off. She indicated there was no statement from whoever turned off the alarm. The corrective action indicated that the employees involved were re-educated on proper incident notification to manager or supervisor. There was no indication that education was provided to proper alarm response. The surveyor made the DON aware that on 7/10/23 at 8:48 AM, the surveyor conducted an interview with Communication Specialist Staff #28. During the interview staff #28 stated she was a float Communication Specialist and filled in when needed. Staff #28 stated she did not get a report and was not aware of the current residents at risk for elopement. She did state that some residents have a device that would alarm when they were by the exit doors. The DON followed up and stated that the particular communication specialist interviewed was new and she would ensure she was educated on the elopement of residents and the elopement book that was kept at the front desk with pictures of residents at risk for elopement. On 7/11/23 at 8:23 AM, the surveyor reviewed Resident #55's progress notes. The review revealed a note written by Licensed Practical Nurse (LPN) staff #16, on 7/9/23, stating Resident #55 was in the garden in the rain due to poor safety awareness. Resident #55's clothes were changed, and no complaints voiced. On 7/11/23 at 9:32 AM, the surveyor interviewed Staff #16. During the interview it was revealed that a Certified Medication Technician (CMT) from Assisted Living was looking outside the window and noticed Resident #55 in the courtyard while it was raining outside. The CMT called the Long-Term-Care unit and relayed the information to the supervisor. One of the Geriatric Nursing Assistants (GNA) was instructed to get Resident #55 from the courtyard. Staff #16 stated that the door to the courtyard is unlocked by the night staff at 7am and locked in the evening shift around 10 fpm. She further stated the residents are allowed to go in and out throughout the day and no one person is responsible for checking the courtyard. Staff #16 stated they are not instructed to lock the door with inclement weather. Staff #16 reported that she went to assess Resident #55 and his/her clothes had already been changed by the GNA. She stated she further dried his/her hair with a towel. On 7/11/23 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated, there was no routine monitoring of the courtyard. The DON reported there was no alarm if a resident with a Roam alert goes out to the courtyard. The floor staff is responsible for monitoring their residents and the facility. The DON further stated the facility only locks access to the courtyard after a team discussion and they have only locked it twice recently due to code red air quality. On 7/11/23 at 2:26 PM, the surveyor conducted a follow- up interview with the DON. She stated the facility has made the decision to lock the courtyard door and have a sign up asking to be let out by staff. On 7/11/23 at 11:08 AM, the surveyor conducted and interview with Senior Maintenance Mechanic Staff #15. The surveyor conducted this interview at the back employee entrance door, where Staff #15 was observed working with a contractor. He explained nothing was wrong with the door, but the facility wanted to make the door more secure. He further explained, prior to today's changes to the door, the door's locking mechanism would be suspended when motion was detected from inside the entrance of the door, allowing people to exit without entering a code or badging in. The surveyor asked what would happen when a Resident with a Roam alert came to the door. Staff #15 stated the door would still open if it sensed motion, but an alarm would go off. The alarm would be sent to the [NAME] system, which then sends an alert directly to the nurses' phones, computer screens in nurses' stations and the front desk. The alert would directly indicate where the alarm was going off. Staff #15 indicated that the front entrance door is different and locks when a Roam alert is detected as well as alarm. He further stated after today anyone leaving from this back employee entrance door would have to push a button labeled, push to exit and then push the door. The Roam alert activation would still not lock the door if activated, however now the button would need to be pushed to leave. On 7/11/23 at approximately 1PM, the surveyor review of policy titled, Alarms Response (Exit Doors, Wander Alert Devices). The first step in the procedure section states, If staff observe or witness a resident triggering exit alarms and/or wander device, they will promptly respond, redirect the resident to an area within the neighborhood away from exit and engage the resident in an individualized activity or task of the resident's choice. On 7/11/2023 at 1:23 PM, the surveyor interviewed Communication Specialist staff #29. Staff #29 stated she normally worked at the front desk of [NAME] Overlook but was off yesterday. The surveyor asked Staff #29 if there was a book to reference for elopement residents. Staff # 29 stated yes and showed the book to the surveyor. Two loose pictures of Residents were noted in the book with no name on the pictures. Staff #29 was able to identify one of the Residents but unable to identify the other. Staff #29 stated the nurse just brought these down. On 7/11/23 at 1:32 PM, the surveyor brought the elopement book to the administrative office. The Nursing Home Administrator was able to identify the second resident. The DON was also in the room. The surveyor asked what the process was for updating the book. The DON stated that the day a Resident is identified as an elopement risk they are put into the book and when they are no longer a risk they are removed. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy and the facility was verbally notified of this determination on 7/13/23 at 4:00 PM. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ at 8:05 PM after 2 initial plans were submitted at 6:43 PM and 7:28 PM. The plan included: Reviewing and updating Resident #55's elopement risk and care plan and additionally all other identified elopement Residents, locking the courtyard on [NAME] Overlook One with access managed by the Administrator, and monitoring the rear staff entrance door by staff until the Roam alert is tied to the locking system. The facility's plan for removal also included the following: All departmental employees will be educated on alarm response policy by 7/12/23, communication staff will be educated on all resident's with active Roam alerts and receive updates with changes completed by 7/13/23, the DON will audit the care plans of the newly identified elopement risks weekly for 4 weeks and then monthly for 2 months, elopement drills with activation of roam alerts will be performed on every shift for the first month and then 1 shift per month for the next 3 months, perimeter exit doors will be checked and include roam activation daily for two week and then weekly for four weeks, audit findings will reported to the Quality Assurance/Performance Improvement Committee (QAPI) monthly for 3 months. Additional audits and education may be determined based on audit findings. After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on 7/13/23 after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents. 2. On 6/28/23 at 10:51 AM, the surveyor observed Resident #49's room. Resident #49 was not in his/her room and no floor mats are observed within the room. On 6/29/23 at 10:41 AM, the surveyor reviews Resident #49's medical record. The review revealed that Resident #49 was admitted in late 2019 and has a history of falling, unsteady on feet, mild cognitive impairment, and fracture of the femur. On 7/6/23 10:00 AM, the surveyor again observed Resident #49's room and no fall mats are noted on floor. On 7/6/23 at 10:04 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) Staff #27. During this interview staff #27 states she has worked with Resident #49 and does not recall ever seeing floor mats for Resident #49. On 7/7/23 at 9:13 AM, the surveyor reviewed documentation from a fall that Resident #49 sustained on 2/23/23. The investigation stated that Resident reported being asleep and rolling out of bed. The report also documented Resident #49 had a fall care plan in place prior to the fall. On 7/7/23 at 10:41 AM, the surveyor reviewed the fall care plan for Resident #49. Wheelchair and fall mat were both listed in a section labeled, these devices will assist me: Approaches to address the risk we listed; frequent monitoring and attend to need in a timely manner, encourage Resident to always seek assistance with all transfers, reorient Resident to room and surroundings, continue fall precautions and frequently monitor safter per plan of care, body pillow to both side of bed and keep environment free from potential hazards. On 7/7/23 6:53 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). During this interview the ADON was made aware of the multiple observation of no fall mats in Resident #49 with a current fall care plan documenting fall mats as an assistive device. The ADON said she would get the fall mats and would follow up on effective intervention for Resident #49.

Based on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 2 of 2 residents (#117 and #1) reviewed. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. The MDS is to be completed 14 days after the assessment reference date. Review of Resident #117's medical record on 7/5/23 9 at 12:30 PM revealed the following: 1. A quarterly MDS with an ARD (assessment reference date) 5/16/23, has not been completed as of 6/6/23. 2. A quarterly MDS with an ARD (assessment reference date) 2/16/23, was completed on 4/7/23. 3. A quarterly MDS with an ARD (assessment reference date) 11/16/22, was completed on 1/5/23. On 07/05/23 at 12:28 PM, an interview with the MDS Coordinator revealed that the facility staff are behind because of the high turn around of residents in the facility. We realized the delay and in April 2023, we submitted it to Quality Assurance and Performance Improvement (QAPI). QAPI is a process used to ensure that services are meeting quality standards and assuring care reaches a certain level and Performance Improvement. Review of Resident #1's medical record on 7/6/23 9 at 9:30 AM revealed the following: 4. A quarterly MDS with an ARD (assessment reference date) 5/18/23, has not been completed as of 7/6/23. 5. A quarterly MDS with an ARD (assessment reference date) 2/14/23, was completed on 4/8/23. 6. A quarterly MDS with an ARD (assessment reference date) 11/16/22, was completed on 1/5/23. The Assistant Director of Nursing was informed of the findings on 7/06/23 at 12:00 PM.

Based on review of medical records, facility policies and interviews it was determined that the facility failed to document the provision of the education and the consent, or refusal, of the pneumonia vaccine. This was found to be evident for 5 (Resident #32, Resident #34, Resident #35, Resident #61, Resident # 69) out 5 residents reviewed for immunizations. The findings include: On 7/13/23 8 AM surveyor requested the pneumonia vaccine education and consents for Resident #32, Resident #34, Resident #35, Resident #61, and Resident #69. On 7/13/23 10 AM the ADON stated the paperwork is at Iron Mountain and we probably will not be able to retrieve it anytime soon. During review of the electronic health record, on 7/13/23 10:45 AM, a document titled Vaccine Survey Report revealed the pneumonia vaccine administration dates for, Resident #34, Resident #61, and Resident #69, The administration date listed for Resident #34 as 2/26/2016, Resident #61 as 9/20/2019 and Resident #69 as 3/4/2017. Further review of the electronic health record in a section labeled E-Clinical, (where physicians document on resident care), indicated that Resident 34's last pneumonia vaccine was administered on 2/9/2007 and Resident #61's last pneumonia vaccine was administered on 8/28/2015. On 7/13/23 11:32 AM during an interview with the ADON, the surveyor 1) reviewed the concern regarding inaccuracies of the current pneumonia vaccine administration dates for Resident #34 and Resident # 61 and 2) requested clarification on the two different locations in the electronic health record where all resident vaccine statuses are recorded. The ADON confirmed that it E-Clinical was the primary location for residents' vaccine status to be placed and not on the Vaccine Survey Report; the ADON stated she was unclear how the information was input into and the usage of the Vaccine Survey Report. On 7/13/23 12:45 PM review of the facility's Standing Operating Procedure- Policy on Infection Prevention and Control, Preventing Transmission of Infectious Agents, Process Screenings and Vaccinations, with a review date of 6/2021 that was provided by the facility on 7/13/2023, revealed that #1- Resident vaccine history will be obtained and recorded in the resident's electronic medical record (EMR) .;#4- Vaccines will be offered to residents when available; Before being offered the vaccine, all residents or the resident's representative will receive education regarding the benefits, risks and potential side effects associated with the vaccine; and #8- The resident's medical record will include documentation that indicates proof of education regarding the benefits, risks, and potential risks associated with the vaccine. On 7/14/23 12 PM during an interview, the Assistant Director of Nursing (ADON) confirmed that the facility did not have the documentation to demonstrate the provision of education, consent/refusal of pneumonia vaccine for Resident #32, Resident #34, Resident #35, Resident #61, Resident # 69.

Based on record review and staff interview, it was determined that the facility staff failed to ensure that a facility reported investigation had been completed. This was evident for 1 of 18 facility reported incidents reviewed during the recertification survey. The findings include: If abuse or certain other incidents occur at a Maryland nursing home, the nursing home is required to report the incident to the state. These reports are called facility reported incidents. On 09/12/2022 facility staff reported in a facility reported incident, that gabapentin (an anticonvulsant that treats seizures and pain) capsules for Residents #47, #55, and #209, could not be accounted for. On 07/11/2023 at 1:30 PM the completed investigation for the missing capsules was requested by surveyor. On 07/12/2023 at 8:00 AM, the Director of Nursing stated it was on the [Assistant Director of Nursing's] desk. We can't find it. The Director of Nursing was able to provide evidence that the investigation had been initiated but could not provide evidence it had been completed. On 07/14/2023 at 1:00 PM, the survey team completed the recertification survey. The completed facility reported investigation had still not been located.

Based on observations, interviews and record reviews, it was determined the facility failed to: 1) identify and provide treatment according to the resident's comprehensive care plan and professional standard for constipation (Resident # 60), 2) maintain correct narcotic count (Resident # 44), and 3) failed to ensure resident's skin was completely assessed and documented per physician orders (Resident # 199). This was found for 3 (# 60, # 44, and #199) out of 66 residents reviewed during the recertification survey. The findings include: 1) On 7/05/23 at 11:26 AM, the surveyor reviewed Resident #60's medical records. The review revealed that Resident #60 was admitted to the facility in May of 2023 and had a past medical history of gastrointestinal hemorrhage (bleeding in the bowels), anemia (low red cell count), and muscle weakness. Further review of Resident #60's medical record revealed a bathroom regimen care plan. In this care plan, the second goals stated, I will not have complication related to constipation (difficulty emptying bowels). Additionally, the care plan stated Resident 60's normal routine was to have a bowel movement every 1-3 days with routine laxatives (medications to aide in bowel movement). The medications were listed as miralax, colace and senna. On 7/5/23 at 12:13 PM, the surveyor reviewed Resident #60's medication orders. Resident was ordered Miralax 17 grams to be given everyday starting on 5/4/23 for bowel regimen/constipation. Docusate sodium 100 mg tablet and senna 8.6 mg tablet were also ordered on 5/4 but written as needed, two times daily for constipation. On 7/6/23 at approximately 10:30 AM, the surveyor reviewed Resident #60's bowel movement log. No bowel movements were recorded on the log on 6/10, 6/11, 6/12, 6/13, 6/14, 6/15 or on 6/16. On 7/6/23 at approximately 12 noon, the surveyor reviewed Resident #60's Medication Administration Record (MAR). The MAR revealed that Resident #60 did not receive docusate sodium or senna on the dates 6/10 through 6/15, the time period no bowel movements were recorded. On 7/6/23 at 1:10 PM, the surveyor interviewed the Assistant Director of Nursing (ADON). During the interview the surveyor reviewed the bowel movement log and MAR with ADON. The ADON stated she would expect an intervention to be done after 3 days of not having a bowel movement. 47758 2) On 7/14/23 at 9:15 AM a record review was conducted of the narcotic count book on the 1st floor nursing unit. During the record review the surveyors, Licensed Practical Nurse (LPN) # 11 and Registered Nurse (RN) # 12 observed a bottle of liquid Morphine Sulfate concentrate 20 milligrams (ml) per milliliter (ml) with a remaining balance of 13 milliliters (ml), however, the narcotic book showed a balance of 4.25 ml. remaining. Further review of the Morphine Sulfate liquid bottle revealed an order for Resident # 44 that read use 0.25 ml (5mg) sublingually every 8 hours. During an interview conducted on 7/11/23 at 10:00 AM, the surveyors reported the findings to the Assistant Director of Nursing (ADON) who stated that she would investigate. The surveyors observed and interviewed Resident # 44 on 7/12/23 at 8:15 AM. Resident # 44 appeared drowsy without respiratory distress, aroused easily when surveyors called his/her name, and denied pain or shortness of breath. On 7/14/23 09:38 AM, the surveyors confirmed with LPN # 24 that the narcotic count sheet had been corrected. 37277 3) On 06/28/2023 at 9:02 AM, an abnormal appearing nickel-sized area was observed by surveyor on Resident #199's left temple area, close to the ear. The Resident was immediately interviewed, and when asked about it, the Resident said that he/she did not know what it was and that it sometimes itched. On 06/29/2023 at 1:30 PM, Resident #199's medical records were reviewed. An order was created on 06/14/2023. The order read: weekly skin assessment on Fridays 7 AM-3 PM. Complete skin assessment using the skin sheet and document findings on wound portal and in progress notes. No assessment that included the area on the left temple could be found in the progress notes written by nursing staff, physicians, or other disciplines. No skin assessment could be found in the wound portal. On 06/30/2023 at 10:00 AM, an interview was conducted with staff #3, a Nurse Practitioner (NP). When asked about the area in question, the NP said that she did not know but would look it up. When no notes could be found she said, I'll go take a look. After Resident #199's skin was assessed, the NP stated, It definitely looks like atypical cells, maybe squamous. She then ordered a dermatology consult. On 06/30/2023 at 10:43 AM the Director of Nursing was made aware. At 12:02 PM she provided documentation that the Resident had been seen by dermatology several months prior to admission to the facility. The Dermatologist notes revealed that Resident #199 had a history of squamous cell carcinoma. This is a common type of skin cancer that requires medical intervention. On 06/30/2023 at 12:28 PM the missing skin assessments were brought to the attention of the Assistant Director of Nursing. She acknowledged the findings and stated, there should have been two by now and they aren't there. A complete skin assessment is an essential part of prevention. Early recognition of skin changes is an important part of maintaining overall health.

Based on review of medical records and staff interviews, it was determined that the facility staff failed to: 1) report recommendations to the attending physician and 2) failed to have a process in place that ensured a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed timely. This was evident for 3 residents (#84, #39, #53) of 5 residents reviewed for medication regimen review. The findings include: 1) Review of Resident #84's medical record on 06/30/23 8:00 AM, revealed two medication regimen reviews (MRR) for January 2023 and April 2023, that had not been acknowledged nor signed off by the attending physician. Both MRR's advised review of the resident's Fluoxetine dosage for a gradual dose reduction (GDR). Fluoxetine is a psychotropic medication to treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and panic disorder. The physician did not review the identified recommendations from the Pharmacist. During an interview with Staff #3 on 6/30/23 9:45 AM, it was revealed by Staff #3 that the Nurse Practitioners should have acknowledged any MRRs noted with recommendations. Staff #3 stated that the Nurse Practitioner visited the residents more frequently than the attending physicians and therefore would normally address any flagged MRRs. On 06/30/23 at 11:28 AM surveyors conducted a telephone interview with Staff #22 and asked about the facility's expectation regarding medication regimen reviews. Staff #22 stated, I usually see long term care patients every 3 months and if MRRs are flagged in the hard chart I would see them during my visits with residents. If there was a recommendation, I would address it. If I do not agree with the recommendation, I write why not on the recommendation sheet. I am not aware of the MRRs for Resident #84. On 06/30/23 at 11:41 AM during an interview with the DON, surveyors asked about the expectation of the facility regarding MRRs. The DON stated, We have a clipboard process, staff will place it on a clipboard and on a clipboard for communication between nursing and Nurse Practitioners. Nurse Practitioners visit residents more frequently than the attending physicians. The MRRs should have been addressed by our Nurse Practitioners or Attending Physician. We will send over the MRRs to the appropriate physician for review. The management of the MRRs is the facility's responsibility. During the exit conference on 7/14/23 the Executive Director, Assistant Nursing Home Administrator, DON, and Assistant DON, were again made aware of the concerns that Resident #84's Medication Regimen Reviews were not acknowledged by the Physician or the Nurse Practitioners. 44440 2) Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative. a) On 6/29/23 at 1:31 PM, the surveyor reviewed Resident #53's medical record. The review revealed Resident #53 was admitted to the facility in mid 2018 and had a past medical history of dementia, schizoaffective disorder and bipolar. Further review of the medical records revealed Resident #53 was prescribed Olanzapine, Clonazepam, Lithium and Trazadone. All of these medications fall under the drug category of psychotropic medications, drugs that affect behavior, mood, thoughts or perceptions. Olanzapine is further classified as an antipsychotic, used to treat psychotic disorders. On 7/5/23 at 8:55 AM, the surveyor reviewed Resident #53's MRRs. The review revealed a MRR conducted on 2/24/23 by Pharmacist staff #26, found a medication irregularity and a report was created. This report stated a recommended for a Gradual Dose Reduction (GDR) of Olanzapine. The rationale given; Centers for Medicare and Medicaid Services (CMS) requires that antipsychotics, being used to treat expression or indications of distress related dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Staff #26 signed the report. The following section on the report lays out a place for the physician's response. Three options are listed for the physician's response. 1) I accept the recommendation(s), please implement as written. 2) I accept the recommendation(s) above with the following modifications: 3) I decline the recommendation(s) above because the GDR is clinically contraindicated for this individual. Option 3 has a space for the provider to write patient-specific rationale why the GDR attempt is contraindicated. The report for Resident #53 had no options indicated and was not signed by the provider. No documentation to indicate that the physician reviewed the recommendations. Staff #26 conducted a MRR on 4/20/23 and wrote an irregularity report recommending a laboratory level be obtained following the MMR. The physician responded by checking, I accept the recommendations above. However, this physician's review was signed on 6/23/23, two months after the recommendation was made. On 7/5/23 at 12:43 PM, the surveyor reviewed the Medication Regimen Review policy. Section 7 of the procedure description states, Facility should encourage Physician/Prescriber or other Responsible Parties receiving MRR and the Director of Nursing to act upon the recommendation contained in the MRR. (7.1) For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide and explanation as to why the recommendation was rejected. Section 10 further stated, if the irregularity does not require urgent action but should be addressed before the net monthly MRR, the facility staff and consultant pharmacist will confer on the timelines based on the resident's clinical conditions. On 7/5/23 at 1:05 PM, the surveyor interviewed the Assistant Director of Nursing (ADON). During the interview the DON explained the process for communicating the irregularity reports from the pharmacy. The Pharmacist sends the report to the DON, ADON and clinical managers. The clinical manger then prints the report and places it on a clipboard for the physician to review the next time they are reviewing the paper records. Urgent matters are handled differently. The DON stated the providers are here monthly and should be reviewing the recommendations. b) On 7/5/23 at 8:21 AM, the surveyor reviewed Resident #39's medical records. The review revealed that Resident #39 was admitted to the facility in early 2023 with a history of major depressive disorder, nontraumatic intracerebral hemorrhage (a bleed in the brain) and repeated falls. On 7/5/23 at 9:13 AM, the surveyor reviewed the MRR reports for Resident #39. An medication irregularity report was created by pharmacist staff #26 on 4/20/23. The medications, Austedo (used to treat involuntary movements), Omeprzole (used to treat stomach acid issues), Loratadine (use to treat allergy symptoms), Bupropion (used to treat depression) and Metoprolol (use to treat heart concerns) were noted in the comment section. It also noted a recent fall that Resident #39 experienced. After the comment, the recommendation was made to the physician to evaluate the medication as possible causing or contributing to a fall. The Physician responded by writing continue the same medications and was signed and dated 6/23/23. This was two months after the recommendation. The following irregularity report dated, 6/22/23 identified an additional fall for Resident #39 along with listing the same medication from the report in April. The recommendation to the physician was; Please evaluate these medications as possible causing or contributing to this fall. Consider changing Omeprazole to as needed. The physician responded to the recommendation by checking, I have re-evaluated this therapy and wish to implement the following changes; Discontinue Omeprazole and Loratadine. The physician signed and dated this review on 6/23/23. This was the same date the physician reviewed that the April recommendations were the same recommendation made. On 7/5/23 at 1:05 PM, the surveyor interviewed the Director of Nursing (DON) and shared the concerns about a MRR report being addressed two months after the initial report was given and after a second fall. The DON stated that providers are in the building monthly and should be reviewing reports.

Past Non-Compliance Based on record review and staff interviews, it was determined that the facility failed to ensure that residents were protected from employee theft. This was evident for 2 (#205, #12) of 2 residents reviewed for misappropriation of personal property. It was determined that the facility's failure to protect residents #205 and #12 from theft resulted in past non-compliance which existed from 07/2022 until 09/26/2022. The findings include: On 07/06/2023, a record review revealed that on 06/14/2022 Resident #205's family reported that the resident's purse had gone missing sometime between 05/27/2022 and 05/31/2022. $46 and a credit card were missing along with the purse. According to staff interviews conducted by the facility during their investigation of the matter, two staff members recalled that Resident #205 had a purse while receiving care at the facility. In June 2022, an attempt to use Resident #205's credit card was attempted but declined by the credit card company. In June 2022, multiple checks were written from Resident #205's account to unknown persons. According to the facility investigation, one check had been written to Staff # 9, an employee that had been working in the facility from May 2022 to June 2022. This was how the alleged perpetrator was ultimately identified. On 07/07/2023, a record review revealed that in June 2022 multiple checks were written from Resident #12's checking account to the same unknown persons as above. After the theft, the facility conducted complete investigations and took all the appropriate measures to prevent further incidents of a similar nature. The measures included: 1. The Medical Director and Responsible Parties were notified and, or updated 2. Security was notified 3. Police were notified 4. Staff were interviewed 5. Residents were interviewed 6. Staff were re-educated on the following topics: a. Customer service, resident rights, and ethical standards b. Facility values, workday competencies, and regulatory compliance 7. The facility reimbursed Resident #205 $46 and the cost of the purse 8. Staff #9 was terminated for job abandonment (abandoned the job on 06/09/2022). Additionally, the facility continued to discourage resident's from bringing valuables to the facility and continued to provide a locking drawer in resident rooms. There is an ongoing criminal investigation for theft involving Staff #9. The survey identified non-compliance with Federal and State requirements that were reviewed in relation to facility reported incidents MD00181071 and MD00179196, which were found to be past noncompliance with a compliance date of 9/26/2022.

Based on observation, medical record review and interview, it was determined the facility staff failed to ensure that Resident #24 received assistance with the hearing devices to maintain hearing abilities and the ability to achieve the greatest independence with performing Activities of Daily Living to Resident (#24). This was evident for 1 of 3 residents selected for review during the survey process. The findings include: Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. Medical record review for Resident #24 revealed on 3/16/22, the physician orders: please change hearing aids batteries on Mondays and Thursdays every week. Observation of Resident #24 on 6/27/23 at 1:08 PM, and 6/29/23 at 12:26 PM, revealed the resident was out of bed in the wheelchair in the dining room, however, the facility staff failed to place the hearing aide. Interview with the resident's Power of Attorney on 6/27/23 at 12:30 PM, revealed that Resident #24 on multiple occasions when he/she visited did not have the hearing aid in place and had to ask staff to place the hearing aide. Interview with the resident on 6/29/23 at 12:30 PM, revealed the resident stated that he/she did not have the hearing aid placed for 2-3 days and would like to have the hearing aids in place daily. Interview with the Director of Nursing on 6/29/23 confirmed the facility staff failed to assist Resident #24 with the hearing device.

Based on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby on 6/27/2023 through 6/28/2023 revealed no evidence of the State inspection results in an open and readily accessible area for residents, staff, and visitors to review. A tour of the facility did not reveal any signs posted telling residents where the state survey results are located. On 6/28/2023 at 09:57 AM an interview with the Assistant Nursing Home Administrator confirmed the facility staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed.

Based on medical record review, observation and interview with facility staff, it was determined that the facility failed to have an adequate system in place to monitor a resident with a reported risk of a suicide/homicide agreement with the resident's spouse and failed to follow physician's orders [REDACTED]. This was found during the investigation of an injury of unknown origin and was evident for 1 of 7 residents (#4) sampled. On (MONTH) 24, (YEAR), at 1:45 PM an Immediate Jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to protect a resident with an identified risk for harm and or abuse after reports of a possible suicide/homicide agreement were made. On (MONTH) 24, (YEAR) at 6:27 PM, the facility submitted an acceptable plan of removal, and the Immediate Jeopardy was removed at 6:45 PM. After the removal of the immediacy, the deficient practice remained at a potential for more than minimal harm with a scope/severity of D for the remaining residents. The findings include: Review of the medical record for Resident #4 on 7/24/18 at 10:24 AM revealed admitting [DIAGNOSES REDACTED]. According to his/her most recent minimum data set assessment completed on 3/4/18, Resident #4 required extensive assistance (hands on) of one person to complete bed mobility, transfers, toileting and bathing. Resident #4 was able to eat independently once the meal was set up. The brief interview for mental status (BIMS) for the 3/4/18 assessment was not completed as the resident was noted to be confused. Resident #4 was initially reviewed on 7/24/18 related to an injury of unknown origin occurring on 3/18/18 at 9:40 PM in which the spouse reported that s/he noted blood on the back of the resident's head. The assigned GNA came in and assessed the resident at that time and noted a laceration on the back of the resident's head. According to the facility investigation completed on 3/19/18, the resident and spouse were unable to state how the incident occurred. However, it was noted that the spouse 'attempts to try and administer all aspects of the resident's care including transfers. The spouse requires redirection at times and does not demonstrate good safety awareness as it relates to the Resident's needs.' During the facility's investigation into the injury, both the spouse and the resident were noted to be upset and crying. When the Social Worker interviewed the spouse the next day s/he stated that they 'go at it' but it is verbal not physical. According to the investigation and psychiatric and nursing documentation, the spouse who at the time of the incident lived in an apartment independently in the adjoining continuing care retirement community and was not a resident of the long-term care facility, visited daily and would frequently bring in wine for the resident and spouse to drink. The physician documented on the 4/11/18 assessment that the resident and the spouse did not understand why the resident could not be discharged , although the resident was discharged many times in the past, s/he would end up back in the long-term care unit. This disconnect caused the resident and spouse to 'present with depressed mood/tearing at this visit because s/he wanted to go home.' This assessment took place related to an 'episode' the resident had when s/he waved a knife at dinner (4/7/18) stating (s/he'd) kill him/herself several days prior to the visit. The resident was placed on 1:1 care at that time. The resident was seen by mental health (a Nurse clinical specialist) on 4/9/18 secondary to the incident on 4/7/18. The assessment stated that the resident cried often and the resident and spouse had been looking for a way to get out of the facility. The resident was also seen by a Psychiatrist (a medical doctor who can prescribe medications) on 4/10/18 who noted the resident to have fair insight and judgement with impaired intellectual functioning. The examination noted that the spouse wanted the resident to suicide with him/her, however, the resident stated s/he doesn't believe in it, but the spouse is instigating the resident to suicide. The psychiatrist noted the resident was better when the spouse was not around, however s/he was present most of the time and even stayed on a cot in the resident's room. The documentation further noted that the resident both feared and loved the spouse, 'as well so fears losing (him/her) via suicide (his/her) own suicide threats including pressuring (her/him) to suicide with (him)her).' The psychiatrist further stated to please continue the 1:1 until the situation was resolved. Further recommendations from the psychiatrist included to restrict any alcohol intake as the alcohol itself and in combination with his/her medications exacerbated the resident's agitation. Further review of the psychiatric evaluation revealed the psychiatrist notified the Director of Nursing, Social Work and the psychologist that 'I fear (spouse) may try suicide/homicide patient if can't get him/her to suicide with him/her.' According to a physician assessment completed on 4/11/18, Resident #4 could hold a conversation and was dependent for most activities of daily living (ADL's). Psychiatric assessment completed by the facility psychiatrist noted on 4/17/18 that the resident's depression was partially triggered due to the resident's loss of mobility. The note further stated that the resident and his/her spouse were having trouble adjusting to their need for long term care. They set each other off and both use the word 'suicide,' which has been a long-term pattern and alcohol worsens it. Further review of the psychiatric evaluation from 4/17/18 revealed recommendations that the team felt the resident was not a risk from the spouse so 1:1 could be discontinued. Although the psychiatrist documented that the previous concern, including the fact that the spouse might try and 'over dose' the resident was alleviated, 30-minute checks needed to continue. Review of Resident #4's medical record on 7/24/18 at 10:49 AM, revealed a physician's orders [REDACTED]. Further review of the medical record failed to reveal a discontinuation of that order. Review of the psychiatric notes from 4/24/18 revealed recommendations to continue the 30-minute checks. Review of the psychiatric notes from 5/1/8 revealed recommendations to continue the 30-minute checks. The spouse was also noted to continue to bring in alcohol to share with the resident, and staff was encouraged to continue to discourage that behavior as it exacerbated both individual's agitation towards each other and staff. Review of the physician assessment for 5/9/18 noted that the resident and spouse were missing their ritual of sharing wine nightly as it was being prohibited by mental health. The resident and spouse continued to express feeling as though the resident was being incarcerated in the facility. It was noted that the presence of the spouse made the resident cry and arguing would start. The Resident was asking for wine as s/he was president of the wine society. The assessment further noted that the resident was followed by mental health, however there was no documentation regarding monitoring in this assessment. Review of the psychiatric notes for 5/15/18 revealed recommendations to continue the 30-minute checks. Review of the psychiatric notes for 6/20/18, did not reveal any mention of the 30-minute checks, or any recommendations to discontinue them. There was a recommendation to encourage the spouse to not bring in alcohol. The last time the psychiatrist saw Resident #4 was on 7/3/18 and at that time the spouse was hospitalized and unable to visit. Since then the resident's spouse had been back and visiting on a regular basis. There had been no other documented attending, mental health or psychiatric follow-up with the resident even though the resident was seen on a regular and consistent basis when the spouse was visiting regularly. The resident was seen by the mental health nurse on: 4/9/18, 4/20/18, 4/30/18, 5/11/18, 5/29/18 and 7/9/18. Documentation from Mental Health staff dated 7/9/18 noted that the resident was depressed, and worried about the spouse as the spouse was currently unable to visit. There were no notes as to continuing or discontinuing the 30-minute checks. The Unit manager and nurse caring for Resident #1 were interviewed on 7/24/18 at 11:16 AM. They were asked where the documentation was related to the 30-minute checks. A form labeled Neighborhood Host Schedule was provided to the Surveyor with a schedule of staff from 9:30 AM - 3:30 PM every half hour that were responsible for activities including but not limited to: 1. 'Engaging the residents in activities, and 2. If you are sitting during your time, you should be either conversing, reading, telling stories or exercising.' The responsibilities were generalized for the unit and not resident specific. The Neighborhood Host Schedule was reviewed with the Director of Nursing and Corporate Nurse on 7/24/18 at 11:43 AM. At that time, they both clarified that it was coverage for the unit not necessarily for Resident #4. Interview with the facility social worker on 7/25/18 at 10:27 AM revealed that there was 'a lot' going on at the time of the MDS assessment and the resident was very upset as there was discussion of him/her going from skilled to long term care and due to his/her emotional state, Resident #4 was unable to complete the assessment. However, the social worker did not verbalize any concerns with the resident's mental capacity during the interview. During interview with the facility DON and Administrator on 7/24/18 and again on 7/25/18 at 1:43 PM regarding documentation of the 30-minute checks, the facility was only able to provide documentation in the nursing notes, which were sporadic, not documented every 30 minutes only shift notes and not daily. They also confirmed that the order for the 30-minute checks on the resident was not discontinued until brought to their attention on 7/24/18. The Director of Nursing (DON) was interviewed on 7/26/18 at 10:49 AM regarding the lack of documentation on the psychiatric assessment regarding the 30-minute checks. According to the facility, they assumed in the timeline created regarding the events that since it was not mentioned it was discontinued. There was no further documentation that the facility could provide of any monitoring other than a nursing note on 4/22/18 at 3:35 PM documenting every 30-minute monitoring continues. A review of the spouse's medical record revealed that s/he was emergency petitioned (statute allows a violent or suicidal person with a mental disorder to be brought to an emergency facility for rapid evaluation regarding the need for emergency treatment) out of the facility for displays of paranoid ideations and suicidal thoughts with a plan and homicidal thoughts with a plan to purchase a firearm. The spouse will further be identified as the 'patient' in the reviewed documents as follows: The 'Report as to Certification as to Commitment,' (petition for emergency evaluation) completed at the facility on 6/22/18 documented that the patient had a current [DIAGNOSES REDACTED]. The patient was noted as a danger to self and others, presenting on physical as; aggressive, lacks insight, has poor judgement and has shown cognitive decline. In addition, the patient required close monitoring and supervision. Further review of the patient's medical records revealed that the patient was admitted to a psychiatric facility for 22 days for psychiatric monitoring and medication stabilization. The hospitalization occurred secondary to; making threats to kill staff at the retirement community as well as the patient's spouse (Resident #4) who is a resident of the community. The patient recently threatened to kill (patient) and (resident) during a visit and brought large quantities of [MEDICATION NAME], Tylenol and liquor to (Resident #4's) room. Patient also becomes increasingly aggressive often screaming at others and throwing furniture, while in the facility. The hospital report also stated that the patient is able to drive, and staff is concerned the patient will purchase a firearm. Inpatient admission was requested due to the concern of the substances brought to the (Residents) room and several unexplained injuries the (Resident) experienced while in the patient's presence. Review of the Inpatient Admission Holding note with Medical history and Physical revealed that the physician documented that although medication was prescribed for the patient, it was suspected that upon discharge the patient would be noncompliant as the patient does not come to scheduled appointments and memory is declining. The patient was discharged on [DATE] to the same skilled nursing facility as Resident #4. The patient's room was one floor above Resident #4's room and was accessible by an elevator. Further review of Resident #4's care plan revealed a late entry note documented on 7/20/18 that included: '1. I will continue to remain free or reduce distressful fearful episodes daily x90 days from my spouse. Will be visited by my spouse per preference.' 3. 'I will like supervised visitation with my (spouse) for safety reasons. 4. 'I need staff to monitor me/my (spouse) for negative actions/expressions.' Interview with the facility psychiatrist on 7/30/18 at 9:32 AM regarding the 6/20/18 assessment revealed that she had spoken with the staff that day and was verbally told by nursing staff that the 30-minute checks were discontinued around 5/15/18. Surveyor asked the psychiatrist if she saw the order and she stated, no. She further stated that it is up to the primary care team to determine the level of observation a resident requires; she just makes the recommendation. Had she known the resident was still on 30-minute checks she would have assessed him/her that day to determine if it was still necessary, however that was not completed. She stated if she was uncomfortable with the fact the order was discontinued she would have reviewed a lot more informal interaction with the resident. She further stated that if she writes an order she does not need to follow-up; she knows that it is done. She only follows up on as needed medications to see how often they are administered. She did not make the recommendation for the resident to come off, however, is not at this time stating that s/he should not have come off the 30-minute checks. She did however, confirm she had made the recommendation to step down the level of observation from 1:1 to 30-minute checks on 4/17/18, but it is up to the primary care team to implement the order. Because of these failures, on (MONTH) 24, (YEAR) at 1:45 PM an Immediate Jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to protect a resident with an identified risk for harm and or abuse after reports of a possible suicide/homicide agreement were made. On (MONTH) 24, (YEAR) at 6:27 PM, the facility submitted an acceptable plan of removal. The plan of removal included the following: 1. Discontinue the 30-minute checks on Resident #4 and initiate 1:1 supervision. A mental health consult was ordered to be completed as soon as possible with re-evaluation of need for 1:1 supervision. 2. Review of current residents will be conducted by the DON or designee to determine if any other residents are at risk of a suicide/homicide pact, a system is in place to monitor the resident, and physician orders [REDACTED]. Date of completion 7/29/18. 3. The staff development coordinator or designee, initiated education on 7/24/18 for staff on the importance of monitoring residents with a reported risk of suicide/homicide pact to include the implementation and execution of physician orders [REDACTED]. 4. Director of Nursing and or designee will conduct weekly audits for 1 month, biweekly for 1 month and monthly for 2 months and annually thereafter to ensure monitoring of residents reported of suicide/homicide pact and implementation of physician orders [REDACTED]. Audit findings will be reported to the Quality Assurance committee monthly for 6 months and quarterly thereafter.

Based on medical record review and interview with the facility's staff, it was determined that the facility failed to have an effective system in place which would promptly honor the wishes of a resident as expressed in an advance directive. This was evident for 1 out of 1 sampled residents selected for review. The findings include: Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During January of 2008, the resident had a gastrostomy tube placed. A gastrostomy tube is surgically inserted directly into the stomach for the purpose of administering nutrition, hydration and medication. Her other [DIAGNOSES REDACTED]. The resident is totally dependent on the facility's staff for all activities of daily living and was certified by her attending physician to lack the capacity to make healthcare related decisions on 1/19/08. review of the resident's medical record revealed [REDACTED]. In this document, she appointed her daughter as her health care agent and also gave clear and unambiguous instructions related to life sustaining procedures. Specifically, the resident clearly directed that her life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially if "she has an end-stage condition, that is, a condition caused by injury, disease or illness as a result of which she has suffered severe and permanent deterioration indicated by incompetency and physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." The document was signed by the resident and two witnesses before a notary public on 11/4/02. On 12/16/10, a Resident Care Advisory Committee (i.e., ethics committee) convened to discuss the resident's current medical condition as it related to her advance directive. Members of the committee included the facility's medical director, director of nursing, assistant administrator, social work manager, social worker, clinical dietitian and the resident's primary care physician. It was the conclusion of the Committee, including the medical director and attending physician, that the continued use of the resident's gastrostomy tube was in violation of the resident's advance directive as she currently met the criteria for end-stage condition. The resident's daughter attended the meeting as well, but did not agree that her mother's tube feeding should be discontinued. On 12/20/10, the resident's attending physician documented in her medical record that she was in an end-stage condition On 12/22/10, the facility's medical director signed a second certification and agreed that the resident was in an end-stage condition. Once these certifications were completed the facility was obligated, under Maryland's Health Care Decisions Act, to follow the expressed wishes of the resident as contained in her advance directive, even over the objections of her daughter. Despite these certifications and the clear realization that continued use of the gastrostomy tube was in direct conflict with the wishes of the resident, the physician continued to order that the resident be fed and hydrated via a gastrostomy tube from 12/23/11 through 6/2/11. The medical director, administrator, director of nursing, social worker and dietitian failed to intervene, and the nurses caring for the resident continued to administer nutrition and hydration via a gastrostomy tube in violation of the resident's advance directive. Interview with the Administrator and the Director of Nursing on 6/9/11 at 4:30 p.m. revealed that they were unable to provide a rationale for continuing to tube feed the resident between 12//23/10 through 6/2/11 despite her wishes not to be given artificial nutrition and hydration once she was certified to be in an end-stage condition. On 6/2/11, the resident's daughter sought and was granted a court order that temporarily compelled the facility to continue the tube feedings.

Based on medical record review and interview of staff, it was determined the social work, dietary and nursing staff failed to honor a resident's right to refuse life-sustaining treatment in accordance with accepted professional standards of clinical practice. This was evident for 1 out 1 sampled residents selected for review. The findings include: Based on medical record review and interview with staff, it was determined that the facility's clinical and administrative leadership team failed to assure that the facility was in compliance with Maryland's Health Care Decisions Act. The Maryland Health Care Decisions Act is a law intended to protect a person's right to make decisions regarding medical care including the right to refuse life-sustaining treatments. Health Care providers are required to honor a person's right to refuse treatment. (Refer to the Annotated Code of Maryland, Health Care General Article, Subtitle 6: Health Care Decisions Act). Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During January of 2008, the resident had a gastrostomy tube placed. A gastrostomy tube is surgically inserted directly into the stomach for the purpose of administering nutrition, hydration and medication. Her other [DIAGNOSES REDACTED]. The resident is totally dependent on facility ' s staff for all activities of daily living and was certified by her attending physician to lack the capacity to make healthcare related decisions on 1/19/08. review of the resident's medical record revealed [REDACTED]. In this document, she appointed her daughter as her health care agent and also gave clear and unambiguous instructions related to life sustaining procedures. Specifically, the resident clearly directed that her life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially if "she has an end-stage condition, that is, a condition caused by injury, disease or illness as a result of which she has suffered severe and permanent deterioration indicated by incompetency and physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." The document was signed by the resident and two witnesses before a notary public on 11/4/02. On 12/16/10, a Resident Care Advisory Committee (i.e., ethics committee) convened to discuss the resident ' s current medical condition as it related to her advance directive. Members of the committee included the facility's medical director, director of nursing, assistant administrator, social work manager, social worker, clinical dietitian and the resident's primary care physician. It was the conclusion of the Committee, including the medical director and attending physician, that the continued use of the resident's gastrostomy tube was in violation of the resident's advance directive as she currently met the criteria for end-stage condition. The resident's daughter attended the meeting as well but did not agree that her mother's tube feeding should be discontinued. On 12/20/10, the resident's attending physician documented in her medical record that she was in an end-stage condition. On 12/22/10, the facility's medical director signed a second certification and agreed that the resident was in an end-stage condition. Despite these certifications and the clear realization that continued use of the gastrostomy tube was in direct conflict with the wishes of the resident, the physician continued to order that the resident be fed and hydrated via a gastrostomy tube. On 2/8/11, the attending physician reviewed the resident's case history, and on 2/26/11, the Medical Director reviewed the resident's medical record. Both concluded that the resident is in an end-stage condition, and to continue the administration of nutrition and hydration via the gastrostomy tube was in clear violation of the resident ' s right to refuse treatment. Nevertheless, the staff continued to provide tube feeding to the resident until June 2, 2011. Despite clear evidence the facility was in violation of the resident's advance directive by continuing to feed the resident via the gastrostomy tube, the social work staff, the nursing staff and the dietitian failed to intervene in any meaningful way to advocate for the resident's right to refuse treatment. Refer to F 155.

Based on medical record review, it was determined that the physician continued to order the administration of nutrition and hydration via gastrostomy tube in direct violation of a resident's right to refuse treatment. This was evident in 1 out 1 sampled residents selected for review. The findings include: Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During January of 2008, the resident had a gastrostomy tube placed. A gastrostomy tube is surgically inserted directly into the stomach for the purpose of administering nutrition, hydration and medication. Her other [DIAGNOSES REDACTED]. The resident is totally dependent on facility's staff for all activities of daily living and was certified by her attending physician to lack the capacity to make healthcare related decisions on 1/19/08. review of the resident's medical record revealed [REDACTED]. In this document, she appointed her daughter as her health care agent and also gave clear and unambiguous instructions related to life sustaining procedures. Specifically, the resident clearly directed that her life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially if "she has an end-stage condition, that is, a condition caused by injury, disease or illness as a result of which she has suffered severe and permanent deterioration indicated by incompetency and physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." The document was signed by the resident and two witnesses before a notary public on 11/4/02. On 12/16/10, a Resident Care Advisory Committee (i.e., ethics committee) convened to discuss the resident's current medical condition as it related to her advance directive. Members of the committee included the facility's medical director, director of nursing, assistant administrator, social work manager, social worker, clinical dietitian and the resident's primary care physician. It was the conclusion of the Committee, including the medical director and attending physician, that the continued use of the resident's gastrostomy tube was in violation of the resident's advance directive as she currently met the criteria for end-stage condition. The resident's daughter attended the meeting as well but did not agree that her mother's tube feeding should be discontinued. On 12/20/10, the resident's attending physician documented in her medical record that she was in an end-stage condition On 12/22/10, the facility's medical director signed a second certification and agreed that the resident was in an end-stage condition. Despite these certifications and the clear realization that continued use of the gastrostomy tube was in direct conflict with the wishes of the resident, the physician continued to order that the resident be fed and hydrated via the gastrostomy tube. On 2/8/11, the resident's attending physician reviewed the case history of the resident. The attending physician documented: "Her (the resident) condition is deemed to be irreversible, and she is totally dependent and severely lacks any mental capacity to make decisions. She has an end stage condition. After reviews of her advance directive she made when competent she did not wish to have any artificial hydration or feedings if she had an end stage condition manifested as severe and permanent deterioration, was physically dependent, incompetent and treatment of [REDACTED]. She clearly fulfills these criteria." The attending physician further documented that the medical staff caring for the resident are in violation of her advance directive by continuing gastrostomy tube feedings. Despite clear evidence the facility was in violation of the resident's advance directive by continuing to feed the resident via the gastrostomy tube, the attending physician continued to sign orders to administer nutrition and hydration via the gastrostomy tube through June 2, 2011. Refer to F 155.

Based on medical record review and interview with staff, it was determined that the facility's clinical and administrative leadership team failed to assure that the facility was in compliance with Maryland's Health Care Decisions Act. This was evident for 1 out of 1 sampled residents selectred for review. The findings include: The Maryland Health Care Decisions Act is a law intended to protect a person's right to make decisions regarding medical care including the right to refuse life-sustaining treatments. Health Care providers are required to honor a person's right to refuse treatment. (Refer to the Annotated Code of Maryland, Health Care General Article, Subtitle 6: Health Care Decisions Act). Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During January of 2008, the resident had a gastrostomy tube placed. A gastrostomy tube is surgically inserted directly into the stomach for the purpose of administering nutrition, hydration and medication. Her other [DIAGNOSES REDACTED]. The resident is totally dependent on facility's staff for all activities of daily living and was certified by her attending physician to lack the capacity to make healthcare related decisions on 1/19/08. review of the resident's medical record revealed [REDACTED]. In this document, she appointed her daughter as her health care agent and also gave clear and unambiguous instructions related to life sustaining procedures. Specifically, the resident clearly directed that her life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially if "she has an end-stage condition, that is, a condition caused by injury, disease or illness as a result of which she has suffered severe and permanent deterioration indicated by incompetency and physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." The document was signed by the resident and two witnesses before a notary public on 11/4/02. On 12/16/10, a Resident Care Advisory Committee (i.e., ethics committee) convened to discuss the resident ' s current medical condition as it related to her advance directive. Members of the committee included the facility ' s medical director, director of nursing, assistant administrator, social work manager, social worker, clinical dietitian and the resident's primary care physician. It was the conclusion of the Committee, including the medical director and attending physician, that the continued use of the resident's gastrostomy tube was in violation of the resident's advance directive as she currently met the criteria for end-stage condition. The resident's daughter attended the meeting as well but did not agree that her mother's tube feeding should be discontinued. On 12/20/10, the resident's attending physician documented in her medical record that she was in an end-stage condition On 12/22/10, the facility's medical director signed a second certification and agreed that the resident was in an end-stage condition. Despite these certifications and the clear realization that continued use of the gastrostomy tube was in direct conflict with the wishes of the resident, the physician continued to order that the resident be fed and hydrated via a gastrostomy tube. On 2/8/11, the attending physician reviewed the resident's case history, and on 2/26/11, the Medical Director reviewed the resident's medical record. Both concluded that the resident is in an end-stage condition, and to continue the administration of nutrition and hydration via the gastrostomy tube was in clear violation of the resident's right to refuse treatment. Nevertheless, the staff continued to provide tube feeding to the resident until June 2, 2011. The clinical and administrative staff failed to act as required by the Maryland Health Care Decisions Act and discontinue the administration of nutrition and hydration via the resident's gastrostomy tube based on the resident ' s wishes as stated in her Advance Directive. Refer to F 155.

Based on medical record review, review of minutes of the Resident Care Advisory Committee and interview with staff, it was determined that the Medical Director failed to provide adequate oversight of the facility's health care practitioners to assure that the wishes of residents as expressed in their advance directives were promptly honored. This was evident in 1 out 1 sampled residents selected for review. The findings include: Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During January of 2008, the resident had a gastrostomy tube placed. A gastrostomy tube is surgically inserted directly into the stomach for the purpose of administering nutrition, hydration and medication. Her other [DIAGNOSES REDACTED]. The resident is totally dependent on facility's staff for all activities of daily living and was certified by her attending physician to lack the capacity to make healthcare related decisions on 1/19/08. review of the resident's medical record revealed [REDACTED]. In this document, she appointed her daughter as her health care agent and also gave clear and unambiguous instructions related to life sustaining procedures. Specifically, the resident directed that her life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially if "she has an end-stage condition, that is, a condition caused by injury, disease or illness as a result of which she has suffered severe and permanent deterioration indicated by incompetency and physical dependency and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]." The document was signed by the resident and two witnesses before a notary public on 11/4/02. On 12/16/10, a Resident Care Advisory Committee (i.e., ethics committee) convened to discuss the resident's current medical condition as it related to her advance directive. Members of the committee included the facility's medical director, director of nursing, assistant administrator, social work manager, social worker, clinical dietitian and the resident's primary care physician. It was the conclusion of the Committee, including the medical director and attending physician, that the continued use of the resident's gastrostomy tube was in violation of the resident's advance directive as she currently met the criteria for end-stage condition. The resident's daughter attended the meeting as well but did not agree that her mother's tube feeding should be discontinued. On 12/20/10, the resident's attending physician documented in her medical record that she was in an end-stage condition. On 12/22/10, the facility's medical director signed a second certification and agreed that the resident was in an end-stage condition. Despite these certifications and the clear realization that continued use of the gastrostomy tube was in direct conflict with the wishes of the resident, the facility continued to tube feed the resident for the next several months. On 2/26/11, the Medical Director reviewed the resident's record and wrote a note which read in part " the resident's moderate to advanced dementia and left sided cortical stroke has resulted in an end-stage condition with severe and permanent deterioration as indicated by complete physical dependency and incapacity ... " Despite the medical director's intimate knowledge of this resident's wishes to forgo life sustaining treatment if in an end-stage condition, the medical director failed to intervene in any meaningful way to stop the tube feeding which continued until June 2, 2011. Refer to F 155.

Based on resident record review, interview and consultation with the facility's Director of Nursing (DON) and Administrator on [DATE] through [DATE], it was determined that the facility's nursing staff failed to honor/observe residents' rights and written instructions regarding health care decisions for 1 of 26 sampled residents in the Stage 2 Sample. This finding is considered past non-compliance. The findings included: Resident #246 was [AGE] years old, admitted to the Long Term Care Facility (LTCF) from the Independent Living Area of the life-care community on [DATE], and had multiple medical conditions which included: Friedreich"s Ataxia, venous embolism and [MEDICAL CONDITIONS], celiac disease, fatigue, chronic diarrhea, [MEDICAL CONDITION], hypokalemia (low potassium level), Vitamin D deficiency, and restless leg syndrome. The resident (according to the medical record review and interview of the DON) was incontinent, alert and oriented to person, place, time and able to make decisions. The resident required extensive assistance/ or was totally dependent for all activities of daily living and moved to the LTCF due to the resident's primary care giver's physical decline. The following observations in the medical record were made: 1. a social work progress note dated [DATE], noted that the resident arrived to the LTCF without Advanced Directives or a Living Will. 2. a physician's admission order and plan of care dated [DATE], was marked as " Code Status B-DNR,but hospitalize " and remained in effect through [DATE]. 3. a certified registered nurse practitioner (CRNP) assessment dated [DATE] in the "Directives" Section stated," EMS, DNR Option A, no aggressive care or life support ", 4. a facility form # 12.2.0, titled,"Code Status Discussion" dated [DATE],0, completed by the CRNP marked Code B (per the facility's code definition-DNR), and noted " DNR option A, declines LSTO(Life Sustaining Treatment Options), trusts husband and daughter- in -law to make decisions", 5. a Maryland Emergency Medical Services (EMS-related to health care in the event of cardiac/respiratory arrest ) form completed on [DATE], noted discission with the resident and that the resident chose Option A : Maximum Efforts to Prevent Cardiac/Respiratory Arrest, DNR if Arrest Occurs-No CPR. 6.Resident's inability to make informed health care decisions. 7. a nursing progress note dated [DATE] at 2:24PM noted that the resident stopped breathing, pulse not found, CPR started, EMS activated, resident was transferred to the hospital. 8. a physician's discharge summary dated [DATE] completed by the CRNP that noted resident's functional decline in condition, cardiopulmonary arrest, transfer to the hospital, and expiration. A review of the resident's nursing progress note dated [DATE] and timed at 2:24 PM revealed that the resident complained of "not feeling good" and wanted to be transferred to bed. The nursing staff ( LPN-licensed practical nurse and GNA-Geriatric Nursing Assistant) transferred the resident back to bed when the resident complained of shortness of breath. The staff noted that the resident's lips turned blue. The nurse started the resident on oxygen at 2liters/min, pulse oximetry (P02) dropped from ,[DATE], and the nurse increased the oxygen (amount of increase in oxygen not noted). Pulse oximetry is a non-invasive monitoring method for assessing the amount of oxygen in a resident's hemoglobin ( part of the red blood cell that carries oxygen); normal range is ,[DATE]%. The resident stopped breathing, a pulse was not found, CPR was started, EMS activated, EMS took over, and transferred resident to the hospital. Additional interview of the DON on [DATE], revealed the following: 1. the resident's DNR directive/status was decided by the resident, 2. the EMS Staff on [DATE] took over/assumed the resident's care after being called , 3. the EMS thought the resident had a pulse,and 4. transferred the resident to the hospital where the resident expired. The nursing staff failed to know the resident's code status, implemented CPR when the resident had a DNR directive/order, honor the resident's wishes, and subjected the resident to unnecessary, aggressive medical treatment.