Every finding on record at Chesapeake Shores Nursing Center

Based on interviews, record review, and observations, it was determined that the facility 1) failed to ensure resident rights to eat in a location of their choice, and 2) failed to follow the resident's preference in care providers. This was found to be evident for breakfast and dinner services and had the potential to affect all residents, and evident in 1 (Resident #28) out of 2 resident reviewed for choices. The findings include: 1) During an interview on 01/05/2026 at 10:22 AM, Resident #49 stated that the only time residents can eat in the dining room is during lunch and has been told they don't have enough staff for residents to eat in the dining room during breakfast and dinner. On 01/06/2026 at 10:36 AM, the facility's schedule of mealtimes was reviewed. Lunch in the dining room was listed to begin at 12:00 PM. There was no dining room serving time listed for breakfast or dinner. On 01/06/2026 at 11:11 AM, Resident #48 was interviewed and stated that they eat in their room for breakfast and dinner. Resident #48 stated residents only eat in the dining room during lunch but would like to eat in the dining room for dinner if that was an option. Resident #48 stated that only lunch in the dining room has been going on for some time. On 01/06/2026 at 12:01 PM, lunch service in the dining room was observed. 14 residents were eating in the dining room being assisted by 4 staff members. The staff members included 1 registered nurse, 1 speech therapist, 1 staffing coordinator, and 1 unknown staff member. On 01/06/2026 at 12:35 PM, the staffing coordinator (Staff #5) was interviewed and stated that there was a rotating schedule for lunch service assistance Monday through Friday, but no weekends. Staff #5 stated there was no dinner service in the dining room because a lot of the day staff who are available to attend and assist the residents have left for the day. On 01/07/2026 at 10:19 AM, concerns about the lack of breakfast and dinner services in the dining room were addressed with the Nursing Home Administrator (NHA). The NHA stated that the facility has plenty of clinical staff but does not have enough kitchen staff to allow residents to eat in the dining room for breakfast and dinner. The NHA stated that residents were allowed to eat in the rehabilitation area if they desire during breakfast and dinner. 2) On 1/8/2026 at 10:29 AM, an interview was conducted with Resident #28. Resident #28 stated that on one occasion a night shift Geriatric Nursing Assistant (GNA #27) came into Resident #28's room unannounced. Resident #28 expressed to the Director of Nursing (DON) that they did not want GNA #27 to care for him/her anymore. According to the resident, GNA #27 continued to care for him/her despite making the DON aware of his/her preferences. On 1/8/2026 at 11:16 AM, an interview was conducted with the DON. When asked if the DON recalled when Resident #28 made a request to not have GNA #27 care for them after they came into their room unannounced, the DON stated that they do recall and ensured the GNA did not work with Resident #28. When asked what happens when a resident requests not to have a certain staff member or a change in nurse, the DON stated that they let the staffing coordinator know so that they do not schedule the Staff member with the resident. This surveyor requested evidence that GNA #27 did not work with the resident after the request. On 1/8/2026 at 11:50 AM, an interview with the DON and review of the staffing schedule was conducted. The DON stated that after their review of the staff schedule for December of 2025, GNA #27 did work with Resident #28 after the request was made. The DON stated that GNA #27 picked up an extra shift and worked with the Resident on 12/27/25 when they should not have. The DON stated that they were made aware of this on 12/29/25 and the facility administration made him a Do Not Return the same day. When asked how other staff members in the facility were made aware of the resident preferences, the DON stated that they currently did not have a system in place to make resident preferences known.

Based on interviews, observations, and record review, it was determined that the facility failed to provide a functional and comfortable environment to residents. This was found to be evident in 2 of 2 facility courtyard awnings.The findings include:During an interview on 01/05/2026 at 11:05 AM, Resident #49 stated to this writer that the awning in the outside courtyard where residents go to smoke was ripped and was told by staff that there were no plans to repair the awning.A observation was made by this writer of the outside courtyard on 01/05/2026 at 12:26 PM from inside the dining room. The awning located outside next to the dining room was observed to have a large tear.On 01/06/2026 at 1:00 PM, surveyors went outside and observed the courtyard. The awning located next to the dining room exit and entrance in the outside courtyard had a long tear of several feet and and dozens of smaller holes. The awning located across the courtyard next to the rehabilitation gym entrance and exit was completely removed.On 01/06/2026 at 1:04 PM, an interview was conducted with Residents #29, #55, #65, and #41 during their smoke break in the outside courtyard. Resident #41 stated it had been a while since there was an awning next to the rehabilitation gym entrance and exit. Resident #29 also stated that there had not been an awning in that location for several years. Resident #65 stated that the awning next to the dining room entrance and exit had been in disrepair since they had been at the facility which was 3 years. The residents interviewed stated they must huddle in little areas underneath the awning by the dining room when it rains so they don't get wet. Resident #65 stated they had heard rumors about the awnings being replaced for years.On 01/07/2026 at 10:11 AM, the facility's Maintenance Director (MD) was interviewed by this writer. They stated they were aware that the awning was in bad condition and has replaced with tarps previously, but they don't last very long. The MD stated that they were not aware of the current status of replacing the awnings.On 01/07/2026 at 10:19 AM, the courtyard was toured with the Nursing Home Administrator (NHA) and surveyor addressed concern of the current condition of the awnings. The NHA stated that the facility has been looking to replace them but cannot find a vendor. The NHA stated they would provide emails of the vendor search.On 1/7/2026 at 2:08 PM, this writer reviewed an email provided by the NHA. The email showed correspondence between facility ownership and Apex Global Solutions on 05/08/2025 about vendors for awning (ownership) and suggesting to buy locally (Apex Global Solutions). No additional information about awning procurement was provided by the facility.

Based on record review and staff interview, it was determined that the facility failed to maintain accurate resident records. This was evident for 1 (Resident #2) out of 27 residents in the recertification survey. The findings include:Based on record review and staff interview, it was determined that the facility failed to maintain accurate resident records. This was evident for 1 (Resident #2) out of 27 residents in the recertification survey. The findings include: On 1/5/2026 at 11:09 AM, a review of Resident #2's progress notes was conducted. During the initial pool record review of Resident #2's chart, a Skin and Wound note from 11/25/25 indicated that the resident had 1 chronic abdominal wound and 2 bilateral lower extremity wounds. On 1/6/2026 at 9:53 AM, further review of the Skin and Wound note from 11/25/25 revealed that the resident's name on the note in Resident #2's chart was another resident's name. On 1/6/2026 at 10:09 AM, an interview with the Director of Nursing (DON) was conducted. The survey team made the DON aware of concern of incorrect name in wound note. DON acknowledged the incorrect name and stated that the resident did not have any wounds. Confirmed with the DON that the Wound Practitioner (Staff #28) entered the incorrect resident's wound note into Resident #2's chart.

Based on record review and staff interviews, it was determined that the facility failed to ensure residents were educated on the benefits and risks of Influenza vaccine following a refusal. This was evident for 1 resident (Resident #41) out of 5 residents reviewed for immunizations during the facility's recertification survey.The findings include:Based on record review and staff interviews, it was determined that the facility failed to ensure residents were educated on the benefits and risks of Influenza vaccine following a refusal. This was evident for 1 resident (Resident #41) out of 5 residents reviewed for immunizations during the facility's recertification survey. The findings include: A BIMS score is derived from the Brief Interview for Mental Status, a brief screening tool for assessing cognitive function in long-term care settings. A score between 0 and 15, where higher scores indicate better cognitive ability, helps facilities track cognitive changes. Scores are categorized: 0–7 is severe impairment, 8–12 is moderate impairment, and 13–15 is cognitively intact. The assessment evaluates temporal orientation and short-term recall. On 01/07/2026 at 1:03 PM, the surveyor reviewed the immunization records for 5 residents randomly selected and identified that Resident #41's immunization record lacked documentation that education regarding the risks and benefits of the influenza vaccine was provided following the resident's refusal of the vaccine. Review of the record showed that Resident #41 had a BIMS score of 13, indicating Resident #41 was cognitively intact. On 01/07/2026 at 1:34 PM, during an interview with the Infection Preventionist (IP), she stated that immunizations were offered to new residents upon admission and that during influenza season, consents were obtained from both new and existing residents. When asked about the facility's expectation regarding education following declination of vaccination, she stated that residents or their representatives were required to receive education on the risks and benefits of the vaccine regardless of whether they consent or decline, and that such education should be documented in the resident's electronic health record. When asked to provide documentation of education given to Resident #41 after declining the influenza vaccine, she stated it would be in the electronic health record and left to retrieve it. On 01/07/2026 at 1:42 PM, the IP returned and confirmed that there was no evidence that education regarding the risks and benefits of the influenza vaccine had been provided to Resident #41 following the refusal. She further stated that the facility should have provided the education and documented it in the resident's health record. On 01/07/2026 at 1:55 PM, the Director of Nursing (DON) was informed of the concern regarding the lack of education provided to residents following refusal of the influenza vaccine. The DON acknowledged this as a concern.

Based on observation and staff interviews, it was determined that the facility failed to maintain appropriate infection prevention and control practices. This failure was identified during observations of Activities of Daily Living (ADL) care provided to 2 of 5 sampled residents (Residents #6 and #54) who were on Enhanced Barrier Precautions (EBP) during the facility's recertification survey.The findings include:Activities of Daily Living (ADL) care involves assisting individuals with fundamental self-care tasks essential for health and independence, such as eating, bathing, dressing, toileting, grooming, and mobility, often assessed in elderly, disabled, or recovering persons to determine their need for support. Enhanced Barrier Precautions (EBP) are infection control measures, primarily for nursing homes, requiring healthcare workers to wear gloves and gowns during high-contact resident care activities (like bathing, dressing) to prevent spreading multidrug-resistant organisms (MDROs) to hands and clothing, even if blood/body fluid exposure isn't expected, extending standard precautions for residents with multidrug-resistant organisms (MDROs) or at high risk (wounds, devices). Personal Protective Equipment (PPE) refers to specialized gear like gloves, gowns, masks, and goggles that create a barrier to protect healthcare workers from infectious materials (blood, body fluids, germs) and prevent them from spreading infections to patients or others. On 01/05/2026 at 9:23 AM, during the initial tour of the facility, the surveyor was present in Resident #6's room. The resident, who had an EBP signage on his/her door, requested assistance to use the bathroom. A staff member passing by was notified. The surveyor observed that two Geriatric Nursing Assistants (GNA #15 and GNA #16) entered the room and provided care without performing hand hygiene prior to entry and without donning a gown, as required under EBP. On 01/05/2026 at 9:27 AM, during an interview, GNA #15 was asked about expectations for appropriate PPE use while providing resident's hygiene care. She stated that she was expected to sanitize her hands and wear gloves. When asked about why she did not use PPE as required in context of the gown, she stated she was unaware that a gown was required during toileting or personal care and believed the gown requirement posted on the resident's door applied only to wound care. On 01/05/2026 at 10:17 AM, during an interview, GNA #16 was asked about expectations for appropriate PPE use during hygiene for residents. She stated that EBP protocol required hand hygiene, gloves, and a gown. When asked why she did not use the required PPE while providing care for Resident #6, she stated she was unaware the resident was on EBP because she usually cared for other residents and acknowledged she should have checked the door signage prior to providing care. 01/07/2026 2:33 PM, surveyor informed the Nursing Home Administrator (NHA) the concern about using inappropriate precaution and she acknowledged the concern. On 01/07/2026 at 2:42 PM, surveyors heard an overhead page requesting nurses to meet with the Director of Nursing (DON) on the B-Wing of the facility. Surveyors observed the DON provides verbal education to nursing staff regarding PPE requirements for residents on EBP. When asked how she identified noncompliance, the DON stated that she had been informed that staff members were not following the PPE protocol and she had also observed staff failing to use PPE appropriately, she added that the verbal education was to reinforce adherence to PPE protocol. The surveyor informed the DON that surveyor had also observed staff not donning PPE appropriately and had informed the NHA about it. On 01/08/2025 at 10:10 AM, during a follow-up walk through the units, the surveyor observed agency staff GNA #26 transfer Resident #54 who also had an EBP post on his/her door from bed to wheelchair while wearing gloves only and no gown. On 01/08/2026 at 10:16 PM, the surveyor reviewed the electronic health records for Residents #6 and #54 and it revealed that both residents had an order for Enhance Barrier Precautions (EBP). On 01/08/2025 at 10:47 AM, during an interview, the Infection Preventionist (IP) was asked about staff expectations regarding PPE use. She stated staff were expected to follow EBP protocols and further indicated the staff member involved was agency staff. When asked if agency staff received facility-specific training prior to working a shift at the facility, she stated no, explaining that agency staff were expected to rely on training provided by their agency. On 01/08/2025 at 10:49 AM, the surveyor, accompanied by the Director of Nursing (DON) and the IP, observed the resident receive a shower while staff wore gloves only and no gown. On 01/08/2025 at 10:50 AM, during an interview, agency GNA #26 was asked about expectations for PPE use when providing ADL care to residents on EBP. She stated the expectation was for her to wear gloves and a gown for the procedure. She further stated she had not previously worked with the resident and reported the resident told her that he/she was not on EBP, which she cited as the reason for not wearing the required PPE.

Based on observation, medical record review, and staff interviews, it was determined that the facility staff failed to ensure residents received respiratory care consistent with professional standards of practice by failing to ensure respiratory/oxygen equipment was properly labeled and dated. This deficient practice was evident for 2 (Residents #48 and #3) out of 4 residents reviewed for respiratory/oxygen therapy during the facility's recertification survey.The findings include:Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. Oxygen tubing is a medical-grade hose that connects an oxygen source (like a concentrator or tank) to an oxygen delivery device, such as a nasal cannula or mask. It is designed to be lightweight, flexible, and kink-resistant to ensure a steady and uninterrupted flow of oxygen for therapy. Liters per minute (LPM) is the standard measurement for supplemental oxygen flow, indicating how much oxygen is delivered over time. On 01/05/2026 at 8:34 AM, during the initial tour of the facility, the surveyor observed Resident #48 in bed receiving oxygen at 3 liters per minute (LPM) via nasal cannula. The oxygen tubing in use was observed to have no date or label. On 01/05/2026 at 10:35 AM, the surveyor conducted a dual observation with Licensed Practical Nurse (LPN) #10, who confirmed the oxygen tubing was not dated or labeled as required and stated the issue would be corrected. On 01/06/2026 at 7:46 AM, during a follow-up visit with residents receiving oxygen therapy, the surveyor observed Resident #3 in bed receiving oxygen therapy. The oxygen tubing in use was observed to have no date or label. On 01/06/2026 at 7:51 AM, during an interview with the Unit Manager on A-Wing (Staff #8), the surveyor asked about the expectation for labeling and dating oxygen equipment. Staff #8 stated that oxygen tubing and humidifiers should be dated and labeled. During a dual observation, Staff #8 confirmed the oxygen tubing for Resident #3 was not dated or labeled and stated nursing staff should have dated and labeled the equipment after it was changed. On 01/06/2026 at 7:55 AM, during a follow-up observation of Resident #48, the surveyor observed the nasal cannula connected to the oxygen tubing remained not dated or labeled. On 01/06/2026 at 7:57 AM, the surveyor conducted a dual observation with LPN #11, who confirmed the oxygen tubing connected to the nasal cannula was not dated or labeled. When asked about expectation, LPN #11 stated the equipment should have been dated and labeled after it was changed. On 01/06/2026 at 8:07 AM, the Director of Nursing (DON) was informed of the concerns regarding the failure to date and label oxygen tubing. The DON acknowledged the concern and stated the oxygen tubing should have been dated and labeled after it was changed.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to arrange vision appointments for a resident. This was evident for 1 (Resident #41) out of 1 resident reviewed for vision. The findings include:Based on resident interview, record review, and staff interview, it was determined that the facility failed to arrange vision appointments for a resident. This was evident for 1 (Resident #41) out of 1 resident reviewed for vision. The findings include: On 1/5/2026 at 9:01 AM, an interview with Resident #41 was conducted. The resident stated that they were supposed to receive new glasses around 3 months ago and they have not received them yet. On 1/6/2026 at 10:51 AM, a review of Resident #41's vision consult notes was conducted. A note from 9/02/2025 the ophthalmologist referred Resident #41 to a Retinologist within 2 weeks for retinal injections evaluation. On the Retinologist note from 9/12/25 the resident received an intravitreal injection of Avastin and was recommended for follow up in 1 month. A progress note from the Director of Nursing (DON) 10/16/2025 stated, Resident and RP notified of having to re-schedule today's retina appointment. Awaiting call back from Retina office. On 1/6/2026 at 11:33 AM, an interview with DON was conducted. This surveyor reviewed the Retina Center note from 9/12/2025 with DON. When asked DON if the follow up appointment was scheduled, The DON stated that the original follow up appointment from 10/16/2025 had to be rescheduled but was not arranged by the facility. The DON stated that the facility would ensure that the appointment is scheduled today (1/6/2026).

Based on record review, observation, and staff interview, it was determined that the facility staff failed to maintain professional standards of practice related to signing off resident care services. This was evident for 1 (Resident #1) of 2 residents reviewed for wounds. The findings include:On 01/05/2026 at 11:32 AM, review of Resident #1's medical record revealed a progress note titled, HP skin and wound note, dated 12/29/25 which indicated the resident had multiple wounds. The progress note noted recommendation of, turning/repositioning precautions per protocol.At the same time further record review revealed another progress note titled, HP skin and wound note, dated 01/08/26 which indicated the resident had multiple wounds. The progress note noted recommendation of, turning/repositioning precautions per protocol. On 01/07/2026 at 8:08 AM, review of the most recent Minimum Data Set, dated [DATE] revealed that the resident needed substantial to maximal assistance (of staff) to roll left and right. The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans and monitor quality of care.On 01/07/2026 at 8:27 AM, an observation of the resident revealed they were on their left side.On 01/07/2026 at 10:21 AM, an observation of the resident revealed they were on their left side.On 01/07/2026 at 12:46 PM, an observation of the resident revealed they were on their left side.On 01/07/2026 at 1:37 PM, review of documentation titled, Documentation Survey Report v2- MONITOR Turn and Reposition, revealed that GNA (Staff #29) documented Y (YES) on the document for dayshift on 1/7/26.At the same time, review of documentation titled, Documentation Survey Report v2- GG Roll Left and Right, revealed GNA (Staff #29) documented that the resident was dependent (needed staff help entirely to turn onto left and right side) for the day shift on 1/7/26.On 01/07/2026 at 2:40 PM, an observation of the resident revealed they were on their left side.On 01/08/2026 at 8:01 AM, an observation of the resident revealed they were on their left side.On 01/08/2026 at 10:03 AM, an observation of the resident revealed they were on their left side.On 01/08/2026 at 10:04 AM, an interview with Wound Nurse (Staff #25) regarding what turning/repositioning precautions per protocol meant revealed that it meant that it was encouraged that staff turn the resident left to right every two hours.On 01/08/2026 at 11:56 AM, an observation of the resident revealed they were on their left side.On 01/08/2026 at 2:01 PM, an observation of the resident revealed they were on their left side.On 01/08/2026 at 2:19 PM, review of documentation titled, Documentation Survey Report v2- MONITOR Turn and Reposition, revealed that GNA (Staff #30) documented Y (YES) on the document for dayshift on 1/8/26.At the same time, review of documentation titled, Documentation Survey Report v2- GG Roll Left and Right, revealed GNA (Staff #30) documented that the resident needed substantial to maximal assistance (needed staff help to do more than half the effort to help the resident turn onto left and right side) for the day shift on 1/8/26.On 01/08/2026 at 2:41 PM, an interview with the Director of Nursing revealed that when the GNAs signed off Y on the document titled, Documentation Survey Report v2- MONITOR Turn and Reposition, it meant the resident was turned throughout the shift. At the same time, the surveyor reviewed the concern with the Director of Nursing, she indicated that the resident often refuses care, but that staff should not be documenting that the resident had been turned and repositioned throughout the shift if they were not.

Based on medical record review and staff interviews, it was determined that facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment. This failure was evident for 1 resident (Resident #4) out of 8 residents reviewed for MDS assessments during the facility's recertification survey.The findings include:The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement. Care Area Assessments (CAAs) are a crucial part of the Minimum Data Set (MDS) process in skilled nursing facilities, serving as prompts for detailed reviews of specific resident issues like delirium, nutrition, falls, or mood, forming the basis for personalized care plans by an interdisciplinary team (IDT) to address needs, set goals, and enhance resident well-being. These assessments trigger deeper evaluations beyond basic MDS data, ensuring comprehensive, individualized care plans for residents. PRN, from the Latin **pro re nata, means as needed or as the situation arises, commonly used in healthcare for medications (taken only when symptoms occur) or for flexible, on-call staffing for nurses and other professionals who work shifts as required, rather than on a fixed schedule. Transdermally means through the skin, referring to the administration of medicine that is absorbed via the skin and into the bloodstream, often using patches (like nicotine or hormone patches) or ointments, to provide a controlled, sustained dose without needing oral ingestion or injections. On 01/06/2026 at 10:58 AM, during review of Resident #4's most current MDS and Care Area Assessments (CAAs) dated 10/17/2025, the surveyor noted the following: Section J showed that the resident received scheduled pain medications and indicated No for receipt, offer, or refusal of PRN pain medication during the last five days of the assessment. On 01/06/2026 at 11:13 AM, review of Resident #4's physician orders for pain management revealed the following active orders: Tylenol Oral Tablet 325 mg (Acetaminophen), give 2 tablets by mouth three times daily for Other Chronic Pain. Fentanyl Transdermal Patch 72 Hour 50 mcg/hr, apply one patch transdermally every three days for Other Chronic Pain. Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl) *Controlled Drug*, Give 1 tablet by mouth every 4 hours as needed for Pain - Severe 6-10 related to Other Chronic Pain. On 01/06/2026 at 11:49 AM, review of the resident's Licensed Nurse Medication Administration Record (LNMAR) for October 2025 showed that Resident #4 received PRN pain medication on 10/01, 10/03, 10/04, 10/06, 10/08, 10/11, 10/12, 10/14, 10/15, 10/16, 10/20, 10/21, and 10/22, which included dates within the five-day look-back period of the MDS assessment dated [DATE]. On 01/06/2026 at 12:18 PM, during an interview with the MDS Nurse (Staff #12), she stated that Section J of the MDS was coded based on the resident's status during the last five days of the assessment period. She stated that Section J, item related to PRN pain medication, indicates whether the resident received, was offered, or declined PRN pain medication during that time frame. When asked how the determination was made, she stated the LNMAR was reviewed. Upon a dual review of the LNMAR and the MDS, Staff #12 confirmed that PRN Hydromorphone had been administered during the five-day look-back period and acknowledged that the MDS was incorrectly coded by another staff member. She stated it should have been coded Yes instead of No. When informed that the inaccurate coding was a concern, she acknowledged the concern and stated she would re-educate staff to prevent recurrence during the resident's next scheduled MDS assessment on 01/13/2026. A copy of the MDS Section J dated 10/17/2025 was requested and provided. On 01/06/2026 at 12:33 PM, the Director of Nursing (DON) was informed of the concern regarding inaccurate MDS coding, and she acknowledged it as a concern.

Based on observations and interviews it was determined that the facility failed to ensure call devices were accessible to residents. This was evident 1) for 1 resident room (room [ROOM NUMBER]-B) and 2) for all residents' bathrooms and facility shower rooms, during the initial resident screening and nursing unit observation of the recertification survey. The findings include: 1) On 5/1/24 at 10:17 AM the surveyor observed resident #35 sitting in a recliner in their room resting. The call device was plugged to the wall but was not within reach of the resident. The resident was asked if s/he had an alternate call device anywhere beside them and s/he said no. The resident was asked how they call for assistance without the call device. The resident stated that s/he uses the call device but sometimes staff would put it out of reach, which makes it difficult to call sometimes so would yell out for help instead. Staff #7, an activity director walked into the room on 5/1/24 at 10:26 AM while the surveyor was still having a conversation with the resident. She placed a brace on the resident's left arm. The surveyor asked if she could find the residents call device. She looked around and said it was notched/twisted under the resident's bed and should not be left like that. She loosened it and placed it close within the resident's reach. The surveyor instructed the resident to press the call device to make sure it works. Resident did and confirmed that it worked. In an interview with staff #50 a Geriatric Nursing Assistant (GNA) on 5/14/24 at 1:14 PM, she was asked the expectation for call bells. She stated that they are expected to be answered promptly by all staff, should not be ignored, and must be placed within residents' reach. She was asked what could happen if they were not within the residents' reach. She stated that most of them will yell or call out for help, but they are supposed to be placed within reach. On 5/14/24 at 1:21 AM the Nursing Home Administrator was made aware that this was a concern. 48168 2) On 5/01/24 at 2:08 PM an observation of resident room [ROOM NUMBER]-B and the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] was conducted. The shared bathroom had a call device on the wall next to the toilet but there was no cord attached to the device, it was only a push button. On 5/14/24 at 10:22 AM another observation of the shared bathroom between room [ROOM NUMBER] and 223 was conducted with the Maintenance Director, (Staff #49). When the surveyor pointed out that the call device did not have a pull cord, Staff #49 explained that all of the call devices in the entire facility were the same, none of them had pull cords. When asked how a resident could reach the alarm if the resident had fallen on the floor, Staff #49 said he did not know. On 5/14/24 at 10:44 AM the Nursing Home Administrator was made aware of the call device deficiency.

Based on observation, interview, and documentation review it was determined that the facility staff failed to 1) ensure the dish washing machine was operating at the appropriate water temperature and sanitation levels, and 2) failed to ensure food has reached proper final internal cooking temperatures and/or all hot foods are held at 135 degrees Fahrenheit or higher on the steam table. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. This was evident during random kitchen inspection/observations of food service conducted during the recertification survey. The findings included. 1) On [DATE] at 2:05 PM, observation of the staff and dish washing machine were initiated at 2:05 PM. The facility's dish machine was an Ecolab model ES-2000 single rack low temperature machine with chemical sanitation. The manufacture's plaque on the machine revealed that the minimal wash and rinse temperature was to be 120 degrees Fahrenheit (F). Review of the current Dish machine log indicated that the water temperature and chemical sanitation level was recorded for breakfast and lunch time dishwashing service by the same employee. Upon questioning the dietary personnel, the staff person that had recorded the water and sanitation levels was identified as the dietary aide (staff #14) preparing the dirty dish ware on racks for placement into the dish machine. Staff #14 was asked to demonstrate how she obtained the recorded water temperature and sanitation level. Staff #14 left the dish machine room and went to the dietary director's office. The dietary director gathered a thermometer and a vial of sanitizer/chlorine test strips from a compartment above the three compartment sinks. The dietary manager placed the thermometer on an empty rack and ran the dish machine for an entire cycle. Upon completion she removed the rack and checked the thermometer. She showed the surveyor the thermometer and the surveyor was unable to read the temperature. She repeated the process and received the same results. Eventually the dietary director realized that the thermometer was still in the protective case. The thermometer was placed on a rack, ran through a dishwashing cycle, and was read at 130 degrees F. The surveyor noted a dial on the lower portion of the dish machine. The dial/gauge was difficult to read as the dial appeared foggy. The dietary director indicated that the county (inspector)said that the gauge was to be fixed. The dishwasher ran through a couple of cycles with the dietary director, dietary staff #14, and the surveyor observing. Both times the temperature gauge barely moved and was no greater than 90 degrees F. Staff #14 was asked to demonstrate how the facility checks the sanitation level. The doors to the dish washing machine were raised to dip the chemical strip into the remaining water in the machine. Upon dipping the test strip into the water, a purple color was noted that was different than the grayscale indicator on the outside to of the test strip vial. The surveyor questioned what the proper way to test the chemical sanitizer and how do the staff record and document the wash and rinse water temperatures. The dietary director was unsure and did not indicate how. The surveyor looked at the test strip vial and found an expiration date of [DATE]. The test strips expired a year ago. The dietary director left the dish washing room. The dietary aide was asked again how she determined the wash and rinse temperatures that she had documented on the dish machine log. She implied that she just wrote 120 on the dish machine log. She never indicated that she looked at the temperature gauge on the dish machine and she did not note when the dietary director was attempting to determine the dish water temperature with the thermometer still in the case. The dietary director returned with the district manager. The district manager was asked if there are instructions on how to properly test the sanitation level of the dishwashing machine. The district manager indicated that there should be a manual. The surveyor requested to review the manual and the district manager implied that he would have to check the with the facility administrative staff. An internet search was conducted on [DATE] at 3:15 PM. The search revealed a 91-page Installation and operation manual for the ES Series door type, chemical sanitizing single and dual rack dish machines for 11 Ecolab models. The district manager supplied a paper copy of the documents, on [DATE] at 12:22 PM, and the Ecolab manual was discussed. The manual did not provide instructions of how to test the chemical sanitation level and he acknowledged the same. The surveyor asked about a Chlorine test kit as found in the manual. Reading, Titrate the rinse water using the chlorine titration test kit. Chlorine titration should be between 50 and 100 ppm. Adjust the cam timer if the chlorine level is not correct He responded that he did not know about the chlorine titration kit. He indicated that he had initiated education to the dietary staff related to dishwashing protocols. On [DATE] at 10:25 AM, the surveyor was provided with documentation of a dish washing machine service call by Ecolab on [DATE]. Ecolab documented that the water wash temperature was not reading. The temperature gauge was bad and needed to be changed. 2) On [DATE] at 11:40 AM a kitchen observation/inspection was initiated. The lunch service tray line started at 11:45 AM with 3 staff on the tray line and the district manager in the kitchen office. The dietary director was on the steam table side. Review of the cooking temperature logbook after the start of tray line revealed temperatures documented for 5 food items on the tray line. The log included columns for cooking time started and cooking time ended and there were temperatures for Initial cooking internal Temp. Recorded as degrees F. Pork at 178 Sweet Potato at 172 Cabbage at 188 Mash Potato at 164 Ground pork at 177. There were not any temperatures recorded in the Final internal temperature column. There was not any temperature recording of the Puree items observed on the tray line. There was not any temperature of the alternative for the Hamburger steak. The pan with the Hamburger steak was noted to sit on top of the steam table straddling two pans and not in the water wells of the steam table. At 11:55 AM, the district manager was shown the current cooking temperature log with emphasis that there was not any documentation in the Final internal temp column and no documentation for other items on the tray line. He walked over to the dietary manager and said something in private to the director and she was overheard saying that she was not used to being on the steam table side. The tray line was observed until the last meal was sent out of the kitchen and noted that the tray line was never paused to perform temperature checks. Review of the [DATE] cooking temperature log on [DATE] at 11:20 AM revealed that Cooking temperature log was completed with all the columns filled in and additional food items added to the log. The [DATE] log was shown to the district manager at 11:30 AM. Discussion about the surveyors expressed concern on [DATE] of the lack of completed temperature documentation. He indicated that the dietary director was not at the facility, and he could not speak for her. On [DATE] at 11:17 AM, a tour of the kitchen revealed two dietary staff members were in the kitchen. The steam table was filled with food pans covered in plastic wrap. Review of the Cooking temperature log for the [DATE], only showed food temperature documentation for the [DATE] breakfast. The form was completely blank for the lunch time meal service. The cook (staff #37) was observed to enter the kitchen from the outside and he initiate the measuring of the pans of food on the steam table at 11:28 AM. The [DATE] lunch time tray line began at 11:45 AM. Food items observed in pans on the steam table included Chicken taco mixture, Mexican street corn, Cilantro Rice, puree meat in sauce/gravy, ground meat, peas, puree peas, mashed potato, and a small pan of porkchops. The cooking temperature log was reviewed at 11:50 AM. It was noted that the cook (staff #37) only documented on 4 of the items on the steam table. He had documented the cooking time started, cooking time ended, initial cooking internal temperature and final internal temperature as follows. Chicken taco cooking time started = 11:15, Cooking time ended = 11:20, initial cooking internal temp = 175 (degrees F), and final internal temp 175. Rice cooking time started at 11:15, cooking time ended 11:20, initial cooking internal temp = 170, and final internal temp 170. Puree rice cooking time started 11:15, cooking time ended 11:25, initial cooking internal temp = 170, and final internal temp = 170. Puree corn cooking time started 11:20 AM, cooking time ended 11:25, initial cooking temp 180 and final internal temp = 175. The district manager was shown the lunch time cooking temperature log at 11:55 AM on [DATE]. He indicated that the cook may have not had time to record the food temperatures. While the cook was tending to the tray line, he was questioned about the incomplete temperature log indicating he did not have time to write the food temperatures because he had to start the tray line. On [DATE] at 10:55 AM a discussion was held with the district manager related to food temperatures not recorded in real time. He showed the Cooking temperature log from [DATE] with additional temperatures of 4 more food items documented on the log after a copy of the log was made on [DATE]. The additional food items indicated that mashed Cooking time started was 11:55 and cooking time ended 11:55, with initial cooking temperature = 165, and final internal temperature = 165. The cooking times started, and cooking times ended were between 11:50 and 12:05, for puree corn, puree rice, and peas. The cooking times overlapped with the active tray line. The cook was serving on the steam table side of the tray line he was not cooking food or taking food temperatures at the times documented on the [DATE] temperature logs. There were not any temperatures recorded for the alternative menu of pork chops, green beans or buttered noodles. An interview with the nursing home administrator was conducted on [DATE] at 11:10 PM to review identified kitchen concerns.

Based on interviews of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: An interview was conducted with the Dietary Director (Staff #12) on 4/30/24 at 9:50 AM. She indicated that she had worked at the facility for [AGE] years with indication that she has had various job duties in the kitchen. She indicated that she has been in full charge of the kitchen for a year. She was asked if she was a Certified Dietary Manager, and she directed the surveyor to a certification on the bulletin board outside her office. Review of the certificate revealed that she was not a Certified Dietary manager. The certificate revealed that she had completed the State Food Safety Food Protection Manager Certification Exam. The date the certificate was issued = January 18, 2024. It was noted that the facility contracts with Health Care Services Group for the overall operation of kitchen and dining services. On 4/30/24 at 12:34, the district manager (Staff #13) for Health Care Services Group introduced himself to surveyor. Upon discussion the district manager acknowledged that the Dietary director was not a Certified Dietary Manager. The district manager revealed that he was not a Certified Dietary Manager and he had supervisory oversight of 4 other buildings. He indicated that he had a CPFS (Certified Professional-Food Safety) certificate. The concern that the Dietary Director did not meet the qualifications to oversee the dietary department was shared with the nursing home administrator on 5/15/24 at 11:10 AM.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 3 residents (Resident #74, #43, and #89) of 5 residents reviewed for pain during the recertification survey. The findings include: A pain scale is a numerical scale, usually 0-10, used to rate a person's severity of pain. 1) On 4/30/24 at 1:19PM during the initial interview, Resident #74 was asked if s/he had pain and how that was managed. Resident stated that they were on pain medication and would ask for it before their pain level gets too high 10/10. Review of the physician's order on 5/6/24 at 10:00 AM revealed an order written on 3/23/24 as Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug *Give 1 tablet by mouth every 4 hours as needed for PAIN and Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for PAIN. Further review did not reveal a pain scale to determine at what pain level each medication should be given. Review of Resident #74 January 2024 Medication Administration Records (MAR) on 5/6/24 at 10:15 AM revealed that on 1/9, 1/17, 1/18, 1/22 and 1/24 Resident #74 got Oxycodone, a pain medication when their pain levels were documented as zero indicating no pain at all. On 5/06/24 at 2:23 PM Staff #35 a Registered Nurse (RN) was asked in an interview their process for administering PRN (as needed) pain medications. She stated that residents are assessed for their pain levels before medications are given. If no pain was indicated, then the medication would not be given. She was asked how they determine which pain medication to give if two different pain medications were ordered without a pain scale. She stated that these medications are given based on nursing judgement and on the severity of the pain levels and that pain scales are usually associated with the orders. She was asked if she will give a resident their PRN pain medication when their pain scale was at zero and she said no. In another interview on 05/06/24 at 2:42 PM with staff #24 a Licensed Practical Nurse (LPN), she was asked if there was a standard pain scale used for pain medication administration and she said a scale of 1-10 was used. She was asked what she would do if a resident had two pain medications ordered without a pain scale. She said she would contact the provider to verify and get a pain scale ordered to know which medication to give first. She was asked if she would give pain medication to a resident with zero pain. She said no but would do further assessment to figure out what was going on and would write a note if she gave it to state why the medication was given. On 5/6/24 at 3:00 PM The Director of Nursing (DON) was made aware of the concerns. 48168 2) On 5/10/24 at 10:17 AM a review of Resident #43's care plan revealed a problem for chronic pain. A review of the resident's medication orders revealed two pain medications to be used as needed, one was a non-narcotic (acetaminophen) dated 4/23/23 and one was a narcotic (oxycodone) dated 4/5/24. Neither medication order included pain scale parameters to indicate when either should be administered. On 5/13/24 at 9:30 AM an interview with Registered Nurse (RN #17) was conducted. When asked how she would decide whether to administer a non-narcotic pain medication or a narcotic pain medication to a resident who had both medications ordered on an as needed basis, RN #17 explained that there were always parameters for what medication to give depending on the assessment of the resident's severity of pain. She said she would assess the resident's pain by asking the resident's pain level on a scale of 0-10. She said that typically the scale was as follows: 1-3 = mild, 4-6 = moderate, 7 or greater = severe. She said that if there was no pain parameter for an order, she would call the doctor. On 5/13/24 at 11:47 AM an interview with the Unit Manager for A Wing (Staff #15), Resident #43's medication orders were reviewed and revealed no pain severity scale was included to indicate when either Tylenol or oxycodone should be administered. When asked if the ordering doctor/provider gave parameters when ordering pain meds, Staff #15 said sometimes, but if Staff #15 discovered the pain scale parameter was missing, he said he would call the doctor/provider for that information. On 5/13/24 at 12:02 PM an interview with the facility Nurse Practitioner (NP #16) was conducted. When asked about pain scale parameters for residents who have as needed orders for both non-narcotic and narcotic pain medications, she stated that there were usually parameters written, and there should be parameters for all pain medication orders given on an as needed basis. When asked to review Resident #43's pain medication orders, she did so and stated that there were no parameters written to indicate when either medication should be given and there should have been. On 5/14/24 at 10:42 AM the Nursing Home Administrator was made aware of the concern regarding the lack of pain scale parameters for pain medication orders. 43096 3) During complaint investigations on 5/10/24 at 8:09 AM, the surveyor reviewed an intake (MD 00185048) reported on 10/30/22 about Resident #89's care. The complainant reported that Resident #89 contacted 911 requesting medical assistance and was in pain. The facility called back and canceled the 911 call, and then the resident called 911 again. Upon arrival at EMS, she was told by nursing staff that medical attention was not needed. However, Resident #89 was observed crying in pain. The Resident was transferred to the hospital. On 5/10/24 at 10:34 AM, the surveyor reviewed Resident #89's medical records and revealed that the resident's BIMS score (Brief Interview for Mental Status is a mandatory tool used to assess the cognitive health of long-term care residents. The BIMS score ranges from 0 to 15 points, and is categorized into three cognitive groups: Intact, Moderate, and Severe) assessed 15 out of 15 on 10/21/22. A continued review of Medication Administration Records (MAR) for October 2022 revealed that the Resident had been prescribed scheduled pain medication on 8/10/22 for acetaminophen-codeine 300-30mg twice a day for pain in unspecified join. However, the MAR had no documentation for 10/13/22, 10/14/22, 10/15/22, 10/28/22, 10/29/22 morning, and 10/30/22 afternoon doses. These days were left as a hole. Additional review of Resident #89's medical record on 5/10/24 at 11:00 AM revealed that a nursing staff wrote a progress note on 10/30/22 at 12:48 PM as resident kept calling 911 stating he/she needed to go to the hospital because his/her stomach was hiring .Abdomen was soft and non-distended. However, there was no further evaluation and/or documentation about Resident #89's pain. During an interview with a registered nurse (RN #17) on 5/10/24 at 11:56 AM, RN #17 stated that all medication should be documented in the MAR, and if it was not given, it should be noted in residents' medical records the reasons. In an interview with the Nursing Home Administrator (NHA) on 5/10/24 at 12:43 PM, the surveyor shared concerns about Resident #89's lack of pain management. She validated the concern.

Based on a review of facility records, interviews with facility staff, and interviews with residents, it was determined that the facility staff 1) failed to ensure that all allegations of abuse, medication storage issues, and unusual incidents were thoroughly investigated and 2) failed to provide interventions to avoid repeated allegations. This was evident for 4 residents (Residents #36, #343, #345, #347) of 18 reported resident incidents reviewed during the survey. The findings include: 1) On 4/30/24 at 10:00 am during the entrance conference of the recertification survey, a request for the facility's investigation files for self-reported incidents was made to the Nursing Home Administrator (NHA). On 5/08/24 at 9:04 AM a review of the facility reported incident # MD00188190 dated 1/24/23 was conducted. The report described the discovery on 1/23/24 of a bruise on Resident #36's arm and an allegation by Resident #36 that a black male GNA had hit the resident a few days before. On 5/08/24 at 9:15 AM a review of the facility's investigation file for #MD00188190 revealed witness statements from staff and residents which asked about any witnesses for the day bruise was discovered on Resident #36's arm, 1/23/24, including a statement from GNA #36, the only black male GNA working on 1/23/24. However, none of the statements asked about any time prior to that day, even though the incident was alleged to have occurred prior to 1/23/24 per the facility's own report statements. During an interview on 5/08/24 at 9:58 AM the NHA was asked if there were any statements from staff and residents that addressed the days before 1/23/24 when the alleged incident occurred. She said there were no statements that asked about that time frame. The surveyor then asked for staff assignments for 1/15/23-1/23/23 and requested GNA #36's employee file. The NHA's response was that GNA #36 no longer worked at the facility and that GNA #36 did not care for the resident during the time of the alleged incident. On 5/08/23 at 10:45 am the NHA brought Resident #36's care documentation that showed GNA #36 documented that he provided care to Resident #36 on 1/18/23 and 1/19/23 on evening shift. The documentation indicated that GNA #36 assisted the resident with bed mobility, dressing, toilet use, personal hygiene, and other tasks. The NHA acknowledged that Resident #36's care documentation was not reviewed during the investigation and should have been. When the surveyor asked to speak to GNA #36 the NHA replied that he no longer worked at the facility and that he was terminated in April 2023 for misconduct. 43096 2) A review of the facility's self-reported incident, MD00182614, on 5/13/24 at 12:40 PM revealed that Resident #343 reported that he/she had been physically and verbally abused by staff on 4/27/23. Further review of the facility's investigation revealed that the facility conducted a head-to-toe assessment for Resident #343 and obtained other residents' interviews and staff interviews, including the alleged perpetrator. However, the investigation packet did not have a statement from the resident. During the review of Resident #343's medical record on 5/13/24 at 3:30 PM, it was revealed that the resident's BIMS (Brief Interview for Mental Status is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility: 0-7 means severe cognitive impairment, 8-12 means moderate cognitive impairment, and 13-15 means intact cognition) was 15 out of 15 on 3/28/22. In an interview with the Nursing Home Administrator (NHA) on 5/13/24 at 4:00 PM, the NHA confirmed that Resident #343 was alert, oriented, and able to be interviewed. The surveyor asked if the facility had any statement from him/herself regarding the incident. The NHA said, The facility staff put details in the self-report form but did not document or obtain a separate statement form from the resident. On 5/15/24 at 11 AM, the surveyor shared concerns about the above issue with the NHA, which she validated. 3) Alprazolam (Xanax) is a controlled substance, which means that it's more likely to be misused or cause dependence. The Alprazolam used for anxiety and panic as psychotropic medication. Nursing home facility nursing staff are required to document controlled medication use on their sheet, which is called a count sheet. On 5/06/24 at 5:12 PM, the surveyor investigated the facility's self-report, MD00196024, about Resident #345's medications (Alprazolam) which were brought from home upon admission was taken by a former employee (Registered Nurse #46) on 8/22/23. Further review of the facility's investigation revealed that the facility obtained two statements from Staff #47 and #48 about the incident. The statements explained that Staff #48 did not feel comfortable having Resident #345's medication in the medication cart without a count sheet. Then, they asked RN #46 (a unit manager) to keep them until Resident #345's family could retrieve the meds. In an interview with the Nursing Home Administrator (NHA) on 5/07/24 at 11:03 AM, the NHA was asked for any written statement from RN #46 regarding the incident. The NHA said, RN #46 was already terminated for another reason when the incident occurred. There was no written statement from her. The NHA added, Since RN #6 was the Director of Nursing (DON) when the incident occurred, she may have the statement. The surveyor interviewed RN #6 on 5/08/24 at 10:18 AM. RN #6 confirmed that since the facility staff were not able to find Resident #345's Alprazolam on his/her discharge date , they contacted RN #46 via phone. On the phone call, RN #46 stated that she accidentally took the medications. RN #46 returned all pills, and they were counted. RN #46 verified that RN #6 did not write any statement about the incident. Also, RN #46 confirmed that she had reported the details to the nursing board but did not write any statements regarding how to contact RN #6, how to receive the medications back, and/or how the incident occurred. A review of the facility's training records related to Resident #345's brought-in-home medication (Alprazolam) on 5/08/24 at 10:55 AM revealed that the facility provided in-service to nursing staff from 8/30/23 to 9/05/23. There were 30 nursing staff signed off on the attending sheet. The Nursing Home Administrator (NHA) was asked about the total number of nursing staff in the building. The NHA stated that approximately 120 nursing staff work in the building, including approximately 70 aides and 50 nurses. The surveyor informed the NHA that education was only provided to some staff to prevent repeated incidents. In an interview with the NHA on 5/08/24 at 11:00 AM, the surveyor shared concerns about the above issue, which the NHA validated. 4) A rectal probe is a thin, long wire that monitors the internal body at a safe rectal temperature. A review of a facility self-reported incident, MD00201894, on 5/06/24 at 10:02 AM revealed that facility staff found Resident #347 had a rectal probe wire attached to their sacral dressing on 1/24/24. Further review of the facility's investigation contained a Geriatric Nursing Aide's (GNA #39) written statement on 1/30/24, On 1/22/24, I was changing [Resident #347], and I saw a patch on his/her bottom, and I just figure it was something that was supposed to be there. So I was very careful when cleaning him/her cause I figure it was supposed to be there. Also, GNA #38 wrote a statement on 1/29/24 as on 1/24/24, I was washing up [Resident #347], turned him/her over I saw something sticking out of his/her butt. I went and told the nurse. The review of the facility's investigative documentation on 5/06/24 at 2:40 PM revealed that the facility provided in-service training on 'checking for foreign objects in or on residents' on 1/25/24. The training attending sheet listed eleven staff members. The surveyor asked about the incident during an interview with the Geriatric Nursing Aide (GNA #39) on 5/07/24 at 6:45 AM. GNA #39 said, A nurse asked me to write a statement about the white patch; I wrote it. No one explained what it was or what was wrong. The surveyor shared the in-service training form related to Resident #347's rectal probe issue, which GNA #39 signed. GNA #39 said, I can't remember what it was. I thought something happened to other residents. No one told me it was related to [Resident #347]. In an interview with the Nursing Home Administrator (NHA) on 5/07/24 at 8:33 AM, the NHA stated that the facility provided in-service to prevent further incidents. The surveyor asked how many nursing staff, including aides, work in the building. The NHA confirmed the facility has more than one hundred nursing staff. The NHA validated that the facility failed to educate nursing staff to prevent similar incidents.

Based on resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 10 (#4, #23, #24, #30, #43, #45, #56, #72, #82, #289) of 19 residents selected in the final sample and a failed test tray was identified on the unit that was served last. The findings included: Upon initiation of the survey on 4/30/24 random food complaints from residents included: Interview of Resident #56 at 10:59 AM was asked about the food and responded, It's not that good and needs seasoning. Resident #56 was unaware of an alternative menu. At 11:09 AM Resident #23 indicated food is bland sometimes. At 12:50 PM Resident #24 indicated the food is nasty, some days it is okay and some days it's not. At 1:36 PM Resident #30 indicated, the food is bad, does not look or taste appetizing, overall food is bad, they don't give you choices, don't get milk any more. The following residents' comments occurred on 5/01/24 when asked about the food. At 8:20 AM Resident #4 indicated food is terrible. I won't feed it to a dog. Meat so dry, they need a cook here. Sometimes food is cold sometimes it's warm. At 8:24 AM resident #72 stated food is disgusting like dog food .fish and Italian sausage are disgusting. Resident #72 further indicated that the facility did not post a menu and he/she did not know of an alternative option. At 10:01 AM Resident #289 indicated that the food not that good, no options. At 11:50 AM Resident #45 indicated the Food is terrible, you don't know what you're going to get. On 5/02/24 at 8:39 Resident # 43 complained of cold food On 5/02/24 at 9:23 AM resident #82 stated the food is not good. On 5/01/24 at 8:50 AM an interview was conducted with the outgoing resident council president (resident #28). Resident #28 indicated that there had been have been resident council concerns of the food mainly being cold and not tasting good. On 5/08/24 at 11:40 AM lunch meal service/tray line observations were initiated in the kitchen. The lunch service tray line started at 11:45 AM with 3 staff on the tray line and the district manager in the kitchen office. The dietary director was on the steam table side. Review of the cooking temperature logbook after the start of tray line revealed temperatures documented for 5 food items on the tray line. The log included columns for cooking time started and cooking time ended and there were temperatures for Initial cooking internal Temp. Recorded as: Pork at 178 Sweet Potato at 172 cabbage at 188 Mash Potato at 164 Ground pork at 177. There were not any temperatures recorded in the Final internal temperature column. There was not any temperature recording of the Puree items observed on the tray line. There was not any temperature of the alternative for the Hamburger steak. The pan with the Hamburger steak was noted to sit on top of the steam table straddling two pans and not in the water wells of the steam table. At 11:55 AM, the district manager was shown the current cooking temperature log with emphasis that there was not any documentation in the Final internal temp column and no documentation for other items on the tray line. He walked over to the dietary manager and said something in private to the director and she was overheard saying that she was not used to being on the steam table side. The tray line was observed until the last meal was sent out of the kitchen and noted that the tray line was never paused to perform temperature checks. It was noted that the B-wing #2 cart was filled and ready for delivery and placed at the kitchen doorway at 12:30 PM. 12:42 PM the cart remained in the kitchen. The cart was followed out of the kitchen and observed at 12:44 PM with dietary staff getting a signature from B-wing staff. A test tray was requested to be placed on the last cart leaving the kitchen. At 12:45 the tray line was stopped as the steam table was out of Pork loin, cabbage, mandarin oranges, and ground meat. The dietary director began to cook frozen steak sandwich meat in a frying pan. The alternative hamburger steak was placed in a food processor for grinding. Fruit cocktail mix was substituted for the oranges. At 12:49 PM there was a continued delay for the last few trays waiting as food was being prepared. The cart with the test tray was delivered to A-wing at 12:57 PM. There were 4 aides on A-wing passing the trays the last resident served was at 1:10 PM. The surveyor waited until the last resident tray was delivered prior to temperature check of the test tray. The test tray food was tested with a calibrated KM14 Comark pocket digital thermometer. The pork loin test temperature was 118 degrees Fahrenheit (F.) Whipped sweet potatoes at 116.8, Cabbage at 119.2 and mixed fruit at 51.6. The temperature of the pork was shown to have had a 60 degree drop since the last kitchen temperature. The sweet potatoes had a 55.2 degree drop, and the cabbage shown to have a 68.8 degree drop since the last recorded kitchen temperature. The food tasted warm not hot. On 5/15/24 at 11:10 AM the nursing home administrator was informed of the negative concerns that were shared by the residents. The observations of the kitchen staff not performing temperature checks of all the food in real time. The kitchen ran out of food on the tray line.

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 resident (Resident #76) of 4 residents reviewed for transfer to the hospital. The findings include. Review of Resident #76's medical record on 5/01/24 at 7:47 AM revealed an einteract SBAR Summary note dated 4/06/24 for 4:55 PM indicating the resident had a fall and a recommendation to transfer the resident to the hospital. The health Status Note that followed indicated the resident was sent out to the hospital for a fall. Review of the einteract note and the health Status note did not document what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why. An interview was conducted with the unit manager (staff #18) on 5/07/24 at 10:35 AM with a discussion related to progress note documentation of resident #76's fall on 4/6/24. The note did not indicate if the fall was observed or where the fall occurred. The unit manager reviewed the nursing progress notes with indication of the writer of the fall note was a new nurse and she acknowledged the documentation of the note was poor. A follow up interview was conducted with the Unit manager at 3:28 PM on 5/07/24 and the regulatory requirement of documenting that the facility must orient and prepare the resident regarding his or her transfer in a form and manner that the resident can understand was reviewed with the unit manager as related to the nursing progress note that were previously reviewed and that the nursing notes did not document the information reviewed. The unit manager revealed that she was unaware of the documentation requirements for a facility initiated resident transfer to the hospital.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 2 residents (Resident #71, #74) of 5 residents reviewed for advance directives during the recertification survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. 1) On [DATE] at 9:25 AM during a review of the clinical record of Resident # 71's chart, the resident's MOLST was located, but there was no documented evidence and/or information indicating that an opportunity to formulate an advance directive was provided to the resident and/or the resident's representative (RP). On [DATE] at 10:30 AM, review of social services progress notes did not reveal any documentation that the resident and/or RP was given the opportunity to formulate an advance directive. On [DATE] at 10:42 AM, in an interview with the Director of Nursing (DON) she stated that all residents' advance directives were scanned into the facility's electronic record (PCC). The surveyor requested a copy of Resident # 71's advance directives. On [DATE] at 12:10 PM, an interview was completed with the Social Worker (SW #2) regarding provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. SW #2 stated that she has worked in the facility for about 3 years and residents were asked about their advance directives during admission and Full life meeting that included members of the interdisciplinary team. SW #2 added that they reviewed and offered information concerning advance directives during the meeting. She further stated that the initial social service assessment will have information on advance directives and social worker will document in progress notes regarding discussion with family to bring advance directive forms if any. She stated that the MOLST form was completed upon admission to the facility and usually came with the resident. The surveyor again requested a copy of Resident #71's advance directives. On [DATE] at 12:35 PM, additional review of Resident #71's medical record was completed: a copy of the resident's advance directives was not located in the medical records. On [DATE] at 8:50 AM, in a follow up interview with SW #2, she stated that Resident #71 did not have a copy of advance directives on file. She stated that the resident had a MOLST which was considered an advance directive and SW #2 gave the surveyor a copy of the resident's MOLST including an incapacity form that indicated that Resident #71 had capacity to make his/her own decision. SW #2 added that she (SW #2) has reached out to the resident's family to bring a copy of the advance directives if they had one. On [DATE] at 8:57 AM, in an interview with the DON and Nursing Home Administrator (NHA), the NHA confirmed that Resident #71 did not have an advance directive on file. NHA stated that she (NHA) was a social worker by profession prior to becoming the NHA and acknowledged that there was a difference between an Advance Directives and a MOLST. On [DATE] at 11:31 AM, surveyor reviewed the facility's policy and procedures for Residents' Rights Regarding Treatment and Advance Directives [NAME] Health implemented on [DATE] and revised on [DATE]: Under policy explanation and compliance guidelines: #3 - Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 44441 2) On [DATE] at 12:10 PM a chart review for Resident #74 revealed the resident was admitted to the facility on [DATE]. Review of the social services history and initial assessment form dated [DATE], under Advanced Care Planning Documented that advanced directive was offered and that resident had one. This document, however, could not be found in the residents' medical records. In an interview with Staff #2 a Social Worker (SW) on [DATE] at 12:15 PM. She was asked about the process for offering Advanced Directives to residents. She stated that she would offer them to the residents on admission and then revisit when she does the quarterly assessments. She was made aware that Resident #74's Advanced directives could not be found and was asked to provide the document. On [DATE] at 1:19 PM - The SW brought the MOLST form dated [DATE] and physician certification related to medical condition decision making and treatment limitations dated [DATE], but not the Advanced directives. She said it was not in the medical records. On [DATE] at 10:47 AM The Director of Nursing (DON) was made aware of the concern. She said she spoke with the resident and the resident said their relatives had them. The DON stated that she asked the resident to have their family member bring it.

Based on record review and staff interviews, it was determined that the facility failed to protect a resident's right to be free from misappropriation and/or exploitation by taking a resident's medications. This was evident for 1 (Resident #345) of 4 residents reviewed for personal property during an annual survey. The findings include: On 5/06/24 at 5:12 PM, the surveyor investigated the facility's self-report, MD00196024, about Resident #345's medications (Alprazolam: psychotropic medication for anxiety and panic, also known as Xanax), which were brought from home upon admission were taken by a former employee (Registered Nurse #46). Further review of the facility's investigation revealed that the facility obtained two written statements from Staff #47 and #48 about the incidents. Staff #47 wrote a statement on 8/24/23: Staff #48 didn't feel comfortable having Alprazolam in her cart without a count sheet, and she was told to give them to RN #46 to return to the family upon discharge. We were unable to find the medications, so we called RN #46 to ask about the location of the meds. RN #46 found the medications in her belongings that were taken out of her office when she was terminated. Also, Staff #48 reported in her written statement on 8/25/23 that she did not feel comfortable taking over the medication cart with an Alprazolam bottle for Resident #345 without a narcotic count sheet. She gave the medicine to her unit manager, RN #46, until Resident #345's family could retrieve the meds. During an interview with a Registered Nurse (RN #6, also previous Director of Nursing) on 5/08/24 at 10:18 AM, RN #6 confirmed that since the facility staff were not able to find Resident #345's Alprazolam, they contacted RN #46 via phone. During the phone call, RN #46 stated that she accidentally took the medications; all pills were accounted for. In an interview with the Nursing Home Administrator (NHA) on 5/08/24 at 11:00 AM, the surveyor shared concerns about Resident #345's home medication being taken by RN #46 without any permission and/or explanation to the resident. The NHA validated the concerns.

Based on observation and staff interview, it was determined that the facility failed to ensure that residents care areas and furniture were kept in good repair. This was evident for 1 resident's bedroom area (Resident #290) and for 1 shared bathroom (room [ROOM NUMBER]/223 shared bathroom) during the initial observation of residents' rooms during the recertification survey. The findings include: 1) On 5/3/24 at 11:41AM an observation of Resident #290's room revealed a nightstand beside the resident's bed that appeared to be in disrepair. The Plastic veneer on the four edges surrounding the top of the nightstand were completely off on one side exposing the rough wood. The other 2 sides of the nightstand were partially peeled off with the Plastic veneer sticking out. The bottom drawer was hanging out of the nightstand and the edges were half peeled off. The wall at the head of the resident's bed was observed with spackled areas measuring about 1x2 foot long. In an interview with Resident #209 on 5/03/24 at 11:45 AM, the resident indicated that the nightstand has been like that for a while and that the spackle on the walls were from staff pushing his bed back and forth during care provision. On 5/14/24 at 10:15 AM, Staff #49 the maintenance director was taken to the resident's room (121-A&B) and shown the nightstand, he said he will fix and put it back together. He was also shown the sparkle on the resident's wall, and he said they have a lot of them from moving the resident's beds and furniture's around. He was made aware that this was a concern. On 5/14/24 at 10:58 AM The Nursing Home Administrator was made aware of the environmental concerns. 48168 2) On 5/01/24 at 2:08 PM an observation of the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] on the B wing of the facility revealed an area measuring approximately 24 inches long by 10 inches wide directly under the sink where the tile was missing, and the concrete subflooring was exposed. On 5/14/24 at 10:22 AM an observation of the bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] was conducted with the Director of Maintenance (Staff #49). Staff #49 stated that the flooring was removed to repair a pipe six months ago. No explanation was given for the lack of repair of the floor tile. On 5/14/24 at 10:55 AM in an interview with the Nursing Home Administrator (NHA), the NHA was informed about the missing flooring in the shared bathroom between rooms [ROOM NUMBERS]. She did not provide any information or explanation.

Based on observation and staff interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by failing to serve all residents at the same table at the same time during dining observations. This was evident for 1 of 40 residents observed during the survey (resident #83). The findings include. On 5/9/24, observations of the lunch time lunch meal service in the Potomac dining room were initiated at approximately 12:10 PM. The lunch cart was already in the dining room and the Social worker (staff #2) and the A-wing unit manager (staff # 15) were delivering meals to the residents in the dining room. At 12:15 PM resident #83 was noted to be sitting at a table without lunch, and the other two residents on each side of resident #83 had their lunch. The unit manager was assisting and feeding one of the two residents seated at the table with resident #83. At approximately 12:25 PM staff #15 requested staff #2 to check on resident #83's lunch. The social worker was able to retrieve a lunch tray from the kitchen and served resident #83's lunch at 12:30 PM. An interview was conducted with the social worker at 12:40 PM discussing how the scheduling of staffing to pass out the lunch meal and resident #83 sitting at a table without a meal while the table mates were eating. She acknowledged that resident #83 had been without a meal for some time while the other residents were eating.