Every finding on record at Chestertown Nursing and Rehab

Number of residents sampled: Number of residents cited: Based on interview and record reviews, it was determined that facility staff failed to ensure sufficient weekend staffing. This deficient practice was evidenced by the Payroll-Based Journal (PBJ) report review during the annual survey.The findings include:A review of the facility's Payroll-Based Journal (PBJ) report on 07/30/25, revealed that the facility was flagged for excessively low weekend staffing levels during the second quarter of 2025. On 08/12/25 at 8:09 AM, a review of the facility assessment showed that the document was updated in 2025. Further review indicated that, to provide continuity of care for residents, the facility's staffing goal is 3.15 Hours Per Patient per Day (HPPD). On 08/12/25 at 8:36 AM, during an interview with Staffing Coordinator (SC) #6, the surveyor discussed that the facility's PBJ report indicated low weekend staffing. The SC #6 acknowledged that the facility had low staffing on the weekends through June 2025. When asked whether the facility uses agency nursing staff, the SC #6 stated that the facility had been agency free since April 2024. When asked what steps the facility would take to ensure proper staffing, the SC #6 reported that the facility would contact its sister facility to request staff support. She explained that in June 2025 the facility hired additional staff specifically to cover the weekend shift and since that time, the facility has not experienced issues with weekend staffing. The surveyor requested to review the HPPD data for March, April and May 2025. A review of the HPPD indicates the following:March 2025: 03/01/25- 2.57, 03/02/25-2.75, 03/08/25-2.41, 03/09/25- 2.51,03/15/25-2/75, 03/16/25-2.77, 03/29/25-2.67, 03/30/25, 2.7. The facility failed to meet staffing requirements 4 out of 5 weekends in March.April 2025: 04/05/25-2.95, 04/06/25-2.87, 04/12/25-2.92, 04/13/25-2.96, 04/19/25-2.7, 04/20/25-2.85, 04/27/25-2.97. The facility failed to meet staffing requirements 4 out of 4 weekends in April.May 2025: 05/03/25-2.89, 05/04/25-2.97, 05/10/25-2.59, 05/11/25-2.57. The facility failed to meet staffing requirement 2 out of 5 weekends in May. The Administrator and Director of Nursing were made aware of the second quarter 2025 PBJ report and were provided with a copy of the report during the entrance conference on 08/04/25.

Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure residents had a homelike dining environment. This was evident for the initial dining observation during the annual survey.The findings include:On 08/04/2025 at 9:35 AM, an initial observation of the Chesapeake unit upon facility entrance revealed the dining room was locked and unused for breakfast. The residents were getting their breakfast delivered to their rooms.On 08/11/2025 at 2:35 PM, an interview with the Nursing Home Administrator (NHA) revealed that the dining room was locked for breakfast and dinner. She said the residents were not up and ready in the morning by breakfast time so it stayed locked until lunch, and was locked again for dinner. The surveyor reviewed the concern.

Based on observation and interview with facility staff, it was determined that the facility 1) failed to maintain kitchen, kitchen equipment and surfaces in a sanitary condition to prevent the potential for food contamination 2) failed to ensure that food items were labeled and dated. This was found to be evident during the observations of the facility's kitchen food service operations during Medicare/Medicaid recertification survey. 1) On 08/04/2025 at 7:43 AM, during the initial facility tour with the Assistant Food Service Director (Staff #1), the surveyor observed five jars of different seasonings on the top shelf, all open, with visible seasoning particles scattered across the shelf. When the surveyor asked why the seasoning jars were not covered, she stated that she had just returned from vacation and that the night staff should have kept it covered. The food preparation sink had lots of white oily stains, when asked what was in the sink, she confirmed that the stains were from oily foods that were washed during the previous shift and proceeded to clean the sink.At 8:00 AM on 08/04/2025, the surveyor observed several dried and wet food stains on the kitchen walls and dried food stains on the counters and tables.At 8:11 AM on 08/04/2025, the three-compartment sink had white lime deposits on the faucets, and the three handwashing sinks in the kitchen were dirty with brown stains. Staff #2 was called for a dual observation and confirmed the sinks were dirty.2) On 08/04/2025 at 8:14 AM, during a continued tour of the kitchen with dietary aide Staff #2 accompanying the surveyor because the Assistant Food service Director, Staff # 1, was dishing out the meals. Inside the walk-in refrigerator, two bowls of lettuce, two bowls of cheese, about 6 pounds of raw ham, desserts (tomatoes, cucumbers and banana cream pies) and several bread rolls were seen with no dates or label.On 08/04/2025 at 8:20 AM, in an interview with the Staff #1, while staff #2 was present, when she asked when the unlabeled and undated food items were made, she stated that she just got back from vacation and did not know when they were made. When she was asked if the food items in the refrigerator should have been labelled and dated, she stated that the food items should have been dated and labelled and added that the right thing to do was to put dates and label on every food item. She went ahead to take the food items out of the refrigerator. Staff #2 also went ahead to date and label the food items, and he stated that the desserts were from lunch on 08/03/2025 and that the staff who placed it in the refrigerator should have put a date on it because nobody would have known when they were made or when the raw ham was taken out of the freezer to the refrigerator.At 10:40 AM on 08/04/2025, the surveyor discussed the kitchen concerns with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the [NAME] President of Clinical services. The NHA stated she would begin investigating immediately.At 10:55 AM on 08/04/2025, the NHA confirmed the surveyor's observations and stated that the dirty kitchen walls, sinks, and all other unclean surfaces would be deep cleaned in the early morning hours of 08/05/2025.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that facility staff failed to ensure a thorough investigation was conducted for an allegation of staff to resident abuse and failed to maintain documentation. This deficient practice was evident for one resident (# 78) reviewed for facility reported investigations during the annual survey.The findings include:On 08/11/25, a review of the facility reported incident (FRI) # 310743 revealed that on 1/26/25, Resident #78 informed a nurse supervisor that a staff member made inappropriate comments while administrating medication on 01/24/25. The resident stated that the comments made them feel uncomfortable and embarrassed. A review of the facility's initial report form dated 01/27/25 indicated that the facility contacted the police. The alleged perpetrator was suspended, a psychiatric nurse practitioner was requested to evaluate the resident, and social worker met with the resident to ensure the resident felt safe. In addition, statements were obtained from Resident #78, the alleged perpetrator, the nurse supervisor, and staff who were working at the time of the alleged incident.A review of family nurse practitioner (NP) #37 progress note dated 01/28/25 indicated that NP #37 was requested to evaluate Resident #78 following an incident reported on 01/24/25. During the evaluation, the resident reported that a staff member exposed them, made inappropriate comments, and the incident made them feel embarrassed. NP #37 documented that that the resident's judgement and insight appeared intact. NP #37 concluded that, in her professional opinion after speaking with the resident, the allegations appear to be example of the resident's attention seeking behaviors and her fantasies about relationships. A review of the resident's medical record did not show documentation of a prior history of such behavior. A review of Resident #78's psychiatric evaluation and consultation dated 01/17/25, indicates that the resident was seen at the request of the facility for medication management. During the examination, the resident was noted as calm, well-groomed and cooperative. The resident's thought process was listed as linear, logical, and goal directed, with no acute psychiatric features observed. Further review of psychiatric evaluation from 09/17/24 through 01/17/25 did not reveal a history of attention seeking behavior. In addition, there was no documentation indicating that the resident was evaluated following the incident on 01/24/25.On 08/11/25, a review of the facility's follow-up investigation report form dated 01/30/25, indicated that the facility was unable to determine whether the incident actually occurred. The surveyor requested documentation to support the facility's conclusion, including evidence of the resident's behavioral concerns, documentation the resident was evaluated by psychology in relation to the incident from 01/24/25, and records verifying that the social worker met with the resident daily as indicated on the follow up investigation report form. During an interview with the Administrator (NHA), on 08/11/25 at 10:35 AM, the surveyor discussed the incident involving Resident #78 and asked about the basis of her conclusion regarding the incident. The NHA stated that her investigation was based on the nurse practitioners progress note. The surveyor explained that a review of Resident #78's care plan, progress notes, and psychiatric evaluations prior to the incident on 01/24/25 failed to reveal a history of attention seeking behavior, fantasies about relationships, or any other similar behaviors. The NHA acknowledged that she did not review the resident records and that her decision not to substantiate the incident was based on NP #37's progress note. On 08/11/25 at 11:06 AM, the Assistant Director of Nursing informed the surveyor that the facility was unable to provide the request

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to report an allegation of abuse within two hours. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents reviewed during the annual survey.The findings include:On 08/11/2025 at 10:34 AM, review of Incident #310745 investigation documentation revealed that on 4/20/25 at 11:30 AM, Geriatric Nursing Assistant (Staff #34) observed bruises on Resident #24's right ankle. Further review of the investigation documentation revealed that on 4/20/25 at 11:30 AM, when Staff #34 asked Resident #24 about the bruising, he/she indicated that GNA was rough and aggressive with him/her on 4/19/25. On 08/11/2025 at 10:43 AM, review of the investigation documentation revealed that the facility failed to report the incident to the Office of Health Care Quality until 4/20/2025 at 1:10 PM.On 8/11/25 at 11:28 AM, the surveyor reviewed the concern with the Nursing Home Administrator, she understood that the incident was not reported within two hours.

Based on review of a facility reported incident , record reviews and staff interviews, it was determined that the facility failed to 1) revise a care plan to accommodate the need after medication was increased and 2) revise a care plan after a facility reported incident. This was evident for 1 resident (Resident #69) out of 3 residents reviewed for care plans during the Medicare/Medicare recertification survey.The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan. Care conferences are usually held on a regular basis, often quarterly, but can be scheduled more frequently if needed based on the resident's condition. 1) On 08/06/2025 at 9:57 AM, during a review of Resident #69’s order in his/her electronic health records, it revealed that the Medical Director, Staff #32 had given an order on 07/09/2025 for “Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day” to be given to the resident in addition to the initial order for Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) which was ordered on 04/05/2025. At 10:03 AM on the same day, review of Resident #69’s care plan did not show that it was revised to reflect the medication change. At 10:07 AM on the same day, a review of the resident’s progress notes in the electronic health record on 07/10/2025 showed “Alert Note with note text: Behaviors, Resident observed very agitated and aggressive towards staff and residents. MD made aware, medication in place”. On 08/06/2025 at 10:57 AM, in an interview with the Director of Nursing (DON), when he was asked for the protocol after a change in residents medication regimen regarding care plan updates, he stated that he would have expected the residents care plan to reflect the new change in the medication regimen with goals and intervention in place. When he was informed that Resident #69s care plan did not reflect the medication change, he confirmed that it was not updated and stated that he would update the care plan immediately. 2) On 08/07/2025 7:34 AM, the surveyor reviewed the facility’s reported investigation packet for intake 310746 which confirmed a verified altercation between Resident #69 and Resident #79. Both residents were documented as having dementia. At 7:48 AM on 08/07/2025, further review of the packet revealed a handwritten statement by Geriatric Nursing Assistant (GNA #39) in which she stated that “Resident #69 was entering and exiting every patient room bothering each patient”. At 10:25 AM on 08/07/2025, several progress notes in the electronic health records of Resident #69 noted that he/she gets agitated easily and gets redirected often. His/her care plan was also reviewed, and it was observed that the resident did not have any care plan in place for bothering other residents by going into their rooms and there was no care plan in place for his/her agitation behaviors as the only behavior care plan was for laying on the floor. On 08/07/2025 at 12:08 PM, in an interview with the Unit Manager Staff #5, while the Director of Nursing (DON ) was present, she was asked about the resident’s behavior, she stated that the resident gets agitated, and wanders into residents’ rooms .When asked if the resident had a care plan in place for such behavior, she checked through the DON’s laptop and confirmed that Resident #69 did not have any care plan to address the behaviors. When she was asked what care plan she would have had in place for the resident, she stated that she would have included agitation and wandering into other resident’s rooms in the care plan update. At 12:12 PM on 08/07/2025, in an interview with the DON, he was asked about his expectations regarding updating a care plan after an incident, he stated that depending on the findings of the investigation, the care plan would be put in updated to reflect the incident, goals and intervention for the incident.

Based on record reviews and interviews, it was determined that the facility staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication. This deficient practice was evident for one resident (#9) reviewed for professional standards during the annual survey. The findings include: On 08/05/25 at 4:51 PM, a review of Resident #9's medication administration record (MAR) for July 2025 revealed a physician's order dated 12/31/24 for Metoprolol 25 milligram (mg) to be administered twice daily for hypertension with instruction to hold the medication if the systolic blood pressure was less than 100 mmHg. The MAR showed that the Metoprolol was administered twice daily for the entire month of July 2025. However, review of the resident's blood pressure readings revealed that it was only recorded on 7/3/25, 7/8/25, 7/16/25, and 7/21/25. On 8/6/25 at 10:45 AM, during an interview with licensed practical nurse (LPN) #5, the survey asked about the process for administering blood pressure medications. The LPN #5 explained that in general residents were ordered for monthly blood pressure checks. She then stated that for residents with blood pressure parameters, she obtains the blood pressure prior to administering the medication. When asked if blood pressures were documented in the system, the LPN #5 confirmed that they were. On 08/06/25 at 11:00 AM, the surveyor discussed Resident #9's blood pressure medication and the lack of documented blood pressure readings in the medical records with the Director of Nursing (DON). The surveyor asked if he could review the resident's medical record for any blood pressure readings the surveyor may have overlooked. The DON stated that if the blood pressure was not documented in the system, it was most likely not done.

Number of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that the facility staff failed to provide appropriate treatment to maintain the resident's ability to perform activities of daily living. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for vision and hearing. The findings include: During an interview with Resident #6 on 08/04/2025 at 10:56 AM, the resident expressed concerns about their vision and hearing and stated that the facility did not address the concerns. A review of Resident #6's medical records revealed that the facility referred the resident to 360 Care for an ear exam due to decreased hearing. The exam was completed on 07/08/25. The audiologist documented that the resident's exam was abnormal due to impacted cerumen (earwax) and recommended Debrox (earwax removal aid) for the resident's left ear. Review of the resident's physician orders failed to show an order for Debrox or documentation explaining why the recommendation was not followed. On 08/05/25 at 9:43 AM, during an interview with the Assistant Director of Nursing (ADON), the surveyor asked about the facility's process for addressing provider consult recommendations. The ADON explained that all recommendations were completed by nursing staff, who first contact the doctor for a verbal order. The nurse would enter the order in the resident electronic medical record. The surveyor informed the ADON of the audiologist recommendation from 07/08/25 and requested proof that the recommendation had been addressed. On 08/05/25 at 10:46 AM, the ADON provided the surveyor with a new order for Debrox dated 8/5/25. When asked why the order was not completed on 7/8/25, the ADON stated that the staff responsible for the resident failed to place the order at that time.

Number of residents sampled: Number of residents cited: Based on interviews and record reviews it was determined that facility staff failed to assist a resident who was dependent on staff for activities of daily living (ADLs) for showers. This deficient practice was evident for 1 (#38) resident reviewed for ADL care during the annual survey. The findings include: During an interview with Resident #38 on 08/04/25 at 11:20 AM, the resident stated they are to receive showers on Wednesday and Saturday during the evening shift. However, staff fail to provide showers and instead offered a bed bath. The resident stated they would prefer showers and reports that staff sometimes document that they refused showers, which the resident stated was not true. On 08/04/25 at 11:30 AM, during an interview with the Unit Manager #7 (UM), the surveyor asked where staff documented residents showers. The UM #7 stated that some staff documented showers in Point Click Care (PCC), and other staff recorded them in the unit's shower log. The surveyor reviewed the shower logbook which revealed that Resident #38 shower days were Wednesday and Saturday. The review also revealed documentation indicating that the resident received a shower on July 9 and July 16, 2025. No additional shower dates were recorded. On 08/07/25 at 11:41 AM, the surveyor requested ADL shower days from PCC for Resident #38 during the months of May, June, and July 2025. On 08/07/25 at 4:14 PM, the surveyor reviewed documentation of ADL-shower days for the months of May, June, and July 2025, which revealed that showers were documented as given on the following days: Saturday May 3 shower evening shift Saturday June 14 shower evening shift Saturday June 21 shower evening shift Saturday June 28 shower evening shift Wednesday July 3 shower evening shift Wednesday July 9 shower evening shift Wednesday July 16 shower evening shift Wednesday July 23 shower evening shift Saturday July 26 shower evening shift On 08/11/25 at 09:05 AM, during an interview with the Assistant Director of Nursing (ADON) the surveyor discussed Resident #38's concerns, the shower log, PCC shower day documentation, and lack of documentation explaining why the resident did not receive a shower. The ADON stated that staff were expected to provide showers to residents and should not substitute a bed bath in place of a shower. The ADON also stated, when a resident refuses a shower, staff were expected to document the refusal in the medical records.

Number of residents sampled: Number of residents cited: Based on interviews, observations, and record reviews it was determined that staff failed to 1.) adequately monitor and assess urinary output and 2.) ensure pain was assessed and managed per the physician's order. This deficient practice was evident for one Resident (#38) reviewed for quality of care and one (#94) of two residents reviewed for pain management during the annual survey.The findings include: 1. On 08/04/2025 at 11:20 AM during an interview, Resident #38 reported that the urine in their foley catheter bag was often dark, bloody with clots and staff fail to irrigate the foley catheter tubing. The resident further stated they were hospitalized in April 2025 for urinary tract infection since staff failed to irrigate the foley catheter tubing. The surveyor observed amber colored cloudy urine in the resident's foley catheter bag. On 08/06/25, a review of Resident #38 medical record revealed a progress note dated 04/27/25 at 10:28 PM, documented by Registered Nurse (RN) #36, which indicated the resident's foley catheter was changed due to blockage and leakage. There was no documentation indicating the doctor was notified of the blockage and leakage, nor was there documentation of urinary monitoring or assessment. A progress note dated 04/28/25 at 11:59 AM, documented by licensed practical nurse (LPN) #35 indicated that Resident #38 urinary tubing and drainage bag contained blood and clots. The Nurse Practitioner (NP) #37 was notified and recommended obtaining a urinalysis (UA) and lab work. A review of the resident's medical records revealed that the UA was not collected, and there was no documentation of ongoing urinary monitoring or assessment.A progress note dated 04/28/25 at 10:04 PM, documented by RN #36, indicates the resident continued to have large amounts of hematuria (bloody urine) present in the foley catheter bag and was noted to be excessively drowsy, confused, with incoherent speech, and unable to follow commands. The NP #37 was notified, and the resident was transferred to the hospital. The Assistant Director of Nursing contacted the hospital for an update; it was reported that the resident was diagnosed with a urinary tract infection and admitted to the hospital on [DATE]. Further review of Resident #38's medical record on 08/06/25, revealed a progress note dated 08/05/25, documented NP #42, indicating the resident was lethargic, diaphoretic and foley catheter in place with yellow cloudy urine in the bag. The resident was transferred to the hospital on [DATE] and admitted for sepsis, urinary tract infection, acute kidney injury and diabetic ketoacidosis. Review of the medical record failed to show evidence that staff were assessing and monitoring urinary output. On 08/08/2025 at 12:07 PM, during an interview with Medical Doctor (MD) #41, the surveyor discussed the lack of urinary output, assessment, and monitoring for Resident #38 prior to both hospital admissions. The physician stated that he expects staff to provide foley catheter care, assess urinary output, and report any changes. He further stated that he would have expected staff to notify him of any observed changes or concerns for Resident #38During an interview with LPN #35, on 08/11/2025 at 2:47 PM, she stated that Resident #38 often has issues with the color of their urine. When asked who was responsible for collecting the urine specimen for the residents UA on 04/28/25, the LPN #35 acknowledged that she was responsible, but did not know why she failed to collect it. During a phone interview with RN #36 on 8/11/25 at 2:52 PM, he stated that he does not always assess resident's urine in the foley catheter bag. When asked how he identifies changes in a resident's urine, he reported that the geriatric nursing assistant informed him of urinary output. The surveyor informed him of the cloudy urine observed in Resident #38 foley catheter bag on 8/4/25. The RN acknowledged that he failed to assess the resident's urinary output on 08/03/25 and 08/04/25.2. Review of Resident #94's medical records on 08/07/25 revealed the resident was admitted to the facility on [DATE], with multiple medical diagnoses, including liver cell carcinoma. A pain evaluation completed on 05/03/25 indicated that during the past five days the resident frequently experienced pain that impacted their sleep at night. The resident reported moderate generalized pain with a pain rating of 5 out of 10. The evaluation further noted that non-medication interventions did not provide pain relief. Review of Resident #94's treatment administration record dated 05/04/25 revealed a physician's order for a pain evaluation every shift. Documentation showed a pain evaluation was completed on 05/04/25, during day and night shift, and again on 05/05/25 during the day, evening, and night shift. The next documented pain assessment was not until 05/14/25 during the day shift. There was no documentation explaining why the resident's pain was not assessed between 05/06/25 to 05/13/25. Review of Resident #94's medication administration record revealed a physician's order dated 05/05/25, for morphine 0.25 milligram (ml) by mouth every 1 hour as needed for shortness of breath and comfort care, with instruction for staff to document a progress note for all non-pharmacologic interventions made. The documentation showed morphine was administered once on 05/7/25 and 05/10/25-05/15/25.On 08/08/25 at 10:47 AM, during and interview with Unit Manager (UM) #7, The surveyor discussed Resident #94 and asked why the resident's pain was not assessed every shift as ordered and why morphine was not administered PRN per the order. The UM#7 stated that she had cared for the resident once, and during that time she assessed pain and administered morphine once but acknowledged that she did not document ongoing pain assessments. On 08/08/2025 11:36 AM, the surveyor discussed Resident #94's admission with pain, the nurse practitioner's progress note, the lack of documented pain assessments, and the failure to administer PRN morphine as ordered. The DON acknowledged the findings.

Number of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure a resident received services consistent with professional standards of practice to prevent new pressure ulcers/wounds from developing. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.The findings include:On 08/04/2025 at 8:20 AM, an interview with Resident #5 revealed that the facility staff did not always turn him/her from side to side every two hours, and as a result, he/she developed two new pressure ulcers/wounds in the facility. He/she further indicated he/she was unable to reposition himself/herself and was dependent on staff for repositioning. On 08/04/2025 at 5:07 PM, a review of Resident #5's medical record revealed a resident assessment with an ARD dated of 2/21/25 that indicated the resident had a Brief Interview for Mental Status (BIMS) of 15. A recent resident assessment with an ARD of 8/6/25 indicated the resident had a BIMS of 14.A Brief Interview for Mental Status (BIMS) is a tool used to screen and identify the cognitive condition of residents in a long-term care facility. The BIMS assessment uses a points system that ranges from 0 to 15 points. A BIMS score of 13-15 indicates the resident's cognition is intact.The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the assessment process.On 08/04/2025 at 5:13 PM, further review of Resident #5's medical record revealed he/she had two wounds upon admission and was being seen by the Wound Nurse Practitioner (Staff #43). Further record review revealed a wound note dated 2/19/25 that indicated preventative measures recommended were turning/repositioning precautions per protocol.At the same time, review of Resident #5's record revealed an order for a low air loss mattress.On 08/04/2025 at 5:18 PM, review of Resident #5's medical record revealed a skin check dated 3/19/25 which indicated the resident had a sacral (bone area above the buttocks) wound that was acquired in the facility first identified on 3/18/25. On 08/04/2025 at 5:26 PM, further review of Resident #5's medical record revealed two documents titled, Documentation Survey Report v2, for February and March 2025. The documents revealed documentation of the Resident being turned/repositioned which was listed by hours within a twenty-four hour period. Documentation revealed that the resident failed to be turned during the following times on the listed dates :Between 4:00 PM and 10:00 PM on 2/26/25Between 12:00 AM and 8:00 AM & 4:00 PM and 10:00 PM on 2/27/25 Between 8:00 AM and 2:00 PM on 2/28/25Between 4:00 PM and 10:00 PM on 3/2/25Between 6:00 PM and 10:00 PM on 3/3/25Between 4:00 PM and 10:00 PM on 3/5/25Between 12:00 AM and 3:00 AM & 4:00 AM and 8:00 AM on 3/6/25Between 4:00 PM and 10:00 PM on 3/7/25 Between 8:00 AM and 10:00 PM on 3/11/25Between 8:00 AM and 4:00 PM on 3/15/25Between 12:00 and 3:00 AM, 4:00 AM and 8:00 AM, & 4:00 PM and 10:00 PM on 3/18/25On 08/11/2025 at 12:48 PM, a follow up interview with Resident #5 revealed that an unidentifiable staff member informed him/her that day to remind them to turn him/her every two hours if they forgot.On 08/11/2025 at 12:57 PM, a review of the facility policy titled, Turning and Repositioning, with a date of 11/13/24, revealed that if a resident was unable to reposition themselves, that the facility would turn them every hour.On 08/11/2025 at 1:44 PM, a phone interview with Wound Nurse Practitioner (Staff #44) revealed that turning residents per protocol is initiated for residents to help improve current and/or prevent new wounds. She further indicated that a low air loss mattress was used along with turning and repositioning for residents. She indicated that one (an air loss mattress or turning and repositioning) does not negate (eliminate the need) for the other to also be implemented.On 08/11/2025 at 2:35 PM, the surveyor reviewed the concern with the Director of Nursing.

Based on the review of Complaint Number 310737, medical records, and interviews with facility staff, it was determined that the facility failed to ensure proper colostomy care was provided and documented for a resident (Resident #98), who had a colostomy. This deficiency was identified during the complaint investigation at the facility's Medicare/Medicaid recertification survey An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. A colostomy bag, also called a stoma bag or ostomy bag, is a small, waterproof pouch used to collect waste from the body. The Minimum Data set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. BIMS stands for Brief Interview for Mental Status. It is a standardized assessment tool used in long-term care facilities to screen residents for cognitive impairment. The BIMS assessment helps identify potential cognitive decline, including early signs of dementia and can help determine if further evaluation is needed. Findings include: On 08/11/2025 at 7:12 AM, review of complaint 310701 showed that on 01/23/2024, Resident #98 filed a complaint with the state agency stating that his/her colostomy bag had not been changed. A review of the resident's clinical records by the surveyor revealed that the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. MDS admission review on 01/03/2024 indicated that the resident had a BIMS score of 14 out of 15, signifying that he/she was cognitively intact at the time of the complaint. On 08/11/2025 at 7:28 AM, a further review of Resident#98’s medical records revealed the following. The resident had every other order but there was no order seen for the colostomy or the colostomy care. The admission notes on 12/26/2025 showed that Resident #98 The patient was admitted for wound care and rehabilitation, remained alert and oriented with full code status, verbal and in a pleasant mood, skin warm and dry, with a large unstageable sacral ulcer managed with wet-to-dry packing, skin tear under the right breast and abdominal folds due to moisture, bilateral edema, clear lungs with palpable pulses, a soft and non-tender abdomen, good appetite on a regular diet, and discharge orders were approved by the Medical Doctor. The wound notes on 12/27/2024 revealed that the patient presented with sacral and bilateral buttock wounds, status post chemoradiation, laparoscopic diverting sigmoid colostomy, and sacral debridement. On 08/11/2025 at 11:15 AM, review of the daily skilled nursing charts showed that the resident’s colostomy bag was changed on the following dates: 12/29/2023, 01/18/2024, 01/22/2024, 01/23/2024, 01/24/2024, 01/25/2024, 01/27/2024, 01/28/2024, 01/30/2024, and 02/22/2024. The last documented colostomy change was on 02/22/2024, which was also the last skilled nursing chart entry found in the resident’s electronic record. The resident was discharged from the facility on 03/20/2024, with no documentation available regarding colostomy bag changes between 02/22/2024 and discharge. On 08/11/2025 at 12:21 PM, during an interview with the Assistant Director of Nursing (ADON), when asked for the facility’s expectation regarding caring for a resident with a colostomy, she stated that the facility’s expectation for caring for a resident with a colostomy was that the colostomy bag should be emptied, cleaned, monitored, and changed as appropriate, with accurate documentation. When asked about physician involvement, she stated that attending physicians were contacted during admission and that charge nurses or unit managers were responsible for reviewing admissions with physicians and obtaining orders for residents with colostomies. When informed that the resident did not have an order for colostomy care, the ADON acknowledged that there should have been a physician order specifying colostomy care, including change times, and appropriate interventions. On 08/11/2025 at 1:15 PM, when the Director of Nursing (DON) was informed about the concerns with Resident #98’s colostomy care, he stated that there should have been a physician order to monitor the site and color of the ostomy, the fecal output, the frequency of colostomy bag changes, and the size of the bag, along with a care plan specifying nursing interventions for colostomy care. When asked about his expectations for skilled nursing charting, he stated he would have expected daily documentation while the resident was under skilled services. He further explained that after the skilled days ended, the order for colostomy care should have been placed on the Treatment Administration Record (TAR) and documented as appropriate. When asked how often the colostomy bag should be changed, he stated it should be changed weekly or as needed (PRN) if soiled.

Based on record review and interview with facility staff, it was determined that the facility failed to 1) initiate a care plan for residents receiving oxygen therapy, 2) initiate a care plan for a resident with Clostridioides difficile (C. Diff), and 3) initiate a care plan for a resident with colostomy. This was evident for 3 residents (Residents #19, #20 and #98) out of 3 resident records reviewed for care plans during the Medicare/Medicaid recertification survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Oxygen (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 your health care provider.Clostridioides difficile (C. Diff) is the currently accepted scientific name, replacing the former Clostridium difficile (C. Diff). Both names refer to the same bacterium, which is a common cause of diarrhea and colitis, particularly in individuals taking antibiotics. A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. A colostomy bag, also called a stoma bag or ostomy bag, is a small, waterproof pouch used to collect waste from the body. 1) On 08/04/2025 at 4:48 PM, during a review of Resident #19's electronic health record, it was noted that an order for oxygen therapy had been given on 07/27/2025. The surveyor reviewed the electronic care plans and found no care plan addressing oxygen therapy.At 5:11 PM on the same day, during an interview with the unit manager, Licensed Practical Nurse (LPN#5), when she was asked when Resident #19 had an order for oxygen therapy, she stated that the resident was placed on oxygen therapy on 07/27/2025. When asked who was responsible for initiating and updating care plans, she stated that the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and at times herself, were responsible for care plan initiation and updates. When asked whether Resident #19 had a care plan to reflect oxygen therapy and related interventions, she responded that she would consult with ADON.At 5:14 PM on the same day, during an interview with the ADON, when asked who was responsible for initiating and updating care plans, she stated that updating care plans was her responsibility, along with the DON and unit managers. When asked whether there was a care plan in place for the resident's oxygen therapy, she said she would check. After approximately five minutes, she confirmed that no care plan had been initiated for oxygen use. When asked if a care plan should have been in place for oxygen therapy, both the ADON and LPN #5 agreed that one should have been created.At 5:49 PM on the same day, when the DON was interviewed regarding the facility's expectations for updating care plans, he stated that care plans should be updated promptly whenever there is a change in a resident's condition. When he was informed of the absence of a care plan for Resident #19's oxygen therapy, the DON stated that the care plan was initiated after being notified by ADON that the surveyor could not find a care plan for Resident #19's oxygen therapy.2) On 08/04/2025 at 11:11 AM, during the initial facility tour, the surveyor observed signage on Resident #20's door indicating Droplet and Contact Precautions. During a brief conversation, the resident referenced his/her health condition stating that he/she had loose stools.On 08/05/2025 at 11:21 AM, review of Resident #20's electronic health record showed the Progress notes dated 07/31/2025 indicated the resident was experiencing recurrent loose stools. The Medical Director was notified, a stool sample was ordered, and an antibiotic was initiated. laboratory results dated [DATE] confirmed Clostridium difficile (C. diff) infection. Progress notes from 08/04/2025 documented more than two loose stools within a 24-hour period. The note indicated Resident #20 receiving treatment for C. diff and the physician was aware.On 08/05/2025 at 11:50 AM, review of the care plan did not show that Resident #20 had any care plan that addressed the ongoing infection.On 08/05/2025 11:57 AM in an interview with Licensed Practical Nurse (LPN) #17 in the presence of the Unit Manager Staff #5, when she was asked about Resident #20's recent health condition, she stated that the resident had C. Diff infection. When asked for the facility's protocol for a resident with such infection, she stated that such resident would be placed on contact/isolation precautions to keep the infection contained. When asked about the care plan for the ongoing infection, she stated that she would check. However, after reviewing the care plan, she acknowledged that no interventions were documented for the infection and stated that a care plan should have been in place.At 12:09 PM the same day, the [NAME] President of Clinical Operations (Staff #16) joined the interview. When asked about facility expectations regarding care planning for an active infection, she confirmed that a care plan should have been developed while the infection was ongoing.At 12:39 PM on the same day, in an interview with the Director of Nursing (DON), he stated that facility expectations include creating a care plan for any active diagnosis, including goals and interventions specific to the condition. He acknowledged that the omission of a care plan for Resident #20's C. Diff infection was a concern and confirmed that a care plan would be initiated immediately. 3) On 08/11/2025 at 7:12 AM, review of complaint 310701 showed that on 01/23/2024, Resident #98 filed a complaint with the state agency stating that his/her colostomy bag had not been changed. A review of the resident's clinical records by the surveyor revealed that the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. MDS admission review on 01/03/2024 indicated that the resident had a BIMS score of 14 out of 15, signifying that he/she was cognitively intact at the time of the complaint.On 08/11/2025 at 7:28 AM, a further review of Resident #98's medical records revealed that the resident had other care plans but there was no care plan seen for the colostomy.On 08/11/2025 at 11:15 AM, during an interview with the Assistant Director of Nursing (ADON), she stated that the facility's expectation for caring for a resident with a colostomy was that the colostomy bag should be emptied, cleaned, monitored, and changed as appropriate, with accurate documentation. She further explained that attending physicians are contacted during admission and that charge nurses or unit managers are responsible for reviewing admissions with physicians and obtaining orders for residents with colostomies. When informed that the resident did not have a care plan to care for the colostomy and asked if there should have been a care plan in place, the ADON acknowledged that there should have been a care plan in place to guide appropriate interventions.On 08/11/2025 at 1:15 PM, when the Director of Nursing (DON) was informed about the concerns with Resident #98's colostomy care, he stated that there should have been a physician order to monitor the site and color of the ostomy, the fecal output, the frequency of colostomy bag changes, and the size of the bag, along with a care plan specifying nursing interventions for colostomy care.

Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure that resident rights are maintained by knocking prior to entering a resident's room. This was evident for 2 of 2 observations on the Chesapeake unit upon facility initial entry.The findings include:On 08/04/2025 at 9:12 AM, during an interview with Resident #8, Registered Nurse (Staff #11) opened the door and walked into the room but failed to knock prior to entering. On 08/04/2025 at 9:21 AM, an observation right outside of Resident #8's room revealed Staff #11 walked into the residents room without knocking.On 08/04/2025 at 4:50 PM, an interview with the Director of Nursing revealed that the expectation was for staff to knock prior to entering a resident's room. The surveyor reviewed the concern.

Number of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure that Advanced Beneficiary Notice of Noncoverage (ABN) was provided as required. This was evident for 1 (Resident #99) of 3 residents reviewed for beneficiary notification.The findings include:The ABN notice is provided to residents/responsible parties in order to provide information so the resident/responsible party can make a decision to continue to receive services that may not be paid for by Medicare and assume the financial responsibility prior to services ending.On 08/11/2025 at 9:07 AM, the surveyor requested Resident #99's beneficiary notification documentation for review.On 08/11/2025 at 11:15 AM, Business Office Manager (Staff #4) provided the documentation for Resident #99's beneficiary notification which indicated the last day covered for Part A Services was 2/4/25. Staff #4 informed the surveyor that she was unable to find documentation regarding the ABN. At the same time, an interview with Staff #4 revealed that Resident #99 was unable to sign so the representative would have been contacted regarding the ABN by phone or mail. The surveyor asked what the expectation was for documentation when a representative was contacted for the ABN, she indicated she was unaware of the process.On 08/11/2025 at 1:22 PM, the surveyor reviewed the concern with the Director of Nursing. He indicated that there should have been some documentation if a phone call was made or if the letter was sent out to the resident's representative.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that a resident was free from abuse. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents (FRIs) reviewed during the annual survey.The findings include:On 08/11/2025 at 10:34 AM, review of Incident #310745 investigation documentation revealed that on 4/20/25, Geriatric Nursing Assistant (Staff #34) observed bruises on Resident #24's right ankle. Further review of the investigation documentation revealed when Staff #34 asked Resident #24 about the bruising, he/she indicated that GNA was rough and aggressive with him/her on 4/19/25. On 08/11/2025 at 10:43 AM, review of the follow-up investigation report form revealed that the allegation was verified by the facility based on statements collected and physical findings.On 08/13/2025 at 8:39 AM, the surveyor reviewed the concern with the Nursing Home Administrator, who was aware that the allegation was verified by the facility.

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that facility staff failed to provide evidence that a level 1 preadmission screening and resident review (PASARR) was completed prior to admission, or at the time of admission for a resident with a mental disability. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for PASARR during the annual survey. The findings include: The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities and related conditions. This initial screening is referred to as Level I Identification of individuals with MD or ID and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility. During a medical record review for Resident #6 on 08/04/25, it was revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia. Further review of the resident's paper chart and electronic medical records failed to show a PASARR had been completed prior or at the time of admission. The surveyor requested documentation showing that a PASARR was completed On 08/05/2025 at 8:00 AM, the Social Worker Assistant (SW) #8 provided the surveyor with Resident #6's PASARR dated 09/16/21. The surveyor informed the SW #8 that the resident had been admitted on [DATE] and again requested the PASARR from 10/28/19. The SW #8 explained that she was not working as a social worker at the time and was unable to local the resident's PASARR from 2019. Review of Resident #6's medical records on 08/05/25 at 11:51 AM, revealed the Regional Social Worker (SW) #9 completed a level 1 PASRR through the electronic platform named Telligen. On 08/06/25 at 8:44 AM, SW #8 provided the surveyor with a copy of the completed level 1 PASRR.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to ensure less restrictive alternatives were attempted and documented prior to administering an additional antipsychotic medication. This deficient practice was evident for 2 (Resident #6 and #69) of 2 residents reviewed for unnecessary medications during a Medicare/Medicaid recertification survey. The findings include: 1) On 08/06/2025 at 10:03 AM, a record review revealed that on 07/09/2025, the Medical Director (Staff #32) ordered an additional prescription of Seroquel (Quetiapine) 25 mg BID, in addition to the standing Quetiapine 50 mg BID, increasing the total daily dose to 75 mg at 9:00 AM and 5:00 PM. On 08/06/2025 at 10:07 AM on the same day, a review of Resident #69's progress notes in the electronic health record on 07/10/2025 showed Alert Note with note text: Behaviors, Resident observed very agitated and aggressive towards staff and residents. Medical Doctor made aware, medication in place. The note did not reflect whether non-pharmacological interventions were attempted prior to the medication increase. On 08/06/2025 at 10:50 AM, in an interview with the Director of Nursing (DON), when he was asked for the non-pharmacological intervention given to Resident #69 on 07/09/2025 when an agitation behavior was observed, he stated that there was none. On 08/07/2025 at 10:57 AM, in a phone interview with the Medical Director (Staff #32), he acknowledged that he ordered Seroquel (Quetiapine) 25 mg on 07/09/2025 due to Resident #69's agitation but failed to document the rationale and did not order non-pharmacological intervention. The Medical Director stated, It was an error from me; I should have documented the reason for the increase and ordered non-pharmacological interventions to resident #69's treatment order. 2) Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. On 08/05/25 at 12:37 PM, a review of Resident # 6's medical records revealed that the monthly medication regimen reviews conducted between 08/12/24 and 07/16/25, and an irregularity was identified on 09/15/24. The surveyor requested to review the irregularity and the pharmacist's recommendation to the physician. Review of the pharmacist's recommendation dated 09/15/24 revealed that Resident #6 was prescribed Seroquel (Quetiapine) 50 milligram (mg), Lexapro (Escitalopram) 20 mg, and Haldol (Haloperidol) 2mg. The pharmacist recommendation note: please indicate if these medications are eligible for a gradual dose reduction (GDR) while concurrently monitoring for the emergence of depressive and/or withdrawal symptoms. Further review of the medical record showed that the Lexapro dosage was not addressed until 03/28/25. The Haldol dosage was not adjusted until 06/20/25, and Seroquel dosage was not adjusted until 06/06/25. During an interview with the Director of Nursing (DON) on 08/05/25 at 1:06 PM, the DON acknowledged that monthly pharmacy reviews were completed for Resident #6 and that irregularities for Seroquel, Lexapro, and Haldol were identified on 09/15/24. When asked if the facility provided the resident with non-pharmacological interventions, the DON stated that he believed interventions were provided but was unable to provide documentation.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that facility staff failed to ensure electronic transfer forms and bed hold notices were completed in Point Click Care for a resident who was transferred to the hospital. This deficient practice was evident for one resident (#93) reviewed for transfer notices during the annual survey.The findings include: On 08/07/2025 12:07 PM, during a review of Resident #93's medical record, the surveyor noted documentation indicating that the resident was transferred to the hospital on 4/24/25. The surveyor confirmed that the facility had completed an electronic transfer form and bed hold notice. Further review showed another transfer to the hospital on [DATE], in which there was no documentation indicating that an electronic transfer form or bed hold notice had been completed. The surveyor requested proof of an electronic transfer form and bed hold notice completed. During an interview with the Director of Nursing (DON) on 08/07/25 at 12:43 PM, when asked about the process for completing transfer notices and bed hold forms for hospital transfers. The DON stated, generally transfer forms and bed hold notices are completed at the time of transfer in Point Click Care using the electronic interact transfer form. The DON further explained that exceptions may occur when transfers happened on the weekend or holidays, however, the notice should still be submitted as soon as possible. On 08/07/25 at 1:10 PM, the Regional Policy Nurse #21 informed the surveyor that the nurse assigned to Resident #93 failed to complete the electronic interact transfer form and bed hold notice for the resident's hospital transfer on 05/09/25.On 08/07/2025 at 1:19 PM, during an interview with the DON concerning the missed transfer form bed hold notice on 05/09/25, the DON stated that the process is a collaborative approach; however, the nurse sending the resident to the hospital is responsible for ensuring that the transfer form and bed hold notice are completed in Point Click Care (electronic medical record).

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure the Minimum Data Sheet (MDS) accurately reflected a resident's status. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need.On 08/04/2025 at 5:13 PM review of Resident #5's medical record revealed a documented skin check dated 4/23/25 that indicated the resident had four wounds. At the same time, further review of the skin check document revealed two of the wounds (the left hip and right heel) were documented as present on admission (the resident had the wounds prior to being admitted to the facility).On 08/04/2025 at 5:19 PM, review of Resident #5's medical record revealed section M of an MDS with an Assessment Reference Date (ARD) of 4/22/25, which indicated all four wounds, including the left hip and right heel were not present on admission. The surveyor then requested a copy from the facility.The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process.On 08/06/2025 at 12:14 PM, Regional MDS Coordinator (Staff #15) provided a copy of the MDS that the surveyor requested, indicated she was aware of the error, and that she revised the MDS error after the surveyor's intervention. Further interview revealed the left hip and right heel should have been marked as present upon admission on the MDS to accurately reflect the resident's status.

Based on observation, interviews and review of facility and other documentation, the facility failed to ensure that essential equipment was operational and safe (1) when the facility boiler that supplied hot water to the kitchen failed on or by 7/6/20 and was not repaired or replaced, and (2) when the dishwasher heating element failed prior to 7/6/20 and it too was not repaired or replaced. For more than two months, the facility continued food preparation and service activities in the kitchen without hot water sufficient for hand washing, and for cleaning, rinsing and sanitizing pots and pans. The failure to ensure safe, hot, potable water was available in the kitchen, created potential for serious harm to all residents, staff and visitors in the building. During deliberation, the State Survey Agency determined that the noncompliance with the failure to correct faulty essential equipment and the related unsafe and unsanitary conditions created in the facility kitchen, constituted an immediate jeopardy situation. The failure to ensure potable hot water in the kitchen began on or by 7/6/20 and continued until 9/18/20 when the facility developed and implemented an acceptable plan to address the immediate concerns. After immediate concerns affecting all residents were sufficiently addressed, the concerns continued at the lower scope and severity level of F. The findings include: Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. (Centers for Medicare and Medicaid Services, State Operations Manual, Appendix Q: 3/6/2019) During tour of the kitchen on 9/15/20, Staff #5 and Staff #6 indicated that since at least May 2020, the nursing home had no Certified Dietary Manager (CDM). In later interview on this same date at 11:45, the Nursing Home Administrator (NHA) stated that she and human resources supervisor had been managing the kitchen since April 2020. However, the Administrator acknowledged that neither she nor the human resources supervisor were certified in dietary management. 1. The facility boiler that supplied hot water to the kitchen failed on or by 7/6/20 and was then not repaired or replaced. Review of facility water temperature logs on 9/16/20, revealed that facility maintenance staff recorded a sharp drop in water temperatures in the kitchen during July 2020. Following six consecutive weekly water temperature readings in the 140s (Fahrenheit), on 7/6/20 the recorded temperature dropped to 76.2. Weekly temperature checks from 7/6/20 through 9/14/20 revealed the water temperatures remained in the 70s at every weekly water temperature check in the kitchen beginning on 7/6/20 (10 recorded checks in total). In a 9/17/20 interview, Staff #13 (facility maintenance staff) reported that the facility had two boilers and one of these two (that served the kitchen) had broken and needed replacement. The Administrator indicated that corporate management required that the facility obtain three estimates prior to replacement, but as of 9/15/20, more than two months after the boiler first failed, the facility had only obtained one. Although the need for three estimates was the reason given why the boiler was not replaced for more than two months, it took the facility only four days to install a hot water heater, as an alternate source for hot water in the kitchen, after a related immediate jeopardy situation was called on 9/18/20 (Federal Tags F-812 Food and Nutrition Services & F-835 Administration). On 9/16/20 at approximately 1:00 PM, the Maryland OHCQ Surveyor contacted the Local Health Department (LHD) regarding the concern with ongoing use of the kitchen without hot water. On the same day, a LHD investigator came into the nursing home and reported that without water at temperatures of at least 100 F for the hand sinks and 120 F for the dishwasher, the facility did not meet minimum standards set forth in the Code of Maryland Regulations ([NAME]) for hand-washing, and for sanitizing the pots and pans. Additionally regulations require hot water for cleaning and rinsing in a three-compartment sink at a minimum of 110 F. Nonetheless, with no hot water, the facility continued to prepare food in the unsanitary kitchen for more than two months. In interview on 9/18/20, after the OHCQ called the Immediate Jeopardy, the Administrator stated that they had believed the contractor was correct when he reported that chemical sanitization was sufficient such that staff could continue conducting food preparation and service activities in the kitchen without hot water. 2. The dishwasher internal heating element failed prior to 7/6/20 and was not repaired or replaced. In 9/16/20 interview at 1:30 PM, the equipment contractor reported to the surveyor that the heating element had been removed from the dishwasher at an unknown date before the survey. Without the heating element, when the boiler failed on or by 7/6/20, there was no hot water supplying the dishwasher. As required by State [NAME] 10.15.03 16 G (3), if manufacturer's specifications for wash and rinse water temperature do not exist, the following standards are followed: (a) for machines using chemical sanitization, the wash and final rinse water temperature is at least 120 F. The specification sheet for the dishwasher in use (CMA Model B, low temperature) noted the heating element assures a continuous supply of 140 F hot water [and] guarantees excellent results. No minimum temperature below 120 F was specified by the manufacturer; and therefore the [NAME] defined minimum of at least 120 F applied. In addition to the direct regulatory requirement, on 9/17/20, a Registered Environmental Health Specialist within the Office of Health Care Quality reviewed the manufacturer specifications for the dishwasher in use in the facility kitchen and confirmed that the dishwasher in use did require hot water as defined in the regulations. In a 9/16/20 interview at 1:30 PM, the equipment contractor reported that after the boiler failed, he then increased the chemicals for sanitization in the dishwasher to 100 Parts per Million (PPM) chlorine. In interview on 9/16/20, the contractor reported that the facility continued using the dishwasher for cleaning only pots and pans. Review of the contractor's documented receipt/report revealed the contractor wrote the dishwasher was a low temp dishwasher and corroborated his verbal report that there was no built in heating system. Consistent with the noted regulatory requirement for hot water at 120 F, the contractor wrote that the dishwasher may not be reaching 120 . but it is receiving 100 PPM chlorine which is on high side of the 50-100 PPM required by the state. In the same documentation the contractor added, I made this adjustment in early July immediately upon it being brought to my attention that there was an issue with hot water. Corroborating these reports, in interview on 9/18/20 at 10:00 AM, the NHA stated that she went along with someone I trusted that the chemicals were enough to clean linens [and] dishes (dishwasher). Review of the Local Health Department (LHD) report on 9/16/20 at 1:00 PM revealed that the lack of hot water at the warewashing machine (dishwasher) operating without water at 120 F was a critical violation of [NAME] 10.15.03 Food Service Facilities. The LHD investigator also spoke with the equipment contractor and he confirmed with her that the warewashing machine was serviced (adding chemicals). The LHD investigator documented that the warewashing machine was not supplied with a booster or heating element, and that for machines using [chemical] sanitization, the wash and final rinse water temperature [needed to be] at least 120. The LHD investigator documented that the warewashing facilities [were] not maintained or supplied with hot water and specifically noted that the facility needed to discontinue use of warewashing facilities until hot water is supplied. The LHD report explicitly requiring the facility discontinue its use of the dishwasher was signed by both the facility NHA and LHD Investigator on 9/16/20. 3. With the boiler broken, the facility failed to ensure hot water for hand washing. On 9/16/20, the LHD closed the kitchen for any food preparation and food service activities due to the facility failure to comply with the food services regulations at Code of Maryland Regulations ([NAME]) 10.15.03.14E,.14F, .18K and .18L. Prominent in these citations was that kitchen staff failed to appropriately wash hands/exposed skin properly and that they did so without warm water. The Centers for Medicare and Medicaid Services noted that, staff should have access to proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. CMS further noted that antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting (State Operations Manual, Appendix PP 11/22/2017). As required by State [NAME] 10.15.03.18 L Hand sinks must be: (1) installed in accordance with applicable State and local laws, ordinances, and regulations; (2) able to discharge: (a) hot and cold running water; or (b) tempered running water at a temperature of at least 100 F through: (i) a mixing valve; (ii) a combination faucet; or (iii) any slow closing or metering faucet that provides a flow of water for at least 15 seconds before the faucet has to be reactivated. With the boiler broken, at 11:00 on 9/15/20, the surveyor documented that there were no paper towels and there was no hot water in the sink in the kitchen by the juice machine; and the surveyor noted that there were no paper towels or hot water at a second sink in the kitchen. Review of temperature logs corroborated that water temperatures in the kitchen did not reach the minimum required 100 F for hand sinks but was maintained only in the 70s. In the 9/16/20 report when the kitchen was closed, the LHD investigator documented direct observations of staff (1) not thoroughly washing hands in the kitchen, and (2) doing so without hot water. The LHD required that the facility discard the food that the staff had worked with after this observation. 4. The facility utilized a three-compartment sink for cleaning, rinsing and sanitizing pots and pans without sufficient hot water. The CMS indicates that a 3-step process is used to manually wash, rinse, and sanitize dishware correctly. The first step is thorough washing using hot water and detergent after food particles have been scraped off. The second is rinsing with hot water to remove all soap residues. The third step is sanitizing with either hot water or a chemical solution maintained at the correct concentration, based on periodic testing, at least when initially filled and as needed, such as with extended use, and for the effective contact time according to manufacturer's guidelines (State Operations Manual, Appendix PP 11/22/2017). The hot water noted by CMS for the first two compartments of a three-compartment sink is defined in both the FDA Food Manual (Chapter 5) and the CMS surveyor guidance as meeting a minimum temperature of 110 F. Sanitization with chemicals in the third compartment of the three-compartment sink can be accomplished effectively at lower temperatures when chemicals are added, but the first compartment for cleaning, and the second compartment for rinsing prior to sanitization, require the minimum 110 F water temperature. The State regulations also require availability of both hot and cold water when using a three-compartment sink. Specifically at [NAME] 10.15.03.16,(E) the State requires that a three-compartment sink is: (1) provided and used wherever warewashing is conducted manually; (2) adequate in length, width, and depth to accommodate the largest equipment items and utensils; [and] (3) supplied with hot and cold running water at each sink compartment. Review of the local health department documentation, revealed that the plumbing and equipment contractor, increased the chemicals for use in the three part sink to 100 parts per million (PPM) of quaternary ammonia and told facility this was sufficient to sanitize the pots and pans (sanitization in third compartment). In a 9/16/20 interview with the Surveyor at 11:00 AM, the contracted service provider for plumbing and equipment repairs corroborated the change in chemicals for the three part sink as was also done with the dishwasher. However, the first two compartments of the three compartment sink did not have the required hot water to ensure pots and pans were effectively cleaned and rinsed prior to attempting sanitization in the third compartment. With insufficient cleaning and rinsing of food matter in the first and second compartments, the sanitization of the pots and pans could not be guaranteed effective in the third. From 7/6/20 through 9/18/20, the facility failed to ensure availability of hot water was supplied consistent with State and Federal requirements, at 100 F to hand sinks in the kitchen, at 110 F at the three-compartment sink in the kitchen, and at 120 F at the dishwasher in the kitchen. The longstanding and ongoing failure to ensure the essential equipment was in safe operational condition and thereby provided hot water to the kitchen, created unsafe and unsanitary conditions in the kitchen and was in part causal to noncompliant and unsafe practices regarding food preparation, food service, and infection prevention and control requirements. The structural failure to provide hot water sufficient to maintain a safe and sanitary kitchen increased the risk for serious harm and possible death from potential food borne illnesses and from potential spread of coronavirus during a known pandemic. On 9/18/20 the Office of Health Care Quality called an immediate jeopardy situation under related tags F-812 and F-835. During deliberation and review the Office of Health Care Quality determined that the concerns cited at the immediate jeopardy level on 9/18/20, also, demonstrated noncompliance at that same level under this Federal Survey tag (F-908). On 9/30/20, the Office of Health Care Quality re-entered the facility, and at 10:00 AM provided the immediate jeopardy worksheet for this additional Federal Survey Tag (F-908). On 9/30/20 the facility submitted two plans to remove immediacy that did not meet minimum standards and were therefore not accepted. At 3:30 PM on 9/30/20, a plan to remove immediacy was received and accepted. Under oversight of the LHD, the facility installed a hot water heater on 9/22/20 and the LHD reopened the facility kitchen after a follow-up onsite inspection. Additionally, the accepted action plan to address the immediate concerns included: The facility assessed all residents and staff and determined none had exhibited signs or symptoms of adverse effects related to food preparation or water temperatures. An outside vendor was approved to provide two (2) meals per day for five days. The dietician communicated with the vendor to assure to textures and dietary needs would be met. (9-17-20 thru 9-22-2020). Facility policy was revised to reflect a system to triage equipment failures in the future such that if the failure is an is determined by the Chief Executive Officer of Peak Health Care to be an emergency, the facility will go with the first vendor available with consultant with NHA. If the issue is not of an urgent nature an interim solution will be put into place while three estimates are being obtained for a permanent solution. On 9/18/20 education was provided the Nursing Home Administrator regarding timely reporting with regards to scope and severity of facility occurrences. The facility NHA will educate department heads regarding timely notification of any occurrence with regards to the scope and severity of facility occurrences. As of September 18, 2020 a full time temporary CDM were secured to oversee dietary department until a permanent full time CDM is hired. As of September 18, 2020 Peak Healthcare Chief Executive Officer and/or NHA from another Peak Facility will conduct random visits and observational rounds weekly to validate facility's compliance in providing full report including specifics on status of facility's needs such as needed emergent repairs As of September 18, 2020 facility has a temporary full-time CDM to support facility until a new CDM is permanently hired for the facility weekly for four weeks then monthly for three months. (Cross referenced from facility immediacy plan associated with Federal F-880 also submitted to the OHCQ on 9/30/20 with this plan for F-908). The NHA will ensure that these audits will be submitted to the QAPI Committee for review and further recommendations as necessary. Kitchen water temperatures will be checked by dietary with each use of the hand sink and three (3) compartment sink; maintenance will, also, check water temperatures daily. Cross Reference Federal Survey Tags F801, F812, F835, F836, F840, F867, F880, and State 100: [NAME] 10.07.02.09 A; State 790: [NAME] 10.07.02.21 B; State 880: [NAME] 10.07.02.21 K; State 1410: [NAME] 10.07.02.33 A; State 1540: [NAME] 10.07.02.38 C; State 1940: [NAME] 10.07.02.43 I; State 3000: [NAME] 10.07.02.64 A; State 6900: [NAME] 10.15.03.16 E; State 6910: [NAME] 10.15.03.16 G; and State 7050: [NAME] 10.15.03.18 L

Based on observation, interviews and review of facility and other documentation, the facility failed to ensure an effective infection prevention and control program when: (1) a facility boiler for hot water failed, (2) the facility made no substantive efforts to replace the essential equipment; and, (3) with insufficient managerial staffing, kitchen staff continued to conduct food preparation and service activities in an unsafe manner in the kitchen without hot water for hand washing, and for cleaning, rinsing and sanitizing pots and pans. The failure to ensure effective infection prevention and control practices increased the risk for serious harm and possible death to all residents in the facility from potential spread of infection and from potential food borne illnesses. During survey deliberation, the State Survey Agency determined that these concerns constituted an immediate jeopardy situation under infection prevention and control requirements and were directly related to immediate jeopardy concerns called earlier on 9/18/20 regarding Federal Survey Tags F-812 (Food and Nutrition Services) and F-835 (Administration). On 9/30/20 at 10:00 AM, the Maryland Office of Health Care Quality called an Immediate Jeopardy regarding the related noncompliance under infection prevention and control requirements. The failure to ensure a functional and effective infection prevention and control program began on 7/6/20 and continued unabated until 9/18/20 when the interim plans developed under F-812 and F-835 were implemented. After immediate concerns were addressed, the infection prevention and control concerns continued at the lower scope and severity level of F. The findings include: Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. (Centers for Medicare and Medicaid Services, State Operations Manual, Appendix Q: 3/6/2019) 1. In 9/17/20 interview, Staff #13 (facility maintenance staff) reported that the facility had 2 boilers and one of these (that served the kitchen) had broken and needed replacement. Review of facility water temperature logs on 9/16/20, revealed that facility maintenance staff recorded a sharp drop in water temperatures for the kitchen during July. Following six consecutive weekly water temperature readings in the 140s (Fahrenheit), the recorded water temperature in the kitchen had dropped to 76.2 on 7/6/20. Weekly temperature checks from 7/6/20 through 9/14/20 revealed that the water temperatures remained in the 70s at every weekly water temperature check in the kitchen beginning on 7/6/20 (10 recorded checks in total). 2. For more than two months the facility made no substantive efforts to replace the essential equipment. In interview on 9/15/20, the Administrator stated that corporate management required that the facility obtain three estimates prior to replacement of the boiler; but more than two months after the boiler first failed, as of 9/15/20 the facility had only obtained one. Although the corporate requirement for three estimates was the reason given why the boiler was not replaced for more than two months, it took the facility only four days to install a hot water heater, as a short-term alternate hot water source for the kitchen, after the immediate jeopardy situation was called on under Federal Survey tags F-812 and F-835 on 9/18/20. 3. With insufficient supervision, kitchen staff continued to conduct food preparation and service activities in an unsanitary manner in the kitchen without hot water for hand washing, and for cleaning, rinsing and sanitization of pots and pans. 3.1 On 3/4/20 the Centers for Medicare & Medicaid Services (CMS) issued guidance in CMS Press Release which indicated that all health care providers must immediately review their procedures to ensure compliance with CMS' infection control requirements, as well as the guidelines from the Centers for Disease Control and Prevention (CDC). On 3/5/20, the Governor of Maryland declared a statewide health emergency related to community spread of COVID-19. With the order to follow CDC guidance in effect, on 4/27/20, the CDC issued Guidance for Healthcare Providers about Hand Hygiene and COVID-19 indicating that Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene . is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. On 9/16/20, the LHD closed the kitchen for any food preparation and food service activities due to the facility failure to comply with the food services regulations at Code of Maryland Regulations ([NAME]) 10.15.03.14E,.14F, .18K and .18L. Prominent in these citations was the failure of kitchen staff to wash hands/exposed skin properly, and the failure to do so with soap and warm water. The Centers for Medicare and Medicaid Services noted that, staff should have access to proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. CMS further noted that antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting (State Operations Manual, Appendix PP 11/22/2017). As required by State [NAME] 10.15.03.18 L Hand sinks must be: (1) installed in accordance with applicable State and local laws, ordinances, and regulations; (2) able to discharge: (a) hot and cold running water; or (b) tempered running water at a temperature of at least 100 F through: (i) A mixing valve; (ii) a combination faucet; or (iii) any slow closing or metering faucet that provides a flow of water for at least 15 seconds before the faucet has to be reactivated. At 11:00 on 9/15/20, the surveyor documented that there were no paper towels and there was no hot water in the sink in the kitchen by the juice machine; and the surveyor noted that there were no paper towels or hot water at a second sink in the kitchen. Review of temperature logs corroborated that water temperatures in the kitchen were not hot and did not reach the State defined minimum required temperature of 100 F for hand sinks; but rather, was maintained only in the 70s. In the 9/16/20 report when the kitchen was closed, the LHD investigator documented direct observations of staff (1) not thoroughly washing hands in the kitchen, and (2) doing so without hot water. The LHD required that the facility discard the food that the staff had worked with after this observation. 3.2 The facility utilized a dishwasher for cleaning, rinsing and sanitizing pots and pans in an unsafe and unsanitary manner without hot water. As required by State [NAME] 10.15.03 16 G (3), if manufacturer's specifications for wash and rinse water temperature do not exist, the following standards are followed: (a) for machines using chemical sanitization, the wash and final rinse water temperature is at least 120 F. The specification sheet for the dishwasher in use (CMA Model B, low temperature) noted the heating element assures a continuous supply of 140 F hot water [and] guarantees excellent results. However, in a 9/16/20 interview at 1:30 PM, the equipment contractor reported to the surveyor that the heating element had failed and was removed from the dishwasher at an unknown date before the survey. In addition to the direct regulatory requirement, on 9/17/20, a Registered Environmental Health Specialist within the Office of Health Care Quality also reviewed the manufacturer specifications for the dishwasher in use in the facility kitchen and confirmed that the dishwasher in use did require hot water as defined in the regulations. No minimum temperature below 120 F was specified by the manufacturer; and therefore the State [NAME] defined minimum of at least 120 F applied. In the interview on 9/16/20 at 1:30 PM, the contractor reported that after the boiler failed, he then increased the chemicals for sanitization in the dishwasher to 100 Parts per Million (PPM) chlorine. The contractor added that the facility continued using the dishwasher for cleaning only pots and pans. Review of the contractor's documented receipt/report revealed the contractor wrote the dishwasher was a low temp dishwasher and corroborated his verbal report that there was no built in heating system. Consistent with the noted regulatory requirement for hot water at 120 F, the contractor wrote that the dishwasher may not be reaching 120 . but it is receiving 100 PPM chlorine which is on high side of the 50-100 PPM required by the state. In the same documentation the contractor added, I made this adjustment in early July immediately upon it being brought to my attention that there was an issue with hot water. Corroborating these reports, in interview on 9/18/20 at 10:00 AM, the NHA stated that she went along with someone I trusted that the chemicals were enough to clean linens [and] dishes (dishwasher). Review of the LHD report on 9/16/20 at 1:00 PM revealed that the lack of hot water at the hand washing sinks, and the warewashing machine (dishwasher) not operating with water at 120 F were critical violations of [NAME] 10.15.03 Food Service Facilities. The LHD investigator also spoke with the equipment contractor and he confirmed with her that the warewashing machine was serviced (adding chemicals). The LHD investigator documented that the warewashing machine was not supplied with a booster or heating element, and that for machines using [chemical] sanitization, the wash and final rinse water temperature [needed to be] at least 120. The LHD investigator documented that the warewashing facilities [were] not maintained or supplied with hot water and specifically noted that the facility needed to discontinue use of warewashing facilities until hot water is supplied. The LHD report explicitly requiring the facility discontinue its use of the dishwasher was signed by both the facility NHA and LHD Investigator on 9/16/20. 3.3 The facility utilized a three-compartment sink for cleaning, rinsing and sanitizing pots and pans without hot water. The CMS indicates that a 3-step process is used to manually wash, rinse, and sanitize dishware correctly. The first step is thorough washing using hot water and detergent after food particles have been scraped off. The second is rinsing with hot water to remove all soap residues. The third step is sanitizing with either hot water or a chemical solution maintained at the correct concentration, based on periodic testing, at least when initially filled and as needed, such as with extended use, and for the effective contact time according to manufacturer's guidelines (State Operations Manual, Appendix PP 11/22/2017). The hot water noted by CMS for the first two compartments of a three-compartment sink is defined in both the FDA Food Manual (Chapter 5) and the CMS surveyor guidance as meeting at least a minimum water temperature of 110 F. Sanitization with chemicals in the third compartment of the three-compartment sink can be accomplished effectively at lower temperatures when chemicals are added, but the first compartment for cleaning, and the second compartment for rinsing prior to sanitization, require the minimum 110 F water temperature. The State regulations also require availability of both hot and cold water when using a three-compartment sink. Specifically at [NAME] 10.15.03.16,(E) the State requires that a three-compartment sink is: (1) provided and used wherever warewashing is conducted manually; (2) adequate in length, width, and depth to accommodate the largest equipment items and utensils; [and] (3) supplied with hot and cold running water at each sink compartment. Review of the local health department documentation, revealed that the plumbing and equipment contractor also increased the chemicals for use in the three part sink to 100 parts per million (PPM) of quaternary ammonia and told facility this was sufficient to sanitize the pots and pans (sanitization in third compartment). In a 9/16/20 interview with the Surveyor, the contracted service provider for plumbing and equipment repairs corroborated the change in chemicals for the three part sink. However, the first two compartments of the three compartment sink did not have the required hot water to ensure pots and pans were effectively cleaned and rinsed prior to attempting sanitization in the third compartment. With insufficient cleaning and rinsing of food matter in the first and second compartments, the sanitization of the pots and pans could not be guaranteed effective in the third. Failing to ensure an effective infection prevention and control program with underlying conditions that were both unsafe and unsanitary, increased the risk for serious harm and possible death to all residents, staff and visitors from potential spread of infection. Additionally, the same unsafe and unsanitary conditions the facility both created and then maintained, increased the risk to all residents for serious harm from food borne illnesses. On 9/18/20 the Office of Health Care Quality had called an immediate jeopardy situation under related tags F-812 and F-835. During survey process deliberation, the Office of Health Care Quality determined that the concerns cited at the immediate jeopardy level on 9/18/20 also demonstrated noncompliance at that same level under this Federal Survey tag (F-880) regarding infection prevention and control requirements. On 9/30/20, the Office of Health Care Quality re-entered the facility, and at 10:00 AM provided the immediate jeopardy worksheet for this additional Federal Survey Tag (F-880). On 9/30/20 the facility submitted two plans to remove immediacy that did not meet minimum standards and were therefore not accepted. At 3:30 PM on 9/30/20, a plan to remove immediacy was received and accepted. The accepted action plan to address the immediate concerns included: All residents and staff were assessed and had exhibited no signs and symptoms (s/s) of adverse effects related to food preparation or water temperatures. Staff and residents will be assessed daily to monitor residents and staff for signs and symptoms of adverse effects related to water temperatures. As of September 16, 2020 the dietary department was granted approval from LHD to temporarily utilize the activity room in the facility as a kitchen. Approved cold meals were provided on September 16, 2020. Handwashing area was designated, as well, for cleaning utensils and pans. Signage was posted for direction and notification for staff and residents. Water temperatures will be checked in the activity room and documented for appropriate handwashing compliance. The LHD approved a local vendor to provide two (2) meals per day that were prepared offsite. A dietician communicated with the vendor textures and dietary needs to assure appropriate meals were provided. (9-17-20 thru 9-22-20) The facility will follow approved corrective action from LHD for safe handwashing, meal preparation, and disinfecting as detailed in Attachment 1 The Hot water heater was installed on 9/22/20. The facility communicated completion of installation a hot water heater to LHD and to the State Surveyor by September 22, 2020. Kitchen water temperatures will be reviewed for compliance. Any deviations will immediately be reported to NHA, Peak Administration (corporate), the LHD, and the OHCQ. As of September 18, 2020 the facility, NHA has secured a full-time CDM at the facility until this position is filled. The full-time CDM will educate staff for proper handwashing, temperature monitoring and disinfecting prior to resuming work September 16, 2020. Kitchen water temperatures will be checked by dietary with each use of the hand sink and the three (3) compartment sink; maintenance will also be check water temperatures daily. Food temperatures regarding hot and cold food and handwashing will be documented and reviewed according to the LHD corrective action plan. (Attachment 1) The facility will notify the LHD and the OHCQ when the boiler has been replaced. The NHA and/or designee will review and report to the Quality Assurance Performance Improvement Committee for three months to assure 100% compliance. Cross Reference Federal Survey Tags F812, F835, F836, F840, F867, F908; and State 100: [NAME] 10.07.02.09 A; State 880: [NAME] 10.07.02.21 K; State 1410: [NAME] 10.07.02.33 A; State 1540: [NAME] 10.07.02.38 C; State 1940: [NAME] 10.07.02.43 I; State 3000: [NAME] 10.07.02.64 A; State 6900: [NAME] 10.15.03.16 E; State 6910: [NAME] 10.15.03.16 G; and State 7050: [NAME] 10.15.03.18 L

Based on observation, interviews and review of facility documentation, the facility failed to effectively allocate resources to meet resident needs and to ensure their highest practicable well-being when (1) the facility administration failed to ensure effective management of dietary services without qualified staff managing the kitchen since April 2020; (2) the facility administration failed to ensure required maintenance was performed to provide a safe and sanitary food service operation in the facility kitchen when no hot water was available beginning on 7/6/20; (3) the facility administration for more than two months allowed unsafe practices regarding food preparation, food service, and infection prevention and control requirements, where these practices continued for at least 72 days, every day and at every meal, by utilizing the facility kitchen with no hot water (a) for hand washing and (b) for cleaning, rinsing and sanitizing pots and pans; (4) while continuing to operate the kitchen in unsafe and unsanitary conditions for at least 72 days, the facility did not report the serious health and safety concerns to State authorities as required; and, (5) the facility did not identify and address the numerous interrelated concerns by analyzing and addressing the root causes of the numerous noncompliant practices. These interrelated administration failures subjected all residents, staff and visitors to potential serious harm or death from infectious pathogens during a declared pandemic, and from potential serious food-borne illnesses. On 9/18/20 at 10:00 AM, an Immediate Jeopardy regarding these interrelated failures was determined. The Immediate Jeopardy began when the boiler failed on 7/6/20. The facility submitted an acceptable plan on 9/18/2020 at 4:00 PM and it was accepted and the IJ was removed on 9/18/20 at 6:00 PM. After removal of the immediacy, the deficient practice remained with potential for minimal harm and at a scope and severity of F. The findings include: Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. (Centers for Medicare and Medicaid Services, State Operations Manual, Appendix Q: 3/6/2019) 1. The facility administration failed to ensure effective management of dietary services without qualified staff managing the kitchen since April 2020. During tour of the kitchen on 9/15/20, Staff #5 and Staff #6 indicated that the nursing home had no Certified Dietary Manager (CDM). In later interview on this same date at 11:45, the Nursing Home Administrator (NHA) stated that she and human resources supervisor had been managing the kitchen since they lost the CDM during April 2020. However, the Administrator also acknowledged that neither she nor the human resources supervisor were certified in dietary management. Without fully certified and competent staff managing the kitchen, administration allowed facility staff to continue food preparation and service activities in the kitchen without hot water for more than two months. 2. The facility administration failed to ensure required maintenance was performed to provide a safe and sanitary environment in the facility kitchen, when the facility had no hot water in the kitchen beginning on 7/6/20. Review of facility water temperature logs on 9/16/20, revealed that facility maintenance staff had recorded a sharp drop in water temperatures for the kitchen during July. Following six consecutive weekly readings in the 140s (Fahrenheit), the recorded temperature dropped to 76.2 on 7/6/20. Weekly temperature checks from 7/6/20 through 9/14/20 revealed the water temperatures remained in the 70s at every weekly water temperature check in the kitchen during this date range (10 recorded checks in total). In 9/17/20 interview, Staff #13 (facility maintenance staff) reported that the facility had 2 boilers and one of these (the one that served the kitchen) had broken and needed replacement. The Administrator indicated that corporate management required that the facility obtain three estimates prior to replacement; but that as of 9/15/20, more than two months after the boiler first failed the facility had only obtained one. Although this reason was given to explain the more than two month delay in correcting the unsafe environment, after the Maryland Office of Health Care Quality (OHCQ) called the Immediate Jeopardy, the facility was able to obtain and install a hot water heater as an alternate source of hot water for the kitchen in four days. 3. For more than two months, the facility administration then allowed unsafe practices regarding food preparation, food service, and infection prevention and control requirements. Beginning on 7/6/20, these practices continued over at least 72 days, every day, and at every meal, by utilizing the facility kitchen with no hot water (a) for hand washing and (b) for cleaning, rinsing and sanitizing pots and pans. As detailed in Federal Survey Tag F-812, the facility utilized a dishwasher and a three-compartment sink for cleaning and sanitizing pots and pans. However, to ensure safe and effective cleaning and rinsing, the three-compartment sink required hot water at 110 F and the facility dishwasher required hot water at 120 F, which was not met. In addition to the lack of required hot water for the dishwasher and three-compartment sink, on 9/16/20, the Local Health Department (LHD) investigator made direct observations of staff not thoroughly washing hands in the kitchen and doing so without hot water. The food that the staff had worked with was discarded after this observation on 9/16/20. Review of the LHD report on 9/16/20 revealed that due to critical code violations, on 9/16/20 the LHD closed the kitchen for any food preparation and food service activities due to the facility failure to comply with the food services regulations at Code of Maryland Regulations ([NAME]) 10.15.03.14E,.14F, .18K and .18L. Prominent in these citations was the above noted inability of kitchen staff to wash hands/exposed skin properly with soap and warm water. Additionally, the facility was noted to have failed to comply with [NAME] 10.15.03.18L - where no potable hot water was provided. Without addressing the faulty equipment, facility administration allowed these unsafe practices to continue for more than two months. 4. Facility administration did not report the serious health and safety concerns to State authorities, as required. Over the many weeks the facility had failed to address the serious health and safety violations, the facility did not notify the OHCQ or the LHD that they were operating the kitchen with no qualified staff managing the kitchen and with no hot water. In follow-up interview on 9/25/20 at 11:10 AM, the LHD investigator confirmed that the LHD had not been notified of any hot water concerns in the facility until they were contacted by the OHCQ surveyor. 5. The facility did not identify and address the numerous interrelated noncompliant practices by analyzing and addressing the root causes of the noncompliant practices under the Quality Assessment Performance Improvement (QAPI) program requirements. Without fully qualified staff managing the kitchen, the facility allowed the serious noncompliant practices to continue for months without ever recognizing the seriousness of the noncompliance and without determining, analyzing, and addressing the root causes of the ongoing noncompliance. When the survey opened on 9/15/20, there had been no effective supervision provided for kitchen staff for more than four months and no hot water provided to the kitchen environment for more than two months. The facility failed to provide an effective Quality Assessment Performance Improvement (QAPI) program that dietary service management should have been reporting into (into QAPI); with QAPI then reporting up to Administration. No such system identified and addressed the serious noncompliance concerns while they continued unabated for more than two months. After the State Survey Agency intervened, the facility brought in a CDM on the same date (same date as the immediate jeopardy declaration) and a hot water heater was installed within four days, yet the facility QAPI program had not sufficiently intervened in the serious concerns for months. These interrelated failures by facility administration to ensure resources were utilized in a manner that allowed (1) for a safe environment and (2) for safe and compliant practices within the building, increased the risk for harm and death to all residents, staff and visitors in the building. In failing to repair or replace essential equipment, the administration created the unsafe environment. Then the facility allowed staff to operate within that environment with unsafe food preparation practices, unsafe food service practices, and unsafe infection prevention and control practices. As a result of these findings, an Immediate Jeopardy (IJ) was declared on 9/18/20 at 10:00 AM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to address the immediate concerns at 12:28 PM that did not meet minimum standards and it was therefore not accepted. The facility submitted a second plan at 2:45 PM that did not meet minimum standards and it therefore was not accepted. The facility submitted a third plan at 4:00 PM that was reviewed and met minimum standards. This plan was accepted by the State Survey Agency at 6:00 PM on 9/18/20. The accepted corrective action plan to address the immediate concerns included the following: Staff and residents will be assessed daily to monitor residents and staff for signs and symptoms of adverse effects related to water temperatures. As of September 16, 2020 the dietary department was granted approval from LHD to temporarily utilize the activity room in the facility as a kitchen. Approved cold meals were provided on September 16, 2020. Handwashing area was designated as well for cleaning utensils and pans. Signage was posted for direction and notification for staff and residents. (The LHD then amended this on 9/17/20 to require offsite food preparation). Water temperatures will be checked in the activity room and documented for appropriate handwashing compliance. Facility will follow approved corrective action from LHD for safe handwashing, meal preparation, and disinfecting. Facility will communicate completion of installing a hot water heater to the LHD by September 22, 2020. Kitchen water temperatures will be reviewed for compliance. Any deviations will immediately be reported to NHA, Peak Administration (corporate), the LHD, and the OHCQ. As of September 18, 2020, the facility, NHA has secured a CDM at the facility until this position is filled. Current full time CDM will educate staff for proper handwashing, temperature monitoring and disinfecting. Kitchen water temperature checks will be completed daily. Food temperatures regarding hot and cold food and handwashing will be documented and reviewed according to the LHD corrective action plan. Will notify the LHD and the OHCQ of completion of hot water heater installation (on or before September 22, 2020). Will notify the LHD and the OHCQ when boiler has been replaced. The NHA and/or designee will review and report to the Quality Assurance Performance Improvement Committee for three months to assure 100% compliance. Cross Reference Federal Survey Tags F801, F812, F836, F840, F867, F880, F908; and State 100: [NAME] 10.07.02.09 A; State 790: [NAME] 10.07.02.21 B; State 880: [NAME] 10.07.02.21 K; State 1410: [NAME] 10.07.02.33 A; State 1540: [NAME] 10.07.02.38 C; State 1940: [NAME] 10.07.02.43 I; State 3000: [NAME] 10.07.02.64 A; State 6900: [NAME] 10.15.03.16 E; State 6910: [NAME] 10.15.03.16 G; and State 7050: [NAME] 10.15.03.18 L

Based on observation, interviews and review of facility and other documentation, the facility failed to ensure that food preparation and service was safe when: (1) since April 2020, the facility operated the kitchen without qualified staff managing the kitchen; (2) the boiler that supplied hot water had failed on or by 7/6/20 and the facility never reported the serious health and safety issue to regulatory authorities, and (3) without fully qualified and competent staff managing the kitchen, beginning on 7/6/20, food preparation and service activities were conducted in the facility kitchen in an unsafe manner with no hot water (a) for hand washing; (b) for safe cleaning, rinsing and sanitization of pots and pans in the facility warewashing machine (dishwasher); and (c) for safe cleaning, rinsing and sanitization of pots and pans in the kitchen three-compartment sink. Continuing to operate the kitchen in an unsafe manner violated safe food practices, violated infection prevention and control practices, and placed all residents, staff and visitors at increased risk for serious harm and possible death from potential serious infection during a known pandemic, and from potential serious food-borne illness outbreaks. This concern began on or by 7/6/20 and continued until 9/18/20 after intervention by the State. On 9/18/20 at 10:00 AM, the Maryland Office of Health Care Quality determined that the facility's failure to prepare foods via safe and sanitary methods due to the lack of hot water in their kitchen starting on 7/6/2020 constituted an Immediate Jeopardy (IJ) concern. The facility submitted an acceptable plan on 9/18/2020 at 4:00 PM and it was accepted and the IJ was removed on 9/18/20 at 6:00 PM. After removal of the immediacy, the deficient practice remained with potential for minimal harm and at a scope and severity of F. The findings include: Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death (Centers for Medicare and Medicaid Services, State Operations Manual, Appendix Q: 3/6/2019). 1. The facility did not have qualified staff managing the kitchen which directly contributed to unsafe practices in the kitchen. During tour of the kitchen on 9/15/20, Staff #5 and Staff #6 indicated that the nursing home had no Certified Dietary Manager (CDM). In later interview on this same date at 11:45, the Nursing Home Administrator (NHA) stated that she and human resources supervisor had been managing the kitchen since losing the CDM during April 2020. However, the Administrator acknowledged that neither she nor the human resources supervisor were certified in dietary management. Without fully qualified and competent staff managing the kitchen, facility staff continued to conduct food preparation and service activities in the unsanitary kitchen without hot water for more than two months. 2. The boiler that supplied hot water to the kitchen had failed on or by 7/6/20 and the facility did not repair it, did not replace it, and did not report the interrelated concerns as required to regulatory authorities. Review of facility water temperature logs on 9/16/20, revealed that facility maintenance staff had recorded a sharp drop in water temperatures in the kitchen. Following six consecutive weekly readings in the 140's (Fahrenheit), the recorded temperature had dropped to 76.2 when checked on 7/6/20. Weekly temperature checks from 7/6/20 through 9/14/20 revealed the water temperatures remained in the 70s at every weekly water temperature check in the kitchen during this date range (10 recorded checks in total). In 9/17/20 interview, Staff #13 (facility maintenance staff) reported that the facility had 2 boilers and one of these (that served the kitchen) had broken and needed replacement. The Administrator stated that corporate management required that the facility obtain three (3) estimates prior to replacement; but more than two months after the boiler first failed; as of 9/15/20 the facility had only obtained only one. Although this was the reason given for not correcting the hot water concern for more than two months, after the immediate jeopardy was called it took only four days to install a hot water heater as a short-term alternate source for hot water in the kitchen. On 9/16/20 at approximately 1:00 PM, the Office of Health Care Quality (OHCQ) surveyor contacted the Local Health Department (LHD) regarding the serious concern with ongoing use of the kitchen with no hot water. On 9/16/20, the LHD investigator came into the facility, validated the concerns, and reported that without hot water, the facility did not meet minimum standards set forth in the Code of Maryland Regulations (under [NAME] 10.15.03) for hand-washing, and for cleaning, rinsing and sanitizing the pots and pans. Citing critical violations the LHD closed the kitchen on 9/16/20. 3. Without fully qualified and competent staff to manage the kitchen, beginning on 7/6/20, food preparation and service activities were conducted in the facility kitchen in an unsafe manner with no hot water for hand washing; for safe cleaning, rinsing and sanitization of pots and pans with the warewashing machine; and for safe cleaning, rinsing and sanitization of pots and pans in the three-compartment sink. Beginning on or by 7/6/20, kitchen staff continued to utilize the kitchen for food preparation and food service activities for three meals daily despite the lack of hot potable water. The kitchen was observed still in use for these activities when toured during the survey that began on 9/15/20. 3.1 On 3/4/20 the Centers for Medicare & Medicaid Services (CMS) issued guidance in CMS Press Release which indicated that all health care providers must immediately review their procedures to ensure compliance with CMS' infection control requirements, as well as the guidelines from the Centers for Disease Control and Prevention (CDC). On 3/5/20, the Governor of Maryland declared a statewide health emergency related to community spread of COVID-19. With the order to follow CDC guidance in effect, on 4/27/20, the CDC issued Guidance for Healthcare Providers about Hand Hygiene and COVID-19 indicating that Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene . is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. On 9/16/20, the LHD closed the kitchen for any food preparation and food service activities due to the facility failure to comply with the food services regulations at Code of Maryland Regulations ([NAME]) 10.15.03.14E,.14F, .18K and .18L. Prominent in these citations was the failure of kitchen staff to wash hands/exposed skin properly, and the failure to do so with soap and warm water. The Centers for Medicare and Medicaid Services noted that, staff should have access to proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. CMS further noted that antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting (State Operations Manual, Appendix PP 11/22/2017). As required by State [NAME] 10.15.03.18 L Hand sinks must be: (1) installed in accordance with applicable State and local laws, ordinances, and regulations; (2) able to discharge: (a) hot and cold running water; or (b) tempered running water at a temperature of at least 100 F through: (i) A mixing valve; (ii) a combination faucet; or (iii) any slow closing or metering faucet that provides a flow of water for at least 15 seconds before the faucet has to be reactivated. At 11:00 on 9/15/20, the surveyor documented that there were no paper towels and there was no hot water in the sink in the kitchen by the juice machine; and the surveyor noted that there were no paper towels or hot water at a second sink in the kitchen. Review of temperature logs corroborated that water temperatures in the kitchen were not hot and did not reach the State defined minimum required temperature of 100 F for hand sinks; but rather, was maintained only in the 70s. In the 9/16/20 report when the kitchen was closed, the LHD investigator documented direct observations of staff (1) not thoroughly washing hands in the kitchen, and (2) doing so without hot water. The LHD required that the facility discard the food that the staff had worked with after this observation. 3.2 Additionally, the facility utilized a dishwasher for cleaning, rinsing and sanitizing pots and pans in an unsanitary manner without hot water. As required by State [NAME] 10.15.03 16 G (3), if manufacturer's specifications for wash and rinse water temperature do not exist, the following standards are followed: (a) for machines using chemical sanitization, the wash and final rinse water temperature is at least 120 F. The specification sheet for the dishwasher in use (CMA Model B, low temperature) noted the heating element assures a continuous supply of 140 F hot water [and] guarantees excellent results. However, in a 9/16/20 interview at 1:30 PM, the equipment contractor reported to the surveyor that the heating element had failed and was removed from the dishwasher at an unknown date before the survey. In addition to the direct regulatory requirement, on 9/17/20, a Registered Environmental Health Specialist within the Office of Health Care Quality also reviewed the manufacturer specifications for the dishwasher in use in the facility kitchen and confirmed that the dishwasher in use did require hot water as defined in the regulations. The manufacturer did not specify any acceptable minimum temperature below 120 degrees Fahrenheit for the operation of the dishwasher. Therefore the minimum temperature defined in [NAME] 10.15.03 would be applied. In the interview on 9/16/20 at 1:30 PM, the contractor reported that after the boiler failed, he then increased the chemicals for sanitization in the dishwasher to 100 Parts per Million (PPM) chlorine. The contractor added that the facility continued using the dishwasher for cleaning only pots and pans. Review of the contractor's documented receipt/report revealed the contractor wrote the dishwasher was a low temp dishwasher and corroborated his verbal report that there was no built in heating system. Consistent with the noted regulatory requirement for hot water at 120 F, the contractor wrote that the dishwasher may not be reaching 120 . but it is receiving 100 PPM chlorine which is on high side of the 50-100 PPM required by the state. In the same documentation the contractor added, I made this adjustment in early July immediately upon it being brought to my attention that there was an issue with hot water. Corroborating these reports, in interview on 9/18/20 at 10:00 AM, the NHA stated that she went along with someone I trusted that the chemicals were enough to clean linens [and] dishes (dishwasher). Review of the LHD report on 9/16/20 at 1:00 PM revealed that the lack of hot water at the hand washing sinks, and the warewashing machine (dishwasher) not operating with water at 120 F were critical violations of [NAME] 10.15.03 Food Service Facilities. The LHD investigator also spoke with the equipment contractor and he confirmed with her that the warewashing machine was serviced (adding chemicals). The LHD investigator documented that the warewashing machine was not supplied with a booster or heating element, and that for machines using [chemical] sanitization, the wash and final rinse water temperature [needed to be] at least 120. The LHD investigator documented that the warewashing facilities [were] not maintained or supplied with hot water and specifically noted that the facility needed to discontinue use of warewashing facilities until hot water is supplied. The LHD report explicitly requiring the facility discontinue its use of the dishwasher was signed by both the facility NHA and LHD Investigator on 9/16/20. 3.3 The facility utilized a three-compartment sink for cleaning, rinsing and sanitizing pots and pans without sufficient hot water. The CMS indicates that a 3-step process is used to manually wash, rinse, and sanitize dishware correctly. The first step is thorough washing using hot water and detergent after food particles have been scraped off. The second is rinsing with hot water to remove all soap residues. The third step is sanitizing with either hot water or a chemical solution maintained at the correct concentration, based on periodic testing, at least when initially filled and as needed, such as with extended use, and for the effective contact time according to manufacturer's guidelines (State Operations Manual, Appendix PP 11/22/2017). The hot water noted by CMS for the first two compartments of a three-compartment sink is defined in both the FDA Food Manual (Chapter 5) and the CMS surveyor guidance as meeting at least a minimum water temperature of 110 F. Sanitization with chemicals in the third compartment of the three-compartment sink can be accomplished effectively at lower temperatures when chemicals are added, but the first compartment for cleaning, and the second compartment for rinsing prior to sanitization, require the minimum 110 F water temperature. The State regulations also require availability of both hot and cold water when using a three-compartment sink. Specifically at [NAME] 10.15.03.16,(E) the State requires that a three-compartment sink is: (1) provided and used wherever warewashing is conducted manually; (2) adequate in length, width, and depth to accommodate the largest equipment items and utensils; [and] (3) supplied with hot and cold running water at each sink compartment. Review of the local health department documentation, revealed that the plumbing and equipment contractor also increased the chemicals for use in the three part sink to 100 parts per million (PPM) of quaternary ammonia and told facility this was sufficient to sanitize the pots and pans (sanitization in third compartment). In a 9/16/20 interview with the Surveyor, the contracted service provider for plumbing and equipment repairs corroborated the change in chemicals for the three part sink. However, the first two compartments of the three compartment sink did not have the required hot water to ensure pots and pans were effectively cleaned and rinsed prior to attempting sanitization in the third compartment. With insufficient cleaning and rinsing of food matter in the first and second compartments, the sanitization of the pots and pans could not be guaranteed effective in the third. From 7/6/20 through 9/18/20, the facility failed to ensure availability of hot water was supplied at 100 F to hand sinks in the kitchen, at 110 F at the three-compartment sink in the kitchen, and at 120 F at the dishwasher in the kitchen. As a result of these findings, an Immediate Jeopardy was declared on 9/18/20 at 10:00 AM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to address the immediate concerns at 12:28 PM and 2:45 PM, however neither met minimum standards and therefore were not accepted. The facility submitted a third plan at 4:00 PM that was reviewed and met minimum standards. This plan was accepted by the State Survey Agency at 6:00 PM on 9/18/20. The accepted corrective action plan to address the immediate concerns included the following: Staff and residents will be assessed daily to monitor residents and staff for signs and symptoms of adverse effects related to water temperatures. As of September 16, 2020 the dietary department was granted approval from LHD to temporarily utilize the activity room in the facility as a kitchen. Approved cold meals were provided on September 16, 2020. A handwashing area was designated as well for cleaning utensils and pans. Signage was posted for direction and notification for staff and residents. (The LHD then amended this to require offsite preparation of food as noted above.) Water temperatures will be checked in the activity room and documented for appropriate handwashing compliance. Facility will follow approved corrective action from LHD for safe handwashing, meal preparation, and disinfecting. Facility will communicate completion of installing a hot water heater to the LHD by September 22, 2020. Kitchen water temperatures will be reviewed for compliance. Any deviations will immediately be reported to NHA, Peak Administration (corporate), the LHD, and the OHCQ. As of September 18, 2020, the facility, NHA has secured a CDM at the facility until this position is filled. Current full time CDM will educate staff for proper handwashing, temperature monitoring and disinfecting. Kitchen water temperatures will be completed daily. Food temperatures regarding hot and cold food and handwashing will be documented and reviewed according to the LHD corrective action plan. Will notify the LHD and the OHCQ of completion of hot water heater installation (on or before September 22, 2020). Will notify the LHD and the OHCQ when boiler has been replaced. The NHA and/or designee will review and report to the Quality Assurance Performance Improvement Committee for three months to assure 100% compliance. Cross Reference Federal Survey Tags F801, F835, F836, F840, F867, F880, F908; and State 100: [NAME] 10.07.02.09 A; State 790: [NAME] 10.07.02.21 B; State 880: [NAME] 10.07.02.21 K; State 1410: [NAME] 10.07.02.33 A; State 1540: [NAME] 10.07.02.38 C; State 1940: [NAME] 10.07.02.43 I; State 3000: [NAME] 10.07.02.64 A; State 6900: [NAME] 10.15.03.16 E; State 6910: [NAME] 10.15.03.16 G; and State 7050: [NAME] 10.15.03.18 L

Based on medical record review and facility investigation reports, it was determined that a geriatric nursing assistant (GNA #2) abused a resident (Resident #1) in one of two sampled resident records reviewed. Additionally, the administrative staff failed to report this incidence of abuse to the police and report the GNA to the Maryland Board of Nursing. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm or saying things to frighten a resident. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The findings included: Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This resident is legally blind and requires extensive assistance for her care, comfort and safety. Review of the facility investigation revealed the following: On 05/30/2014 at approximately 6:00 a.m., GNA #1 was bathing this resident. According to GNA #1's statement while bathing the resident she "noticed a big purple dark bruise on her left thigh. Also, she had bruises on her wrists. (Resident) said to me 'she was put to bed with her hair soaking wet'. Then she said she had a shower last night and 'someone was rough with her jerked her all around'. I went to the nurse (nurse #1) and reported it to her. While (nurse #1) was in the room (resident) also told her the bruises hurt." Review of the nursing notes revealed: 05/30/2014 at 6:19 a.m.: "Bruises to the L (left) & R (right) as well as bruise to the left upper thigh." Further review of the facility investigation revealed the following: 05/30/2014 at 7:30 a.m., nurse #2: "I assessed resident and observed purple colored hematomas to bilateral forearms and left thigh area. ..." On 05/30/2014, the social work designee conducted an interview with the resident. The social work designee documented the following resident statement: "GNA (GNA#2) was rough c (with) her and had grabbed her by her wrists. She said she remembers hitting her thigh on something, not sure what it was (resident blind) but she said to the GNA (GNA #2) - Ouch that hurt! The GNA (GNA #2) never responded to the resident. She also told this writer that the GNA (GNA #2) refused to give her the call bell when she asked where it was." It is worth noting that though the administrative staff conducted an investigation and reported this incident of abuse to the Office of Health Care Quality, the resident's physician and family they failed to call the police or report GNA#2 to the Maryland Board of Nursing. By this resident's account GNA #2 was abusive by being rough, grabbing her wrist, hitting her left thigh on something, placing her in bed with wet hair and refusal to provide her call light Additionally, the administrative staff failed to report this incidence of abuse to the police and report the GNA to the Maryland Board of Nursing.

Based on complaint, interviews with the resident and the facility staff, and reviews of a resident's closed medical and hospital records, it was determined that the facility staff failed to follow a physician's orders [REDACTED]. This was evident for 1 of 7 residents reviewed during a complaint survey. The findings include: Review of complaint MD 170, on [DATE], revealed an allegation indicating the nursing staff failed to obtain physician ordered PT/INR levels as instructed which lead to resident #3 being hospitalized . Resident #3 is a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 completed a Life Sustaining Treatment Options (LSTO) form on [DATE] which indicated resident #3 wanted all available treatments and life sustaining procedures while he resided in the facility. Review of resident #3's closed medical record, on [DATE], revealed physician admission orders [REDACTED]. The [DATE] admission orders [REDACTED]. The [DATE] physician orders [REDACTED].#3 for signs and symptoms of bleeding. Review of resident #3's, facility obtained PT/INR results on [DATE] revealed the following: [DATE] - PT - 16.1, INR - 1.75 [DATE] - PT - 18.7, INR - 1.55 On [DATE], resident #3's attending physician was notified, by nurse #4, of the [DATE] PT/INR results. Resident #3's attending physician gave a new order instructing the nursing staff to increase resident #3's daily [MEDICATION NAME] dose to 3 mg, to be given orally, every evening at 6 pm and continue to obtain a PT/INR level twice weekly. Review of resident #3's nursing documentation, dated [DATE], revealed resident #3 complained of shortness of breath at 12:30 pm that was not relieved with oxygen and a inhaled nebulizer treatment. Resident #3 was also noted with a thick greenish/brown productive cough. Resident #3's physician was contacted and made aware of resident #3's new symptoms who intern instructed the nursing staff to send resident #3 to the emergency room . Review of resident #3's [DATE] hospital admission record, on [DATE], revealed resident #3 was admitted to the emergency room with a [DIAGNOSES REDACTED]. Resident #3's [DATE] hospital admission record noted resident #3's [DATE] hemoglobin level to be 6.6 (normal 14.0 - 18.0) which was down from the resident's baseline of 10.7 in [DATE]. Review of the facility anticoagulant therapy protocol revealed residents receiving [MEDICATION NAME] should have a therapeutic INR result between 2.0 - 3.0 unless otherwise instructed. Review of resident #3's anticoagulant therapy care plan, on [DATE], revealed a nursing evaluation, dated [DATE], instructing the nursing staff to 1) administer a 3 mg daily dose of [MEDICATION NAME] to resident #3, 2) continue to obtain a PT/INR level twice weekly, and 3) to continue to monitor resident #3 for signs and symptoms of bleeding. In an interview with the facility Director of Nursing (DON) on [DATE] at 10 am, the facility DON confirmed resident #3's physicians orders, dated [DATE] at [DATE], instructing the nursing staff to obtain a PT/INR level two times a week. In an interview with resident #3 on [DATE] at 2:02 pm, resident #3 stated he was unconscious and awoke in a Baltimore hospital after being transferred to the hospital on [DATE]. Resident #3 stated he nearly died but could not remember why he was sent to the hospital. In conclusion, the facility staff failed to follow resident #3's [DATE] and [DATE] physician's orders [REDACTED].#3 while he was receiving the anticoagulant [MEDICATION NAME]. This in turn lead to the subsequent hospitalization and administration of a blood [MEDICAL CONDITION] and blood products, to resident #3, to reverse the elevated PT/INR level of 12.86 on [DATE].

Based on complaint, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a safe environment and adequate supervision, during care, to prevent the resident from falling out of a mechanical lift onto the floor and receiving an injury. This occurred for 1 of 7 resident reviewed during a complaint survey. The findings include: Resident #7 is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 has been deemed cognitively impaired. Resident #1 is totally dependent upon the facility staff for all aspects of her care and is unable to protect herself from any potential accidents and injury. Review of complaint MD 732, on 01/25/2012, revealed an allegation resident #7 fell out of a mechanical lift, during a transfer, and suffered a laceration to her forehead and a abrasion to her hand on 01/16/2012. Review of resident #7 ' s post fall nursing concurrent review dated 01/16/2012 at 9:30 am, on 01/25/2012, revealed resident #7 was being transferred from a chair to her bed via a Hoyer lift (a type of mechanical lift that uses a sling device) when resident #7 slid to the floor, hit her head, and received a 2 inch laceration to the posterior scalp and a half inch skin tear to the left hand. Nursing documentation indicated that resident #7 was sent to the hospital for evaluation and treatment. Review of resident #7 ' s closed medical record revealed that resident #7 had a history of [REDACTED]. Further review of resident #7 ' s medical record revealed nursing documentation, dated 04/24/2011, where the Hoyer lift sling strap broke during a transfer from the bed to a recliner chair. Resident #7 was found on the floor on 04/30/2011 and again on 05/04/2011. No injuries were noted to resident #7 after the 04/30/2011 fall. Resident #7 was sent to the emergency room to be evaluated for the 05/04/2011 fall. On 06/07/2011 at 4 am, nursing documentation indicated that resident #7 rolled out of bed onto a mat, which was located on the right side of the bed, while GNA #1 attempted to place a dry pad under resident #7. In an interview with GNA #1, on 02/01/2012 at 5:18 pm, GNA #1 stated that resident #7 is an obese lady. On 06/07/2011 at 4 am, GNA#1 stated that she assisted resident #7 onto her side, and then left the room to get a clean pad. GNA #1 stated when she came back to the room resident #7 was on the floor. GNA #1 stated that she did not have any assistance from any other staff member while providing care to resident #7 on 06/07/2011 4 am. GNA #1 stated that she did not adjust resident #7 ' s bed height prior to the fall. GNA #1 stated that she observed a skin tear to resident #7 ' s left hand after the 06/07/2011 4 am fall. Further review of resident #7 ' s closed medical record revealed that resident #7 was sent to the local emergency room for evaluation and treatment on 06/07/2011 at 4 am. On 06/07/2011 at 6:50 am, resident #7 returned from the emergency room . On 06/07/2011 at 6:50 am, nursing documentation also indicated that resident #7 was observed with a 3 cm (centimeter) bruise to her left neck and a dressing to the left forehand. Further review of resident #7 ' s nursing documentation, dated 01/16/2012 at 9:30 am, revealed that resident #7 was being transferred from the chair to the bed using a Hoyer lift when resident #7 slid to the floor. The 01/16/2012 9:30 am nursing documentation indicated that resident #7 hit her head and received a 2 inch laceration to the posterior scalp and a skin tear to the left anterior hand. Resident was sent to the emergency room at 10 am on 01/16/2012. Further review of resident #7 ' s nursing documentation, dated 01/16/2012 at 3:15 pm, revealed that resident #7 was readmitted from the emergency room and was noted with a large hematoma, with sutures, to the crown of her head, a small skin tear to the left hand, and a small scrape to the right side of the face. In an interview with GNA #2 on 01/25/2012 at 11:20 pm, GNA #2 stated she that was providing care to resident #7 on 01/16/2012 at 9:30 am. GNA #3 stated that resident #7 is totally dependent and cannot protect herself from falling. GNA #2 stated that she was transferring resident #7, without assistance, with a Hoyer lift on 01/16/2012 at 9:30 am. GNA #2 stated that she was in the process of transferring resident #7 from the chair back to bed when resident #7 slid out the right side of the sling. GNA #2 stated that the prior GNA placed the sling under resident #7 to transfer her form the bed to the chair earlier in the morning. GNA #2 stated that the sling was too small for resident #7 and that she was not aware the sling was too small until she was in the process of transferring resident #7 back to bed. GNA #2 stated that she was not aware that resident #7 was supposed to be transferred with two staff attendants. GNA #2 admitted that she has been transferring resident #2 by herself since she has been taking care of resident #7. GNA #2 stated that she broke resident #7 ' s fall, but also stated that resident #7 hit her head on the Hoyer lift support leg. Review of resident #7 ' s fall prevention care plan, dated 01/04/2012, revealed the following nursing interventions: Use a Hoyer lift and 2 staff members for transfers. In conclusion, the facility staff failed to provide resident #7 with a safe environment and adequate supervision, during care on 06/07/2011 at 4 am and 01/16/2012 at 9:30 am, to prevent resident #7 from 1) falling out bed, onto the floor, and receiving a 3 cm (centimeter) bruise to her left neck and a dressing to the left forehand on 06/07/2011 at 4 am, and 2) falling out of a sling on to the floor, while using a mechanical lift on 01/16/2012 at 9:30 am, which required resident #7 be transferred to the hospital for treatment to the scalp laceration with hematoma, a small skin tear to the left hand, and a small scrap to the right side of the face.

Based on review of the medical record, interview with staff and review of hospital report, the facility failed to remove a medicated patch prior to application of a second. The resident experienced a significant change in medical condition and was transported to the hospital. The findings include: Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident on admission was prescribed the following medications. [MEDICATION NAME] 0.25 milligrams in the a.m. and [MEDICATION NAME] 0.5 milligrams in the p.m. [MEDICATION NAME] Patch 4.6 milligrams 24 hour patch every day. [MEDICATION NAME] is a medication used for the treatment of [REDACTED]. Potential drug interactions between [MEDICATION NAME] and [MEDICATION NAME] include a neurotoxic effect with [MEDICATION NAME] potentiating the strength of the [MEDICATION NAME].. During the course of the resident's stay at the N.H. from 9/10/11- 9/23/11 the resident's behavior consisted of combativeness during care and yelling out at night per nursing notes. On 9/16/2011 11:30 a.m. physician order; " [MEDICATION NAME] 9.5 mg patch 9.5 mg.(milligrams)/24 hrs(hours)." On 9/23/2011 6:45p.m. physicians order, " D/C(discontinue) [MEDICATION NAME] 0.25 mg p.o. a.m. [MEDICATION NAME] 0.50mg q(every) a.m. D/C [MEDICATION NAME] 0.50mg p.m. [MEDICATION NAME] 0.75mg p.o. q. p.m." As noted, the resident's medications were increased in dosage. On 9/27/2011 per the nursing note, the resident was unresponsive, BP 70/40, pulse ox. 88. Physician notified and resident transferred to the hospital via 911. Hospital report reveals the following information dictated by admitting physician. " Of note, during my skin examination, I noted an [MEDICATION NAME] on the patient's left posterior scapula which was dated 09/26/11 and an [MEDICATION NAME] on the patient's right deltoid dated 09/27/11 ( patient had 2 [MEDICATION NAME]es on)." Surveyor review of the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"off." This entry indicates that the nurse removed the old patch and replaced with a new patch. MAR dated 9/27/11- 8 a.m. nurses initials, Site- RA(right arm), Removal of old patch," check." Again indicating the old patch was removed and a new patch replaced. Interview with the facility DON on 10/26/11 in her office revealed that she was aware the family told her the findings from the hospital, that 2 patches were on the resident at time of hospital admission but since the family did not have more information the allegation was not investigated. The DON then stated that she did call the hospital but the nurse did not confirm. It was at this time the surveyor informed the DON and presented the hospital report which indicated the above. As noted in the MAR, the nurse who applied the patch on 9/27/11, checking off that the previous patch was removed was not the case as noted by the hospital physician report. Medication errors with [MEDICATION NAME] have resulted in serious adverse events including drug interactions with antipsychotics. The majority of serious adverse events have led to hospitalization . The errors occur when one patch is not removed prior to putting on a new patch. Per hospital report dated 10/3/2011 " Patient was placed off [MEDICATION NAME] and [MEDICATION NAME] and slowly but surely she has a workup to baseline mental status."