Every finding on record at Citizens Care Center

Based on clinical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 7 (#3, #4, #6, #123, #12, #34, #50) of 13 residents reviewed for MDS accuracy during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a comprehensive, federally mandated assessment tool used to evaluate a resident's functional, cognitive, and health status to create individualized care plans, monitor quality of care, and support reimbursement for Medicare and Medicaid certified facilities. 1) On 01/21/2026 at 3:07 PM, a review of Resident #3's physician order dated 12/14/2025 for siderails: 2 1/4 padded bed rails for seizure precautions. On 01/22/2026 at 8:05 AM, a review of the Minimum Data Set (MDS) 5-day assessment for Resident #3, completed on 12/16/2025 and locked on 12/29/2025, revealed a discrepancy. Specifically, Section P0100, titled Restraints and Alarms, had a designated section for Bed rail with options: 0. Not used, 1. Used less than daily, 2. Used daily, and -Not assessed. The chosen response was 0. not used. However, a subsequent review of Resident #3's Treatment Administration Record (TAR) for December 2025 indicated that the siderails were signed off as being used during every shift. 2) On 01/22/2026 at 11:20 AM, in review of Resident #4's physician order dated 11/14/2025 for siderails: 2 1/4 rails up for use of bed controls every shift. On 01/22/2026 at 11:39 AM, a review of the Minimum Data Set (MDS) admission assessment for Resident #4, completed on 11/20/2025 and locked on 11/21/2025, revealed a discrepancy. Specifically, Section P0100, titled Restraints and Alarms, had a designated section for Bed rail with options: 0. Not used, 1. Used less than daily, 2. Used daily, and -Not assessed. The chosen response was 0. not used. However, a subsequent review of Resident #4's Treatment Administration Record (TAR) for November of 2025 indicated that the siderails were signed off as being used during every shift. 3) On 01/22/2026 at 9:12 AM, in review of Resident #6's physician order dated 9/2/2025 for side rails: 2 1/4 rails for bed controls and to assist with positioning. Every shift, they may use 4 rails as requested. On 01/22/2026 at 9:10 AM, a review of the Minimum Data Set (MDS) quarterly assessment for Resident #6, completed on 10/27/2025, and locked on 11/04/2025, revealed a discrepancy. Specifically, Section P0100, titled Restraints and Alarms, had a designated section for Bed rail with options: 0. Not used, 1. Used less than daily, 2. Used daily, and -Not assessed. The chosen response was 0. not used. However, a subsequent review of Resident #6's Treatment Administration Record (TAR) for October of 2025 indicated that the siderails were signed off as being used during every shift. On 01/22/2026 at 12:08 PM, during an interview with Staff #11 and Staff #12 (MDS Coordinator Nurses), it was confirmed that, according to the RAI manual, siderails are considered a restraint and should have been coded as used daily. On 01/22/2026 at 12:36 PM, the concern was shared with the Director of Nursing. 4) On 01/23/2026 at 11:32 AM, a review of Resident #123's Minimum Data Set (MDS) admission assessment, completed on 01/05/2026 and locked on 01/12/2026, revealed a discrepancy. Specifically, Section M0100, titled Determination of Pressure Ulcer/Injury Risk, had a designated section A for the question of whether the resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing device with the options Yes or No. The chosen response was No. However, a subsequent review of Resident #123's revealed a progress note dated 01/05/2026 at 1:06 PM; Resident #123 noted an open area to the sacrum measuring 1.2 cm (centimeters) x 0.7 cm with granulation tissue. On 01/28/2026 at approximately 1:10 PM, during an interview with Staff #11 and Staff #12 (MDS Coordinator Nurses), it was confirmed that the acquired wound Resident #123 sustained on 01/05/2026 should have been documented as yes in the admission Minimum Data Set (MDS). On 01/28/2026 at approximately 2:00 PM, the Director of Nursing (DON) was made aware of the concerns. 5) A review of Resident #12's medical record on 01/20/2026 at 11:24 AM revealed an MDS completed on 1/7/2026. Section P0100. Physical restraints indicated that bed rails were not used. On 1/20/2026 at 11:26 AM, further record review confirmed a physician order was written on 11/12/2025for siderails: 2 - 1/4 rails up for use of bed controls. On 1/20/2026 at 11:28 AM, A review of the Treatment Administration Record (TAR) for January 2026 revealed that the resident was being monitored for the use of padded side rails every shift for injury prevention/history of seizures. 6) On 1/20/26 at 11:30 AM, a review of Resident #34's medical record revealed an MDS completed on 10/30/2025, which indicated in Section P0100. Physical restraints, that bed rails were not used. The surveyor noted on 1/20/26 at 11:34 AM, a physician order written on 2/13/2021 for siderails: 2 - 1/4 rails up for use of bed controls. Further review of Resident #43's medical records on 1/20/2026 at 11:45 AM, revealed in the Treatment Administration Record (TAR) for January 2026, Resident #43 was monitored for the use of side rails every shift for bed controls. 7) On 1/20/2026 at 11:50 AM, a review of Resident # 50's medical record revealed an MDS completed on 11/14/2025, indicated in Section P0100. Physical restraints, bed rails were not used in bed. Further record review of Resident #50's medical record on 1/20/26 at 11:55 AM, revealed a physician order written on 11/3/2025 for siderails: 2 - 1/4 rails up for use of bed controls. On 1/20/2026 at 12:00 PM, a review of Resident #50's Treatment Administration Record (TAR) for January 2026 revealed Resident #50 was being monitored for the use of side rails every shift for bed controls. The MDS Coordinators (Staff # 11 and Staff # 12) were interviewed on 01/22/2026 at 12:08 PM and they verified that the MDS should have been coded as A. bed rail 2. Used daily. The Director Of Nursing (DON) was made aware of the concern on 1/22/2026 at approximately 1:30 PM.

Based on clinical record review, observation, and interviews with the facility staff it was determined the facility failed to properly assess a resident for bedrails as evidenced by: not assessing a resident for entrapment risk, reviewing risks and benefits with the resident/representative, or obtaining informed consent prior to installation. This was evident for 5 Residents (# 34, # 50, #3, #4, and #6) of 5 residents observed having siderails in use during the facility's recertification/complaint survey. The findings include:Bed rails are adjustable bars attached to beds. While they can aid mobility and safety, they can also act as a restraint, preventing exit, and pose an entrapment risk if incorrectly installed. Proper evaluation of resident needs is essential before installation to maximize benefit and prevent risk. A side rail is a specific type of bed rail mounted on the sides. Entrapment occurs when a resident is caught or entangled in or around the bed rail, potentially causing injury, impairment, or death. 1) On 1/20/2026 at 11:01 AM, during the screening process of the annual survey, the surveyor observed Resident # 34 lying in bed with a 1/4 bedrail raised at head of the bed. On 1/20/2026 at 11:05 AM, Resident # 34 stated during an interview that he/she cannot easily and voluntarily release the bed rails. On 1/20/2026 at 2:00 PM, a review of Resident # 34's medical record revealed that Resident # 34 had a Brief Interview of Mental Status (BIMS) of 13 and diagnoses that included a history of falling, unspecified dementia, muscle weakness, and hemiplegia affecting left nondominant side. In addition, there was an order written on 2/13/2021 for siderail: 2 - 1/4 rails up for use of bed controls. There was no consent for the use of the bedrail and no assessment documented. 2) On 1/20/2026 at 11:10 AM, Resident # 50 was observed in bed with 1/4 bedrail raised on each side of the bed. Resident # 50 was unable to demonstrate use of the controls on the bedrails. A review of Resident # 50's medical record on 1/20/2026 at 2:05 PM revealed that Resident #50 have diagnoses that included unspecified dementia, muscle weakness, other abnormalities of gait and mobility, and other lack of coordination. There was an order written on 11/3/2025 for siderails: 2 - 1/4 rails up for use of bed controls. There was no consent from the responsible party or assessment for the use of the bedrails in the medical record. On 01/21/2026 at 3:25 PM, during an interview, the Director of Nursing (DON) stated that the use of two siderails required a physician's order and are primarily for residents repositioning and assistance with bed control. The DON confirmed that no specific assessment is performed prior to the use of siderails. During a follow up interview on 01/22/2026 at 7:51 AM with the Director of Nursing (DON), she stated that the facility does not have a formal bedrail policy, and all purchased beds complied with entrapment measurement guidelines and are checked by maintenance. However, the DON could not provide the manufacturer guidelines for the purchased beds or documentation of maintenance checks. On 1/22/2026 at 12:36 PM, the Director of Nursing was made aware that siderails can lead to entrapment and not having consent for side rails and no assessment for the use of side rails is a concern. 3) On 01/20/2026 at 1:11 PM, during an observation, Resident #3 was lying in bed with one 1/4 bedrail raised on each side of the bed and blue padding inside the rails. On 01/21/2026 at 3:07 PM, a review of Resident #3's medical records revealed a 12/15/2025 physician order for Siderails: 2 1/4 padded bed rails for seizure precautions. However, the medical record contained no documentation of a bedrail assessment or any additional details concerning the use of bedrails. On 01/22/2026 at 8:09 AM, during an interview with Resident #3, he/she stated that he/she did not request the side rails; they came with the bed. 4) On 01/20/2026 at 10:00 AM, during the initial tour and observation, Resident #4 was sitting on the side of the bed with 2 1/4 side rails raised on each side of the bed. On 01/22/2026 at 11:20 AM, a review of Resident #4's medical record revealed a physician order dated 11/14/2025—Side Rails: 2 1/4 rails up for use of bed controls every shift. However, the medical record contained no documentation of a bedrail assessment or any additional details concerning the use of bedrails. 5) On 1/20/2026 at 8:20 AM, an observation of Resident #6 lying in bed with the upper and lower sections of the quarter-length side rails raised on both sides. On 1/22/2026 at 8:24 AM, during an interview with Staff #6, Registered Nurse (RN), it was verified that all four siderails were up on Resident #6's bed. The nurse stated that a physician's order and assumed a safety assessment would be required for the use of siderails. On 01/22/2026 at 9:12 AM, in review of Resident #6's physician orders dated 9/2/2025 for side rails: 2 1/4 rails for bed controls and to assist with positioning. Every shift may use 4 rails as requested. However, the medical record contained no documentation of a bedrail assessment or any additional details concerning the use of bedrails. On 01/21/2026 at 3:25 PM, during an interview, the Director of Nursing (DON) explained the facility's process for siderail use. The DON stated that while four siderails are not used, two siderails are occasionally used. The use of two siderails requires a physician's order and is primarily for resident repositioning and assistance with bed control. The DON confirmed that no specific assessment is performed prior to the use of siderails. On 01/22/2026 at 7:51 AM, the Director of Nursing (DON) informed the surveyor that the facility does not have a formal bedrail policy. The DON asserted that all purchased beds comply with entrapment measurement guidelines and are checked by maintenance. However, the DON could not provide the manufacturer guidelines for the purchased beds or documentation of maintenance checks. On 01/22/2026 at 10:06 AM, during an interview, Staff #10 (Rehab Director) stated therapy does not complete any evaluations for side rails; the side rail is already in place on the beds. The only time therapy would evaluate is if the bottom rails are requested, and she stated she has not had a request for an evaluation for siderails in years. On 1/22/2026 at 12:36 PM, the Director of Nursing was made aware of the concern.

Based on record review and interviews, the facility failed to develop and implement a person-centered care plan to meet and address the residents' medical and physical needs. This was evident for 2 (Resident #2 and Resident #125) of 40 care plans reviewed during the recertification/complaint survey process.Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team.1) On 01/20/2026 at 09:18 AM, the surveyor observed Resident #2 receiving oxygen (O2) with no date observed on the O2 tubing to indicate when the O2 tubing was last changed.On 01/21/2026 at 2:30 PM, a review of the physician orders dated 01/17/2026 revealed Supplemental Oxygen 2 Liters via nasal cannula to maintain O2 saturation of 90%.On 01/23/2026 at 2:52 PM, a review of Resident #2's care plan revealed no documented evidence of that respiratory care plan was developed to ensure a resident-specific treatment was a part of the treatment plan.On 01/23/2026 at 3:40 PM, the Director of Nursing (DON) interview confirmed that care plans should be initiated by day 21, done quarterly, or updated for a significant change in status (lasting > 7 days). The DON explained that care plans must address interventions, Activities of Daily Living (ADL) needs, goals, preferences, and all active diagnoses/issues such as oxygen usage. The DON was informed that the facility failed to develop a respiratory care plan and the surveyor's findings was acknowledged.2) On 01/21/2026 at 9:43 AM, during the initial pool phase, the surveyor observed oxygen (O2) at Resident #125's bedside; however, the oxygen was not in use at time. The O2 tubing was on top of the oxygen concentrator machine (which was on the floor), not stored in a sanitary environment and the attached humidifier was dated 01/13/2026.On 01/21/2026 at 09:46 AM, in an interview with RN #27, she stated the resident used 2 liters via nasal cannula O2 as needed (PRN) for anxiety.On 01/22/2026 at 1:57 PM, the Assistant Director of Nursing (ADON) was notified of Resident #125's O2 tubing storage and a second observation of the resident's O2 tubing was made with the ADON.On 01/23/2026 at 2:49 PM, a review of Resident #125's care plan revealed the facility failed to develop a respiratory care plan to address the residents' needs.On 01/23/2026 at 3:00 PM, a review of Resident #125's medical records showed an order for Oxygen 2 Liters per minute via Nasal Cannula PRN which was started 3/14/2025 but discontinued on 12/27/2025; however, the O2 was still being used by the resident.On 01/23/2026 at 3:40 PM, the DON was notified that the facility failed to develop a resident-specific care plan and she acknowledge the surveyor's findings.

Based on record review and interviews, it was determined that the facility failed to provide documented evidence that the residents' care plans were reviewed and revised by an interdisciplinary team to address the resident's medical and physical needs after a change in health status. This was evident for 1 (Resident #2) of 40 care plans reviewed during the recertification/complaint survey process.Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team.Restorative Care is a supportive service that usually follows rehabilitation to maintain function and prevent further decline, focusing on incorporating skills into daily life.1) On 01/23/2026 at 1:40 PM, the surveyor observed Resident #2 wearing a brace on the left upper extremity as she sat in the chair next to the bedside. On 01/28/2026 at 3:54 PM, a review of Resident #2's medical records revealed orders to wear hinged elbow brace, remove brace for hygiene. Elbow motion 40 to 100 degrees okay to progress 10 degrees in 2 weeks; 1/16/26 Sling to Left Upper Extremity (LUE) to remain in place at all times with the exception of providing ADL care; 1/16/2026 Non-weight bearing to the LUE; and on 1/16/2026 physical therapy (PT) recertification order revealed continue with skilled PT services 3-5 x week for 30 days.On 01/29/2026 at 10:00 AM, a review of Resident #2 care plan revealed no documented evidence to support that the facility revised the care plan to address the resident-specific needs and interventions related to the LUE brace usage and maintenance.On 01/29/2026 at 10:00 AM, in an interview with the Director of Nursing (DON), she was asked if the facility provided any restorative care services to aid with maintaining the resident independence and function, and she explained that it was done through physical therapy and the PT staff also leaves instruction on the unit when necessary.On 01/29/2026 at 10:48 AM, in an interview with the DON, she stated that Resident #2's care plan was reviewed and she acknowledged and verbalized that the care plan did not address the LUE brace. She explained that the floor staff was educated on the removal and replacement of the brace; however, there was no documentation to suggest that staff education was provided.2) On 01/20/2026 at 9:21 AM, in an interview with Resident #2 it was revealed that resident had a bed sore on his/her sacrum.On 01/28/2026 at 1:45 PM, a review of Resident #2's medical records revealed that on 1/6/2026 the skin assessment revealed that the resident had an actual skin impairment on the left inner buttocks and treatment included cleanse with normal saline medihoney/alleyn; on 1/16/2026 a right Inner buttocks wound was identified and treatment included Medihoney/Allevyn dressing; on 1/21/2026 the Resident's skin assessment revealed Moisture Associated Skin Damage (MASD) on the left and right buttocks and treatment included cleanse w/ normal saline solution apply acquacel AG; cover with foam daily pressure reducing mattress turn every 2 hours, gel cushion in chair, house shake three times per day and multivitamin. On 1/28/2026 a suspected deep tissue injury was identified on the sacrum.On 01/28/2026 at 2:57 PM, a review of Resident #2's medical records revealed that on 12/03/2025 the resident was identified as at risk for pressure ulcer development related to urinary incontinence, gait/balance issues and a care plan was developed; however, there was no documented evidence to support that the care plan was reviewed and revised to include the treatments and interventions related to an actual skin impairment as documented. The facility failed to ensure that an active wound care plan was in place to ensure that the resident's needs were addressed as required.On 01/28/2026 at 3:38 PM, the DON confirmed that the Care plan identified risk but failed to address the active wound care needs. She verbally confirmed that care plan should have been updated to reflect the current treatment needs and interventions after a new wound was identified.

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure that the resident had the opportunity to participate in an activity program and failed to provide documentation of participation in desired activity. This was found to be evident for 1(Resident # 34) of 5 residents reviewed for activity during the recertification/complaint survey.The Findings include:During the survey investigation process on 01/20/2026 at 12:38 PM, Resident # 34 stated that he/she missed BINGO twice because no one assisted him/her to BINGO.A record review was conducted on 1/22/2026 at 09:53 AM that revealed an Activities- Initial Review for Resident # 34 was conducted on 7/20/2017. Documented in section A. past activity interests were [Resident #34] enjoys fishing, hunting, and card games; section D. limitations/special needs: question 5. Assistance should be provided to get resident to the activity- yes. Question 6. If any of the above are answered yes, please describe the accommodation that should be made to encourage/promote activity participation - Transportation assistance to and from activities is needed.An interview was conducted on 01/22/2026 10:00 AM with the Activities Director (AD), Staff # 24, who stated that the activity staff is responsible for bringing the residents down to activities, such as BINGO, but the Administrator had asked others to assist, such as nursing, admin staff and managers; anyone can assist with transport to activities. When surveyor asked if Resident # 34 attended BINGO, the AD stated that BINGO is offered on Mondays and Thursdays and that Resident # 34 attends BINGO. The surveyor requested documentation that Resident # 34 participated in BINGO within the past 30 days.On 01/22/2026 at 11:06 AM, the AD provided documentation for Resident # 34 participation in activities within the last 30 days with the following dates and times:12/19/25 - Happy Hour 2:30 PM 12/31/25 - New Years Eve Party - 2:45 PM 1/8/26 - Birthday Party - 12:30 PM1/9/26 - Catholic Mass - 2:00 PM, Happy Hour - 2:45 PM1/2/26 - Active participation in Group - documented at 3:59 PM1/12/26 - Catholic Mass - 2:00 PM1/21/26 - Active participation 1:1 at 12:29 PMThe surveyor asked AD if there were any documentation for participation in BINGO, and the AD stated that the activity staff failed to document when resident attended BINGO. The surveyor informed the AD that if participation is not documented, then Resident # 34's claim of not getting assistance to BINGO cannot be refuted. AD agreed and stated that the activities staff will do a better job with documentation of attendance to daily activities and assisting residents to activities.On 1/22/2026 at 12:02 PM, the Director of Nursing was made aware of the concern about resident's activities.

Based on record review and interview, it was determined the facility failed to ensure that a resident received treatment and care in accordance to professional standards of practice, as evidenced by failing to: 1) properly manage a bowel regimen that led to persistent constipation, and 2) appropriately assess, evaluate, and modify interventions for a newly developed pressure ulcer. This was evident for 1 (Resident #123) of 8 residents that were reviewed during the recertification/complaint survey.The findings include: According to the Mayo Clinic, constipation is a problem with passing stool. Constipation generally means passing fewer than three stools a week or having a difficult time passing stool.According to the Centers for Disease Control (CDC), pressure ulcers (bed sores, pressure sores, or decubitus ulcers) are wounds from unrelieved pressure on the skin, per the CDC. They are staged by severity: Stage 1 is persistent skin redness; Stage 2 is partial thickness loss (abrasion, blister, shallow crater); Stage 3 is full thickness loss exposing subcutaneous tissue (deep crater); and Stage 4 is full thickness loss exposing muscle or bone. An unstageable ulcer involves full-thickness skin and tissue loss where the extent of damage is obscured by slough or eschar.The standard of practice for the care of pressure ulcers is for the facility staff to conduct weekly assessments and document findings that include the location, measurement, stage, and characteristics of a pressure ulcer. This information provides facility staff with information to determine whether the pressure ulcer is healing or worsening at future assessments and to evaluate which treatment plan would be most effective to heal the pressure ulcer. 1) On 01/20/2026 at 11:24 AM, during an interview with Resident #123, the complainant raised concerns regarding constipation and a new wound. On 01/23/2026 at approximately 12:40 PM, a review of the facility's bowel protocol revealed the following: The charge nurse checks the BM (Bowel Movement) list each shift. If a resident hasn't had a BM by day two, the nurse administers and documents that prune juice was given in the nurse's notes; if unsuccessful, the next shift gives milk of magnesia or a prescribed laxative. On the third day, the nurse administers a physician-ordered enema and documents it in the nurse's notes. If there is still no BM, the doctor must be notified for further orders. Results are checked and reported to the next shift until successful. On 01/23/2026 at approximately 12:30 PM, a review of the facility's bowel and bladder elimination report for Resident #123, revealed a significant gap in documented bowel movements. The report indicated no applicable size for a bowel movement from 01/09/2026 until 11:59 PM on 01/21/2026, which finally noted a medium bowel movement. This constituted an 11-day period without a recorded bowel movement.On 01/23/2026 at 12:27 PM, a review of Resident #123's physician orders revealed: -12/30/2025: Bowel routine as per policy.-01/18/2026: Fleet Enema (Sodium Phosphates): 1 application rectally every 24 hours as needed for bowel policy.-01/19/2026: Senna Plus (Sennosides-Docusate Sodium): 2 tablets by mouth in the evening for bowel regimen.On 01/23/2026 at 12:16 PM, a review of Resident #123's progress note dated 01/18/2026 at 4:14 PM revealed the last documented BM was on 1/9/26, and Milk of Magnesia (MOM) was given yesterday with no results. Fleet given today with no results thus far. Order obtained for Senna Plus QHS. However, this was 9 days after a documented bowel movement. On 01/23/2026 at 12:34 PM, a review of Resident #123's medication administration record (MAR) documented the administration of the following laxatives: Milk of Magnesia (MOM) on 1/11, 1/16, and 1/19; Fleets on 1/18; and Senna (2 tabs) on 1/12. However, the record lacked subsequent documentation to confirm that the facility's bowel protocol was followed.On 01/23/2026 at 12:21 PM, a review of the physician's note dated 1/19/2026 at 12:03 PM revealed the patient is in the bed resting except for intermittent constipation. Plan to continue with stool softener and to check abdominal x-ray.On 01/23/2026 at 12:22 PM, a review of progress note 1/20/2026 at 1:28 PM revealed Resident #123, complaining of chest pain and a history of constipation, was sent to the emergency room, and at that time the abdominal x-ray was still pending.On 01/23/2026 at 12:32 PM, a review of the discharge instructions dated 01/20/2026 from the hospital indicated constipation. On 01/23/2026 at 12:50 PM, during an interview with the Director of Nursing (DON) indicated the facility's protocol for bowel movement (BM) monitoring: staff documents daily BM checks in the task record for nurse review each day shift. If no BM occurs in three days, a bowel protocol is initiated (batch order on admission if the physician ordered). If interventions fail, the physician is notified for further constipation management. She acknowledged the concern regarding delayed follow-up, which was shared with her at this time. 2) On 01/23/2026 at 11:16 AM, a review of Resident #123's medical record revealed a progress note from 12/30/2025 at 2:42 PM indicated that the resident's skin was assessed with no open areas. Further review indicated a progress note dated 01/05/2026 at 1:06 PM; Resident #123 noted an open area to the sacrum measuring 1.2 CM (centimeters) x 0.7 CM with granulation tissue. On 01/23/2026 at approximately 11:45 AM, a review of Resident #123's Wound Evaluation Sheet revealed a sacral wound identified on 01/05/2026 (1.2 X 0.7 X 0.1 CM, scant yellow exudate, granulation) with no stage documented. A reassessment on 01/14/2026, 9 days later, showed the wound worsened (3 X 2.5 CM, unstageable, moderate serous drainage, 10% granulation, 90% slough). The medical record showed a care plan dated 01/12/2026 for a sacral pressure injury due to immobility post hip surgery, with interventions (air mattress, avoiding friction/bony prominences, not positioning on wound). However, these interventions were initiated 7 days after the wound developed and worsened.On 01/28/2026 at 10:27 AM, an interview was conducted with Staff #3 (Assistant Director of Nursing), ADON, who manages facility wounds. The ADON explained the in-house wound process: the nurse assesses the wound, notifies the physician and responsible party, initiates treatment, and notifies the ADON. The ADON then assesses the wound, evaluates treatment, completes a skin sheet, evaluates the need for support surfaces and nutrition, documents a progress note, and revises the care plan. Wound rounds are held on Wednesdays with the interdisciplinary team.On 1/23/2026 at 2:18 PM, a review of the progress note for Resident #123 revealed a nutrition/dietary note dated 01/12/2026 at 11:11 AM. While this note indicated a nutrition follow-up for weight review, it failed to include any follow-up regarding the resident's nutritional status as it relates to the newly developed wound.On 01/28/2026 at 9:26 AM, during an interview with Staff #14 (Dietician), she discussed her role in managing resident wounds. She explained that she is typically notified by nursing staff, or she identifies wounds during Thursday wound rounds or weekly meetings. She stated that she was unaware of Resident #123's sacral wound and would have immediately assessed the resident if she had been notified.On 01/28/2026 at 10:51 AM, during an interview, the Director of Nursing (DON) expressed an expectation that Resident #123's new wound should have been evaluated sooner. Specifically, the DON questioned why the wound was not further assessed the immediate Wednesday on 01/07/2026 or prior following its identification, along with updated interventions, including those from the dietician. The concern was shared with the DON during this interview.

Based on observation, record review, and interview, it was determined the facility failed to maintain a restraint-free environment as evidenced by ensuring least restrictive measures were attempted prior to utilizing restraints. This was identified for 2 (Resident #4 and #6) of 2 residents reviewed for restraints during the recertification/complaint survey. The findings include:1) On 01/20/2026 at 10:02 AM, during initial tour and observation, an alarm activated when Resident #4 got out of bed. At 10:07 AM, Resident #4 was observed standing in the doorway, appearing anxious due to the alarm's sound. The resident commented to staff (unknown) at the nearby medication cart, Don't you get tired of that sound, to which the staff member replied, Sometimes. At 10:09 AM, a different staff member came to the door, stating, I am going to turn the alarm off, and Resident #4 responded, Thanks, it is enough to drive you nuts.On 01/22/2026 at 11:15 AM, a review of Resident #4's admission record revealed Resident #4 was admitted to the facility on [DATE]. On 01/22/2026 at 11:17 AM, record review revealed a physician's order for a bed alarm, dated 11/14/2025, stipulating its use for Resident #4's safety during all shifts. However, Resident #4's medical record failed to document any prior interventions that were attempted or evaluated before the implementation of the bed alarm, nor was there evidence of an ongoing evaluation for the continued necessity of the bed alarm. On 1/22/2026 at 8:24 AM, during an interview with Staff #6, Registered Nurse (RN), Regarding alarms, it was stated that the facility utilizes bed or chair alarms for residents identified as a fall risk. These alarms are in place to alert staff when a resident is attempting to get out of bed or a chair.On 01/21/2026 at 3:28 PM, during an interview the Director of Nursing (DON) confirmed the alarm process: bed/chair pressure alarms are used for residents at risk for falls and if ambulatory or impulsive the facility uses bed/chair alarms, with no other assessment performed.2) On 1/20/2026 at 8:20 AM, an observation was made of Resident #6 lying in bed with the upper and lower sections of the quarter-length side rails raised on both sides. On 01/22/2026 at 9:12 AM, in review of Resident #6's physician orders dated 9/2/2025 for side rails: 2 1/4 rails for bed controls and to assist with positioning. Every shift may use 4 rails as requested. However Resident #6's medical record lacked evidence of documentation of any prior interventions that were attempted or evaluated before the implementation of the use of 4 siderails, nor was there evidence of an ongoing evaluation for the continued necessity of the siderails.On 1/22/2026 at 8:24 AM, during an interview with Staff #6, a Registered Nurse (RN), it was confirmed that all four siderails were raised on Resident #6's bed. The nurse indicated that both a physician's order and assumed a safety assessment would be required for the use of siderails. On 01/21/2026 at 3:25 PM, during an interview, the Director of Nursing (DON) explained the facility's process for siderail use. The DON stated that while four siderails are not used, two siderails are occasionally used. The use of two siderails requires a physician's order and is primarily for resident repositioning and assistance with bed control. On 01/22/2026 at 10:06 AM, during an interview, Staff #10 (Rehab Director) stated therapy does not complete any evaluations for side rails; the side rail is already in place on the beds. The only time therapy would evaluate is if the bottom rails are requested, and she stated she has not had a request for an evaluation for siderails in years.On 01/22/2026 at 11:04 AM, the Director of Nursing (DON) provided the surveyor with the facility's physical restraint policy. This policy states the facility's goal is to maintain an environment free of restraints. Furthermore, the section titled Alternatives encouraged emphasizes that the facility will prioritize non-restraint methods-such as environmental changes, increased supervision, and behavioral strategies-to manage resident risk.On 01/22/2026 at 12:36 PM, the concern was shared with the DON regarding restraints and she shared the facility was going to work on reducing.

Based on surveyor observation, review of the medical record, and interview with facility staff it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to change out an empty humidifier bottle, failing to maintain nasal cannula in a sanitary manner, and failing to administer oxygen as prescribed. This was evident for 3 (#138, #125, #3) out of 6 residents reviewed for Respiratory Care during the recertification/complaint survey.The Findings Include:1) On 01/21/2026 at 9:43 AM, a surveyor's observation revealed that Resident #125 had oxygen at bedside. The oxygen tubing was observed laying on top of the oxygen concentrator and not stored in a sanitary environment. It was also observed that the attached humidifier was dated 01/13/2026. At the time of the observation the resident was asked if he/she used oxygen and the resident stated that they used oxygen in the afternoons. On 01/21/2026 at approximately 09:46 AM, in an interview with RN#27, she stated that the resident used 2 liters via nasal cannula oxygen as needed for anxiety. On 01/22/2026 at 1:57 PM, the Assistant Director of Nursing (ADON) was notified that Resident #125 oxygen tubing was observed resting on top of the oxygen concentrator and stored in an unsanitary environment. A second observation of Resident #125's room was made with the ADON to verify the surveyor's observation. 2) During the survey screening process on 1/20/2026 at 12:25 PM, the surveyor noted that Resident #138 had a respiratory precaution sign on room door. After putting on Personal Protective Equipment (PPE) and entering room, the surveyor observed resident receiving oxygen through a nasal cannula at 2.5 liters. The oxygen humidifier bottle (a liquid that adds moisture to oxygen for enhancing comfort and preventing dryness in the respiratory system during oxygen therapy) was empty and had a label dated 1/7/2026. On 1/21/2026 at approximately 1:39 PM, a second observation noted that the humidifier bottle remained empty and the oxygen setting remained at 2.5 L/Min. An interview was conducted with Staff #7 on 1/21/2026 and when asked about oxygen administration process, staff #7 stated that once an order is written for oxygen, an oxygen concentrator is brought to the room with nasal cannula tubing and humidifier bottle. The oxygen is set to the desired amount, and the humidifier is labeled with a date it was attached to the concentrator. Staff #7 also stated that the humidifier is changed when it is empty and the oxygen tubing is changed every 30 days or as needed. The surveyor requested staff #7 to check the oxygen setting and the humidifier bottle in Resident #138's room. Staff #7 stated that she would. Record review on 01/22/2026 at 9:08 AM revealed the following: The care plan indicated that Guest is on contact/droplet monitoring isolation x 10 days for positive COVID-19 test. Date Initiated: 01/20/2026. Orders were initiated on 1/14/2026 for Oxygen 2L/min via Nasal Cannula every shift and check and change prefilled oxygen humidifier water bottle as needed. During a follow up observation on 1/22/26 at 1:39 PM surveyor noted that the humidifier bottle remained empty with the oxygen still at 2.5 Liters. The surveyor interviewed staff #23 and asked what the order for oxygen administration for Resident #138 was. Staff #23 checked the electronic record and verified that it was 2L/Min. when asked how often the humidifier bottle should be changed, staff #23 stated that it should be changed when empty. The surveyor requested that staff #23 go to resident's room and check the oxygen setting and humidifier bottle. On 1/22/2026 at approximately 2:00 PM, the Director of Nursing (DON) was made aware of the concern that the oxygen setting, and the empty humidifier bottle were not corrected even after surveyor's intervention. The DON acknowledged the concern and had no comments. 3) On 01/20/2026 at 9:29 AM, during an observation of Resident #3, the oxygen tubing that was connected to the oxygen concentrator was on the floor. On 01/22/2026 at 8:11 AM, during a second observation of Resident #3, the oxygen tubing was connected to the concentrator and stored unbagged on top of the unit. On 01/22/2026 at 8:12 AM, during an interview with Resident #3, he/she verbalized that he/she uses oxygen every night. On 01/21/2026 at 2:53 PM, in review of Resident #3's medical record, a Physician order dated 12/10/2025 for Respiratory: Oxygen 2 liters per minute via nasal cannula at bedtime for shortness of breath. On 01/22/2026 at 8:14 AM, during an interview with Staff #8 Registered Nurse (RN), verified that the oxygen tubing for Resident #3 was not stored in a bag, and indicated the requirement that oxygen tubing be bagged when not in use. On 01/22/2026 at 1:55 PM, during an interview with Staff #3 (Assistant Director of Nursing) ADON confirmed that proper storage for oxygen tubing, when not in use, requires placing it in a bag to prevent sanitary concerns. This concern was shared with the ADON during the interview.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's blood sugar was properly monitored. This was evident for one (Resident #5) out of five residents reviewed for the unnecessary medication review task during the recertification/complaint survey.The findings include: This surveyor reviewed Resident #5's clinical record on 1/23/26. The resident's physician wrote an order on 10/10/25 for the resident to be administered Admelog (insulin) 100 units/ml 3 units to be injected every morning but to be held if blood sugar is below 70. The resident had their blood sugar checked on 1/11/26 at 7:00 AM. The blood sugar was 65 and the medication was held. The clinical record was reviewed and there was no evidence that the physician was notified to ensure adequate monitoring of the resident's blood sugar levels. Failure to notify the physician denied the physician the opportunity to intervene. The Director of Nursing (DON) was interviewed on 1/23/26 at 3:40 PM. She was shown the Medication Administration Record and informed that there was no evidence of the physician being informed. She said she would investigate and get back to the survey team. The DON returned on 1/23/26 at 4:45 PM. She said she investigated and confirmed that a call to the physician was not made but should have been made.

Based on clinical record review, resident interview, and staff interview, it was determined that facility staff failed to ensure a resident received routine dental services. This was evident for one (Resident #5) out of three residents reviewed for dental services during the recertification/complaint survey. The findings include: This surveyor interviewed Resident #5 on 1/22/26 at 9:41 AM. This surveyor asked if the resident has seen a dentist in the past 12 months and if the resident was having any mouth pain. The resident stated that they have not been to the dentist or had a dentist come to see them at the facility for over a year. The resident also reported no mouth or tooth pain. This surveyor interviewed the Unit Manager (#26) for Bay Lane unit on 1/22/26 at 12:05 PM. She said they assess residents for pain, discomfort, chewing and/or swallowing issues and will call the dentist when appropriate. She was unaware that the resident needed to go to the dentist since the resident has not been complaining or has stated a need to see a dentist. A review of the clinical record on 1/22/26 failed to discover any dental consult or dental visit. The Director of Nursing (DON) was interviewed on 1/23/26 at 3:35 PM. She was informed of the interview with the resident and the absence of a dental consult in the clinical record. The DON stated she would investigate. The DON returned on 1/23/26 at 4:45 PM. She was interviewed and stated that she could not find a record of the resident ever going to the dentist in either the physical clinical records of the electronic clinical record.

Based clinical record review and staff interview it was determined that the facility staff failed to ensure a resident reporting serious pain received a follow up assessment after receiving treatment for the pain to ensure effectiveness of the treatment. This was evident for one (Resident #46) out of three residents reviewed pain during the recertification/complaint survey.The findings include: A review of a facility reported incident (#2704171) was conducted on 1/20/26. A review of the resident's clinical record on the same day revealed that Resident #46 was ordered Tylenol extra strength 500 mg to be administered in the morning for pain. The resident reported pain on 12/30/25 that was rated as 8 out 10. The resident was administered the medication at approximately 9:00 AM but there was no evidence that staff went back to see if it was effective. The resident's physician added a medication order at 5:00 PM on the same day for Tylenol extra strength 500 mg one tablet every 8 hours for the diagnosis of pain. The resident received their first dose at 6:02 PM and had a pain level of 0 as a result. The Director of Nursing (DON) was interviewed on 1/23/26 at 3:40 PM. This surveyor informed her of the facility reported incident that prompted a review of pain levels and the administration of pain medication during the month of December 2025. She was then shown the Medication Administration Record (MAR) for December 2025 and the lack of a documented follow up to the pain level of 8 on 12/30/25. She said she would investigate. The DON returned to the conference room where the survey team was working on 1/23/26 at 4:45 PM. She informed this surveyor that she investigated the concern and was aided by the unit manager. They could not find evidence that a nurse followed up on the effectiveness of the pain medication.

Based on the investigation of complaints, medical record review, and interviews with facility staff, it was determined that the facility failed to ensure that changes in residents' condition were notified to the physician in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.The findings include: As part of the investigation into complaint #361874, the surveyor reviewed Resident #8's medical records on 11/05/25 at 8:30 AM. The review revealed the following: -Staff #11 (Registered Nurse) documented in a progress note on 5/12/25 at 12:38 PM that Resident #8 was tearful with increased confusion.-Staff #4 (Social Worker) recorded Resident #8's confusion on 5/12/25 at 1:26 PM in a progress note, stating: [Resident's name] was tearful during our exchange. Unable to provide year, month stating 'I'm confused.'However, there was no documentation indicating that Resident #8's change in mental status was notified to the provider.In an interview with the Assistant Director of Nursing (ADON) on 11/05/25 at 12:09 PM, she confirmed that a resident's change in mental status should be considered a change in condition, which must be documented in the electronic medical record system and communicated to the provider.On 11/05/25 at 2:32 PM, the Director of Nursing (DON) verified that there was no documentation to support that Resident #8's change in mental status had been notified to the provider. She validated the concern.

Based on the investigation of complaints, medical record review, and staff interviews, it was determined that the facility failed to update residents' (and/or responsible parties') wishes related to life-sustaining treatment and assess residents' capacity to make decisions in a timely manner. This failure was evident for one (Resident #8) of the eight residents whose care was reviewed during this complaint survey.The findings include:A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient.As a portion of the investigation into complaint #361874, the surveyor reviewed Resident #8's medical records on [DATE] at 8:30 AM. The review revealed that the resident was their own Responsible Party (RP) and had a most recent MOLST dated [DATE] at 12:31 PM, which indicated No CPR option B, palliative and supportive care by the patient.Further review of Resident #8's medical record revealed that the resident was transferred to the hospital due to condition changes on [DATE] and re-admitted to the facility on [DATE]. Staff #4 (Social Worker) wrote a progress note on [DATE] at 9:13 AM stating, Resident wished to attempt CPR. Resident presented as alert and oriented. Social Worker will continue to follow. An additional progress note dated [DATE], written by Staff #4, stated, MOLST attempt CPR.Resident is their own decision maker, children are involved in their care.The surveyor conducted a continuous review of Resident #8's medical records. The review revealed that the resident had another hospital transfer on [DATE] due to a lethargic condition and was readmitted on the same day. On the following day of readmission ([DATE]), Staff #4 documented that: The resident returned from the hospital on 5/14 with a MOLST dated [DATE]. Visited with [resident name] and this writer is not comfortable discussing their code status. A fax was sent to [attending physician] requesting a re-evaluation of capacity. Capacity form and a blank MOLST form were left on the chart. Further documentation by Staff #4 at 4:52 PM on [DATE] showed that the staff spoke with the son/RP to discuss the MOLST, and the attending physician said to keep the one that was on the resident's chart (at the physician's office) dated [DATE], DNR-B per patient.During an interview with the Director of Nursing (DON) and Staff #4 on [DATE] at 1:40 PM, the surveyor reviewed Resident #8's MOLST and progress notes. The DON and Staff #4 confirmed that the resident was their own responsible party, able to make decisions before their mental status changes on [DATE]. However, there was no capacity evaluation completed in a timely manner, and the medical records, including progress notes, were unclear as to who the decision maker was. The DON and Staff #4 validated this finding.Additionally, Staff #4 validated that there were discrepancies in Resident #8's MOLST. Staff #4's assessment on [DATE] indicated the resident clarified that they wanted a Full Code; however, the MOLST was recorded as DNR-Part B, even though it was documented later than Staff #4's notes. The DON agreed that the facility should have obtained a Full Code MOLST for Resident #8 and then subsequently revised it to DNR.

Based on an investigation of intakes, reviewing medical records, and interviewing facility staff, it was determined that the facility failed to ensure that a resident's Treatment Administration Records (TAR) were correctly documented. This was evident for one (Resident #8) of eight residents reviewed for care during this complaint survey.The findings include:During the investigation of complaint #361874, on 11/05/25 at 8:30 AM, it was noted that Staff #8 ( Licensed Practical Nurse) wrote a progress note on 5/14/25 at 7:14 PM as returned from hospital without boots.Further review of Resident #8's progress notes revealed that multiple staff documentation about the resident's boots, which could not be found. Specifically: A note dated 5/15/25 by Staff #4 wrote, Resident #8 reported that he/she don't know where his/her blue boots were he/she was supposed to wear them. The nurse clarified that there were no boots. A note dated 5/16/25 by Staff #4 wrote, Resident asked for his/her blue boots. Nursing to follow up. A note dated 5/17/25 by Staff #9 (Registered Nurse) wrote that they were unable to find protector boots during the evening shift, and they were still missing. A note dated 5/18/25 by the attending Physician documented that the resident wants his/her boots back and that the physician was told they must be ordered: Please order the boots he/she wants.The review of Resident #8's TAR for May 2025, on 11/05/25 at 10:30 AM, revealed that the resident had an order of Heel protector boots on at all times, remove for bathing every shift for heel protection from 4/24/25 to 5/27/25. However, the TAR documentation for all shifts from 5/14/25 to 5/18/25 indicated that the boots were applied.During an interview with the Director of Nursing (DON) on 11/06/25 at 12:19 PM, the surveyor reviewed Resident #8's TAR and progress notes with the DON. She validated that there were discrepancies regarding Resident #8's boots: progress notes documented they were missed, but the TAR documented they were applied.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that water temperatures remained within acceptable range. This was found to be evident during 11 room observations made of the Harbor View Unit and 2 residents (#31,#32) during the facility's survey. Findings include: 1. On 4/30/24 at 10:39 AM the surveyor made observations of water temperatures in resident rooms located on the Harbor View Unit. Bathroom temperatures for the following rooms were observed: Room# 148 had a temperature of 122 degrees Fahrenheit (F) Room # 149 had a temperature of 122 degrees F Observations were made on the same date at 11:05 AM of the water temperatures of the sink located inside the resident rooms as follows: Room # 149 sink temperature was 120 degrees F Room # 150 sink temperature was 120 degrees F After the surveyor identified elevated temperatures on the above unit, the Director Maintenance of (DOM), Staff # 21 was notified and arrived on the unit at 11:30 AM to obtain temperatures on the Harbor View Unit with the surveyor. The following temperatures were obtained: Room # 149 Bathroom sink temperature was 124.2 degrees F Room # 150 Bathroom sink temperature was 123.8 degrees F Room # 152 Bathroom sink temperature was 121.2 degrees F Observations were made in the following resident rooms of sink temperatures by the DOM as follows: Room # 149 sink temperature was 123.9 degrees F Room # 150 sink temperature was 122.5 degrees F After the DON obtained the above temperatures on the Harbor View Unit, he was told that that the temperatures are a concern. He stated that this morning, the facility powered down the boiler for use of the chiller, to use the air conditioner. He stated that this could affect the water system as the rooms are located above the boiler room. When the surveyor asked if water temperatures were obtained in the resident rooms while powering down the boiler, he could not provide documentation of this to the survey team. Let it be noted that the residents that resided in the rooms with the elevated temperatures are unable to use the bathroom and or sink in the above noted rooms except for resident # 31 and # 32. During an interview with resident # 32 on 4/30/24 at 1:05 PM the resident stated that s/he uses the bathroom with assistance and denied any burns to the hands when using the water from the sink. During an interview with resident # 31 on 4/30/24 at 1:20 PM the resident stated that s/he does not use the bathroom, however, s/he uses the sink inside of the room to brush his/her teeth, wash face and hands and that s/he never experienced any problems with the water being too hot. All concerns were discussed with the Administration team on 4/30/24 at 1:45 PM. 47200 2. On 4/30/24 at approximately 10:11AM the surveyor tested the temperature of the water in the following resident rooms with a calibrated thermometer: room [ROOM NUMBER] was found to be 133.9F, and room [ROOM NUMBER] was found to be 135.9. On 4/30/24 at 10:38AM the water temperature in room [ROOM NUMBER] was observed to be 121.3F On 4/30/24 at 10:38AM the water temperature in room [ROOM NUMBER] was observed to be 122.9F On 4/30/24 at 10:39AM the water temperature in room [ROOM NUMBER] was observed to be 121.2F On 4/30/24 at 10:42AM the water temperature in room [ROOM NUMBER] was observed to be 137.5F On 4/30/24 at 10:48AM the water temperature in room [ROOM NUMBER] was observed to be 130F On 4/30/24 at 10:52AM the water temperature in room [ROOM NUMBER] was observed to be 130.1 On 4/30/24 at 10:59AM the water temperature in room [ROOM NUMBER] was observed to be 125.3F at the sink in the resident's room and 124F at the resident's bathroom sink. On 4/30/24 at 11:03AM the water temperature in room [ROOM NUMBER] was observed to be 121.5F at the sink in the resident's room and 128.5F at the resident's bathroom sink. On 4/30/24 at 11:05AM the water temperature in room [ROOM NUMBER] was observed to be 126F at the sink in the resident's room. On 4/30/24 at 11:14AM the surveyor requested a dual observation of water temperatures in resident rooms with Staff #21, Director of Maintenance, and observed them obtain their thermometer. On 4/30/24 at 11:16AM the surveyor observed Staff #21 obtain a water temperature of 133.4F at the sink in room [ROOM NUMBER], and then a water temperature of 132.3F in the resident's bathroom sink. On 4/30/24 at 11:19AM during an interview conducted by the surveyor with Staff #21 they stated that the area of the building with higher water temperatures was located above the facility's boiler for that area of the building. On 4/30/24 at 11:19AM the surveyor observed Staff #21 obtain a water temperature of 129.9F at the sink in room [ROOM NUMBER], and a water temperature of 129.2 F in the resident's bathroom sink. On 4/30/24 at 1:31PM surveyors conducted an interview with the Administrator and Staff #21 which revealed water temperatures in resident rooms was not being monitored. The Administrator communicated to surveyors that this was an oversight, they thought the temperatures were being done, but it was not being done in resident rooms, temperatures were being taken of the boiler.

Based on medical record review and interviews with facility staff it was determined the facility failed to: (1) to ensure that a resident followed up with the Urologist for management of the foley catheter; (2) transcribe physician pain scale orders for resident #1. (3) follow a treatment order as ordered by the physician for resident #59. (4) follow physician orders as evidenced by a resident not being properly positioned to receive enteral nutrition, enteral nutrition not being administered during the ordered times, medications were not administered the times ordered, and the ordered amount of oxygen was not delivered for several days. This deficient practice was evident in 5, (Resident #1 # 18, #33, #59, #100) of 38 resident records reviewed during the Survey Findings include: 1. The facility failed to ensure that resident #18 followed up with the Urologist for management of the foley catheter. A medical record review was done on 5/2/24 at 10:00 AM and it revealed resident # 18 was admitted to the facility with the following but not limited to diagnosis: Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), and Benign Prostatic Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Review of the facility resident matrix indicates the resident currently has an indwelling catheter in place. The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. On 5/2/24 at 11:00 AM the DON provided the survey team with a copy of the resident's most recent Urology Consultation that was dated 4/11/22. Upon review of the Consultation Report it revealed the following recommendation: follow-up in six (6) months and continue current management. During an interview with the DON on 5/3/24 at 11:30 AM she was asked if the resident followed up with Urology Consultation appointment as recommended within six (6) months and she stated, no. The DON went on to say that the resident was scheduled for an appointment in 2023, however, the resident did not go to that appointment because the physician could not accommodate the resident via a stretcher. The DON acknowledged that arrangements needed to be made for resident # 18 regarding a follow up with Urology and that the facility will work on scheduling this. 50385 2. During observation rounds on 4/29/24 at 8:13am, resident #59 was observed lying in bed with his/her head turned to the right. The resident was observed with a dark red dried substance on the left side of the earlobe, neck, and pillow. The Licensed Practical Nurse (LPN) (staff #32) was immediately made aware. Staff #32 stated, it is not my resident, but I will look at it. During a follow-up observation on 4/29/24 8:30 am Staff #32 was observed cleansing and applying lotion to the left earlobe. During an interview with staff #32 on 4/29/24 at 10am, when asked by the surveyor if she knew how long the resident left earlobe had contained the dark red dried substance she stated, I don ' t know but we do walk report for on-coming and off-going shifts and someone should have seen it. Review of the medical record on 5/2/24 at 1pm, revealed a physician order dated 3/20/24 to apply bacitracin to the left ear every morning and evening shift until healed. 50457 3. On 4/29/24 at 9:32 am upon entering Resident #59 room, the surveyor observed the resident in bed with the foot of the bed elevated and the head of the bed about 15 degrees with the tube feed infusing at 80 milliliter/hour (ml/hr) . An interview with License Practical Nurse (LPN) #23 on 04/30/24 at 9:37 am at Resident #59 bedside, the surveyor asked how the staff adjusts the head of the bed for residents who are receiving tube feeding. LPN #23 verbalized not knowing how to adjust the settings on the bed to determine the elevation of the head and he/she just eyeball the bed. LPN #23 also verbalized that the resident adjusts the bed themselves. On 05/01/24 at 10:38 am during an assessment of Resident #59 ability to change the settings on the bed, the surveyor asked the resident to adjust the controls on the bed. Resident #59 attempted to press the controls to adjust the head of the bed. The surveyor observed the resident being unable to reposition themselves to reach the controls on the bed to make adjustments. On 05/02/24 at 11:02 am review of the facility's tube feeding policy revealed during gastrostomy feedings the resident's head should be elevated to at least a 35-degree angle to prevent aspiration and to promote digestion. Review of Resident #59 treatment and medication administration records (TAR/MAR) revealed an order was written on 02/08/24 for aspiration precautions and for the resident to sit upright during all meals. On 05/02/24 at 9:06 am the surveyor observed Resident #59 slouched down in bed while the enteral nutrition Jevity 1.5 at 80 ml/hr was infusing. Review of Resident #59 orders on 05/02/24 at 10:57 am, revealed the resident was scheduled to receive Jevity 1.5 at 80 ml/hr for 20 hours per day for a total of 1600ml. Administration should have begun at 1pm and ended at 9am. On 05/02/24 at 9:50 am while in Resident #59 room, the surveyor observed Jevity 1.5 infusing at 80 ml/hr when the feeding was scheduled to end at 9:00 am. On 05/02/24 at 1:32 pm during an interview with LPN #17 when asked to tell the surveyor about Resident #33 gastrostomy feeding they verbalized the feeding is Jevity 1.5 at 80 ml/hr for a total of 1600 ml daily. The feeding is scheduled to start at 1 pm and end the next day at 9am. The nurse verbalized stopping the feeding around 9:15 am that day and starting the feeding a little after 1 pm. The surveyor made LPN #17 aware the feeding was observed infusing at 9:50 am. The nurse denied the feeding was still infusing at that time. On 05/02/24 at 12:51 pm a review of the facility's Medication Administration Audit Report that was received from Assistant Director of Nursing (ADON) #3 revealed Resident #59 did not receive medications as scheduled by LPN #17 on 04/29/24 and LPN #23 on 05/01/24. The resident was scheduled to receive these medications through a gastrostomy tube on 04/29/24 at 9 am. Famotidine tab 40mg Cholecalciferol tab 10 microgram (mcg) Amiodarone tab 200 milligram (mg) Apixaban tab 5 mg Ascorbic Acid Tab 500mg Ferrous Sulfate solution LPN #17 documented the above-mentioned medications were administered on 04/29/24 at 11:21 am. On 5/01/24 at 10:00 am the resident was scheduled to receive these medications through gastrostomy tube: Metoclopramide tab 5mg Thera-M Tablet LPN #23 documented the above-mentioned medications were administered on 5/01/24 at 11:25 am. On 05/06/24 at 11:44 am during an interview with RN Unit Manager #33, the surveyor asked what the expectations are for medication administration of the nurses. Unit Manager #33 verbalized their understanding that the medications can be given 1 hour before and 1 hour after the prescribed time. If the medication was not given during the required time frame, it turns red in PointClickCare (PCC). He/she is still learning how to run the reports to check if the medications are given on time. The surveyor provided RN Unit Manager #33 with the medication administration audit report with the listed medications that were given past the allotted time. He/she verified the medications were given late and thus far he/she has not been taught how to run the report. On 05/02/24 at 1:32 pm during an interview with LPN #17, the surveyor asked if the resident is on any precautions. LPN #17 verbalized, 'You would have to ask the nurse manager. ' 4. On 04/29/24 at 8:08 am, 4/30/24 at 9:23 am, and 05/07/24 at 10:11 am, upon entering Resident #33 room, the surveyor observed the resident in bed with 3L of oxygen via nasal cannula (NC). On 04/30/24 at 10:18 am a review of Resident #33 electronic medical record revealed an order written on 01/10/19 at 2:49 pm oxygen 2L NC every shift. On 05/07/24 at 10:14 am during an interview with LPN #22, the surveyor asked how much oxygen the resident was receiving; LPN #22 replied, 2L. The surveyor asked the nurse if they assessed the resident's oxygen concentrator and LPN #22 replied no. The surveyor made LPN #22 aware the resident had received 3L oxygen via NC since 04/29/24. The surveyor asked if Resident #33 was experiencing shortness of breath or any respiratory symptoms which may warrant an increase in oxygen therapy. LPN #22 responded, no. 48167 5. On 05/02/24 at 1:05 PM review of the resident medical record revealed that a physician ordered on 12/14/2023 for resident #1 to receive Tylenol Extra Strength 500mg 1 tab by mouth every 6 hours as needed for pain and Tramadol HCL 50mg 1 tab by mouth every 6 hours as needed for pain. Further review revealed that on 02/26/2024 a pharmacy review was completed and a Letter to Physician was sent to the physician recommending specifying when Tylenol Extra Strength and Tramadol should be used and given to resident #1 by using a pain scale. On 02/29/2024 the physician wrote an order for Acetaminophen pain level 1 -5 and Tramadol pain level 6 -10 and this order was not transcribed or processed. On 05/02/24 at 01:30 PM during an interview with staff #3 she stated that the physician order had not been transcribed or processed. 6. On observation rounds on 04/29/24 at 10:55 AM it was observed that resident #100 was on 4.5 liters of oxygen by nasal cannula. During an interview on 04/29/24 at 11:10 AM with staff #17, she stated that resident was on 4.5 liters of oxygen and should be on 2 liters of oxygen by nasal cannula. After surveyor intervention, staff #17 placed resident #100 on 2 liters of oxygen by nasal cannula. Review of resident's #100 medical record on 04/29/24 at 11:27 AM revealed a physician order dated 3/31/2024 for resident #100 to be administered 2 liters of oxygen by nasal cannula continuously.

Based on observations and interviews it was determined that the facility staff failed to get a resident out of bed for four out of five days and failed to dress the resident in his/her own clothing. This deficient practice was evident in 1(#59) of 2 residents observed for dignity during the survey. The findings include: On 04/29/24 at 1:14 pm The surveyor entered Resident #59's room and observed him/her in bed wearing a soiled hospital gown, and tube feed infusing. On 05/01/24 at 10:35am The surveyor observed Resident #59 in bed wearing a hospital gown, and his/her hair was not combed. On 05/02/24 at 10:35am The surveyor observed Resident #59 in bed wearing a hospital gown, uncombed hair, and the blinds closed. During an interview with Geriatric Nursing Assist (GNA)#30 on 05/02/24 at 1:46 pm, the GNA reported being assigned to Resident #59 the previous day (05/01/24) and the resident prefers to wear a hospital gown while in bed. GNA#30 did not get Resident # 59 out of bed (OOB) on 05/01/24 or 05/02/24. Resident #59 did not get out of bed Monday (4/29/24) and had on a gown because they wanted to remain in bed. GNA #30 was unable to confirm whether the assigned nurse was made aware, that Resident #59 was not dressed in his/her clothing and did not get OOB for several days. During an interview with Unit Manager RN #33 on 05/06/24 at 11:44 am, when asked to describe a typical day for residents on Harbor View, he/she stated typically night shift provides breakfast trays to residents and day shift helps with distributing breakfast trays. Afterwards the residents are bathed and get out of bed. Activity comes around and updates the activity calendar. If a resident refuses to get out of bed the nurse should be made aware.

Based on record review and interview it was determined that the facility failed to issue the bed hold notice. This was evident for 1 out of 1 resident (#109) reviewed for hospitalization during the facility's recertification survey. The findings include: Review of the medical record by the surveyor on 5/3/24 at 11:16AM revealed a nursing progress note dated 9/24/21 that Resident #109 was transferred to the hospital on 9/24/21, however, no documentation could be found in the medical record to indicate the facility issued the bed hold notice. On 5/3/24 at 11:32AM the surveyor made a request to the Director of Nursing (DON) for any documentation of the bed hold notice having been provided to Resident #109 and/or their representative. During an interview on 5/3/24 at 12:15PM the DON informed the surveyor that the facility did not have any documentation that the bed hold policy was issued to the resident.

Based on a review of the medical record and interviews with the facility staff it was determined the facility failed to follow the resident care plan for the management of a resident with a foley catheter. This was found to be evident for 1 (Resident # 18) of 39 residents reviewed during the facility's survey. Findings include, 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 care. A medical record review was done on 5/2/24 at 10:00 AM and it revealed resident # 18 was admitted to the facility with the following but not limited to diagnosis: Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), and Benign Prostatic Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Review of the facility resident matrix indicated the resident currently had an indwelling catheter in place. The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. Review of the care plan revealed the resident has an indwelling suprapubic catheter (urinary catheter inserted into the bladder from a small cut in the belly, just above the pubic bone) related to Neurogenic bladder (several urinary conditions in people who lack bladder control due to brain, spinal cord or nerve problem) that was initiated on 1/26/2017 with a revision date of 8/19/22. One of the interventions listed includes Urology (Genitourinary) consults as ordered. During an interview with the DON on 5/3/24 at 11:30 AM she was asked of the resident care plan intervention that included Urology consults as ordered, and that the resident did not follow-up in six (6) months following the Urology Consultation on 4/11/22 as recommended. The DON acknowledged that the resident care plan was not followed and further added that the physician could not accommodate the resident in a stretcher. She went on to say that arrangements will be made for the resident with Urology for management of the catheter. All concerns were discussed with the Administration team at the time of exit on 5/7/24 at 3:00 PM

Based on observations, staff interviews, and record review, it was determined that the nursing staff failed to meet professional standards of care by not ensuring that medication was consumed prior to leaving the resident room. This was evident for 1 (Resident #89) of 4 residents observed for professional standards. The findings include: On 04/30/24 at 11:39 AM, the surveyor observed Licensed Practical Nurse (LPN) #22 administer medications to Resident #89. LPN #22 placed a dark amber colored liquid in a small cup at the resident's bedside table. The LPN left the room. The cup was untouched, and no directions were given to the resident on what to do with the cup. On 04/30/24 at 11:41 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) #25 and LPN #22. GNA #25 stated that's the protein when asked about what was in the cup on Resident #89's bedside table. When the surveyor asked LPN #22 about what the standard of practice is when administering medications, the LPN confirmed it is the standard of practice to ensure the resident completes the medication before leaving the resident ' s room. On 5/2/24 at 1:02 PM, a review of the Medical Administration Record (MAR) audit for Resident #89 was conducted. The MAR audit showed the following medications ordered for 9am: Tylenol 650 mg tablet (a pain relief medication), 1 Potassium Chloride 10 mEq tablet (a potassium supplement), Lasix 40 mg tablet (a diuretic) , and Prostat 30 ml (a protein supplement) scheduled to be administered at 10am on 4/30/24. Review of the MAR audit revealed that the Lasix was documented at 11:29 AM. The Potassium, the Tylenol, and the Prostat were documented at 11:34 AM. The standard of practice when giving medications is to administer medications an hour before and an hour after the due time of the medication.

Based upon medical record review, facility documentation review and staff interview it was determined that facility staff failed to safely secure a resident during a Hoyer Lift transfer resulting in the resident's subsequent injury and hospitalization . This was evident for 1 of 46 residents reviewed (Resident # 62) during survey investigation. The findings included: Resident # 62's medical history included [DIAGNOSES REDACTED]. A review of Resident # 62's Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 9/25/2017 was conducted on 2/28/2017. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. MDS Section G: Functional Status is coded to reflect that Resident # 62 was totally dependent on staff for transfers (how the resident moved between surfaces including to or from the bed, chair and wheelchair) and required the support of two or more individuals to transfer. Resident # 62's care plan was reviewed on 2/28/2017. 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. Resident # 62 was determined to have an ADL (Activities of Daily Living) self-care performance deficit related to abnormal gait/muscle weakness and cognitive impairment. Interventions included use of the Hoyer Lift with the assist of two staff members for transfers. A Hoyer patient lift is a portable assistive medical device. The lift typically uses electric, hydraulic, or battery power, and specialized sling-style pads that slide under the patient's body to securely and comfortably transfer an individual from one surface to another. Medical record review reveals that Resident # 62 sustained a fall from the Hoyer Lift on 12/9/2017. A Health Status Note entered into the medical record by RN # 1 on 12/9/2017 at 2:10 PM reads: Called into room by GNAs (Geriatric Nursing Assistants) who were transferring into bed using mechanical lift. One of the straps came undone. Resident fell to floor and hit the back of her head hard, occipital area. No swelling or bleeding. Kept on floor to keep C-spine stable. Contacted (Physician) who is on call, states to send to ED for evaluation. GNA # 1 was interviewed on 3/01/2018 at 10:00 AM. GNA # 1 stated I was working the floor alone when I saw my coworker and asked for help with a transfer. We wheeled Resident # 62 into his/her room. The sling was underneath Resident # 62 and we hooked him/her up to the Hoyer and lifted the resident up. We didn't do anything differently than what we normally do. We turned the Hoyer and were about to put the Hoyer legs under the bed. Resident # 62 had an old school bed and I had to go around to get the remote to raise the bed up. When I bent down to pick up the remote I heard a snap. The hook holding her right leg fell loose. Resident # 62's right leg went up and his/her head went down. The resident's head hit the base of the Hoyer Lift. I put a pillow under her head and notified the nurse. GNA # 2 was interviewed on 3/6/2018 at 9:18 AM. GNA # 2 stated: GNA # 1 asked me for help with a transfer. GNA # 1 got the Hoyer and we hooked the sling up and lifted Resident # 62. The sling was underneath the resident in the wheelchair and we each hooked up one side of the sling to the Hoyer. GNA # 1 then went to the other side of the bed to operate the bed controls when I heard a pop and Resident # 62 started to go down. When the resident fell GNA # 1 ran and got the nurse. RN # 1 was interviewed on 3/1/2018 at 9:35 AM. RN # 1 stated I was called into Resident # 62's room by the call light. The resident was on the floor and the GNA's said she had fallen from the lift. I went in and assessed the resident. He/She was alert and oriented. I called the doctor and then called 911. Medical record review reveals that Resident # 62 was transferred to the emergency room at Harford Memorial hospital on [DATE] where a Head CT (Computed Topography) Scan was performed. The CT Scan is a diagnostic tool that can be utilized to diagnose problems such as trauma and other disorders. Resident # 62's CT Scan Report revealed a Subarachnoid Hemorrhage. A subarachnoid hemorrhage is bleeding in the space between the brain and the surrounding membrane (subarachnoid space). Resident # 62 was then transferred to University of [NAME]land Shock Trauma and was discharged and returned to the facility on [DATE]. Facility investigative documentation was reviewed on 3/01/2018. A Quality Improvement Follow Up Documentation form dated 12/11/2017 reads: Determined 2 employees failed to operate Hoyer safely. The facility Administrator was interviewed on 3/01/2018 at 9:00 AM. When asked how the facility determined that GNA #1 and GNA # 2 did not operate the lift correctly he/she responded After the incident we had GNA # 1 and GNA # 2 do a return demonstration which they did perfectly. Administration also did a demonstration. We put a staff member in the Hoyer and it worked perfectly. The sling was taken out of circulation immediately and the Hoyer was taken out of operation on 12/11. The sling was in perfect condition and there were no problems with the Hoyer. We determined that the resident would not have fallen if the sling had been looped correctly. The Administrator and the Director of Nursing confirmed that staff failure to safely operate the Hoyer Lift resulted in Resident # 62's fall with injury and hospitalization .

Based on medical record review, facility investigation review and interviews it was determined that the facility failed to maintain a safe environment for residents at risk of elopement. This was evident when Resident # 88, who was a known elopement risk exited the facility in September 2016 and the facility failed to initiate an appropriate and thorough investigation. The facility then failed to prevent further elopements when a break down in the facility's elopement prevention procedure resulted in Resident # 88 eloping again in February 2017. The facility also failed to maintain elopement care plans for 4 out of 27 residents reviewed that were at risk for elopement. Based on these findings, on March 1, 2017 at 1:50 PM, an Immediate Jeopardy was identified. The facility submitted an acceptable plan of removal to the State Survey Agency on March 1, 2017 at 6:41 PM and it was accepted. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of D level for the remaining residents. The findings include: Medical record review on March 1, 2017 for Resident # 88 revealed the resident was originally admitted to the facility 2009 with a re-admitted in 2013. On 3/29/13 the facility staff initiated an elopement care plan. The care plan stated resident is an elopement risk/wanderer (wandering looking for parents/spouse) related to dementia. The care plan interventions were to: identify pattern of wandering, is often looking for family. Intervene/distract as appropriate. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or book. Record review revealed on 7/23/16 the facility staff assessed the resident and determined the Resident # 88's BIMS was 3. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. A BIMS score of 0-7 points: the person is severely impaired. Further record review revealed on 9/8/16 at 1:13 PM the following note from nurse #1: resident observed outside on front porch without staff being present. Resident had earlier in the week attempted to leave building. Social worker made aware and photo copies are to be placed at security desks. Interview with Nurse #1 on 3/1/17 at 12:55 PM revealed the nurse stated he/she did not have a real clear memory of that event. Nurse #1 revealed a phone call was received on the nursing unit to notify the staff that Resident # 88 was outside of the facility, on the porch. Nurse # 1 also revealed that since the security guards cannot leave the desk he/she was needed in order to get Resident # 88 off of the porch. Nurse # 1 could not remember how the resident got out side of the facility and on the porch. The nurse also revealed Resident # 88 was easily re-directed back into the facility and on the unit. Nurse #1 also stated she/he left a message with the social worker; however, failed to notify any other administrative staff (unit manager, charge nurse, Director of Nursing, Administrator) which was the expectation of the staff. Interview with the Director of Nursing on 2/28/17 at 2:00 PM and 3/1/17 at 7:30 AM revealed the administrative facility staff was not aware of this incident until 2/6/17 (after Resident # 88 left the facility the second time). The Director of Nursing further stated it is the expectation of the facility staff to notify the immediate supervisor of any adverse behaviors or incidents so investigations could begin and interventions put in place. However, despite the expectation of the Director of Nursing and administration to be notified regarding incidents of elopement, on 9/8/16, Social Worker # 1 placed a photo at the front desk and updated the resident's care plan related to Resident # 88's photo at the front desk but failed to alert anyone in administration. In addition, the security guard that called the nursing unit and Nurse # 1, who escorted Resident # 88 back into the facility, also all failed to report the incident to their immediate supervisors. On 11/23/16 at 12:35 PM the facility staff documented: Resident at the reception desk by the front desk. Noted with increasing agitation and attempting to elope to go home to her/his home. Attempted to redirect back to unit but unsuccessful. Activities assistant also tried to redirect resident to no avail. As needed medication administered as per order to help with anxiety. Resident currently sitting in chair at the front desk. No acute distress noted at this time. Further record review revealed on 2/6/16 the resident was noted to have eloped from the facility. It was further noted upon the facility staff investigation that the security guard at the front desk opened the front door and the resident left the facility. It was further noted the resident was dressed with shoes and a coat. Resident # 88 had also removed his/her identification bracelet identifying him/her as a facility resident. It was further noted the resident had ambulated to the neighboring hospital (approximately 4 blocks, .2 miles). At that time, the resident was able to state his/her name and the facility was notified that the resident was at the hospital. The Director of Nursing, a Geriatric Nursing Assistant and Security guard went to the hospital and assisted the resident back to the facility. (There were no injuries noted to the resident). Review of the 2/6/17 facility investigation notes, revealed the security guard on duty was distracted by multiple people when he/she buzzed the resident out. Surveyor observation of the security camera footage on 3/1/17 at 12:24 PM revealed security guard # 1 at the desk. Two staff members were also at the desk and it was unclear the degree of interaction between security guard #1 and the 2 staff members. Further observation of the security film revealed Resident # 88 walked past the desk and security guard # 1. It was further noted, security guard #1, looked at the resident with an apparent glance to the right and buzzed Resident # 88 out of the facility. The resident was not observed on the security camera footage signing out on the visitor's log. The facility layout has 2 locked entrances/exits that are locked at all times and manned by security guards. One locked entrance is staffed by one security guard 24 hours a day. The second locked entrance is staffed by one security guard from 8:00 AM to 6:00 PM and is only accessible for use during those hours. Interview with the Director of Nursing and Administrator on 2/28/17 at 1:30 PM revealed that all people are to be buzzed in and out of the facility. Furthermore, all people who enter or leave the facility are to sign in and out at the security desk. Interview with the Director of Nursing on 3/1/17 at 2:00 PM revealed that a facility wide assessment of residents with the potential to wander and elope was conducted. Upon the completion of that assessment, the Director of Nursing revealed 27 residents were identified to be at risk for wandering and elopement. Record review on 3/1/17 revealed that 4 of the 27 residents (Residents # 13, # 65, # 17 and # 51) identified by the facility as at risk for elopement had no evidence of elopement care plans. As a result of the aforementioned findings, an Immediate Jeopardy was called on 3/1/17 at 1:50 PM. The Director of Nursing and Nursing Home Administrator were notified at that time. Initial plan to remove immediacy was given to the survey team at 6:00 PM. This plan was not accepted by the survey team and the Office of Health Care Quality. At 6:35 PM another plan to remove the immediacy was given to the survey team and reviewed by the Office of Health Care Quality. To remove the immediacy, the facility staff initiated the following interventions: A. The immediate positioning of another staff member at the security desk, this allowed 1 person to focus only on the door and no other functions. B. The initiation elopement care plans for Residents # 13, # 65, # 17 and # 51. The immediacy was removed at 6:41 PM.

Based on observations, medical record and facility investigation review, as well as interviews with the facility staff, it was determined that the facility staff failed to position a resident in her bed properly before leaving the area. This resulted in the resident rolling out of bed onto the floor and sustaining a fractured femur. This was evident for 1 of 2 residents (resident #1) selected for review. The findings included the following: On 7/21/14, the surveyor reviewed the medical record and facility investigation as well as interviewed the director of nursing (DON) and administrator. The facility investigation included written statements from the nurses and geriatric nursing assistants (GNA) involved. In addition, the surveyor observed the resident's bed with the prime air mattress in place with the administrator. The resident was not available for observation or interview at the time of the survey. On 7/22/14 at 2:00 pm, the surveyor interviewed the DON, GNA #1, nurse #2 and nurse #3. By way of history the resident was her own decision maker, alert and oriented. Her [DIAGNOSES REDACTED]. On 4/5/14 and 5/29/14, her quarterly minimum data set (MDS) and Maryland monthly assessment (MMA), noted that the resident required extensive assistance of 2 persons for bed motility. Bed mobility was described to be how the resident moved to and from a lying position, turned side to side, or positioned her body while in bed. From 5/24/14 - 6/4/14, her activities of daily living (ADL) sheet for bed mobility revealed the same. Review of the treatment administration record (TAR) noted that the resident had requested that both ? side rails be up; the order was initiated on 2/27/13. On 6/3/14, a prime air mattress was applied to her bed for pressure relief as the resident had a new pressure area to the sacrum. During the survey, the surveyor and the administrator observed the resident's bed with the prime air mattress in place with the ? side rails in the up position. The mattress elevated the bed to a height that left about 2 inches of the side rail above the mattress. On 6/4/14, sometime between 12 and 12:30 pm, according to GNA #1's interview with the surveyor and written statement, she provided the resident with her morning care/ bath, turned her on her right side and left the room to get nurse #2 so she could do the treatment to the resident's buttocks. After she found the nurse she returned to the room to find the resident on the floor. According to GNA #1, when she left the resident was on her right side with her left arm holding the top of the ? side rail. When she returned the resident was on her back with her head face up on the seat of the bedside chair. During surveyor interview and in a nursing note written at 1:09 pm, nurse #3 noted that she heard GNA #1 yelling that the resident was on the floor. Nurse #3 described the resident lying on the floor on her back with her head propped up on the chair. The resident was quoted to say, "I rolled out of bed, hit my knees, and hit my head on the chair."The resident's pain was assessed to be 9 out of 10 (on a scale of 1-10) in both knees. The resident was transferred back to bed with the Hoyer lift during which time nurse #3 described holding the left leg as straight as possible. During surveyor interview and documented in a statement written at 3:30 pm, nurse #2 noted that she had asked GNA #1 to let her know when she was done with the resident's morning care so that she could do the treatment to her sacrum. The GNA came out and told her she was ready. The next thing she heard was the GNA stating that the resident had fallen out of bed. Nurse #2 assessed the resident to be lying on the right side of the bed on her back, half way dressed and that she had fallen out of her bed and hit her knees. She complained of pain in her knees and the nurse noted that her left knee was slightly swollen. She described the bed to be in the highest position and that following the fall the resident was returned to bed using the Hoyer lift. GNA #1, #4, #5, nurse #3 and nurse #2 returned the resident to bed using the Hoyer lift. The physician was notified and ordered X-rays of both knees. At 12:25 pm, a portable x-ray was done of both knees due to the fall, pain and to rule out a fracture as the resident was unable to move her legs for positioning, per the X-ray report in the medical record. At 2:00 pm, the x-ray results were faxed to the facility. The results noted that there was soft tissue swelling and suspected joint effusion; an acute mildly angulated and impacted fracture of the distal femoral metaphysic/supracondylar area; osteoporosis and advanced osteoarthritis. The x-ray results noted: effusion - increased intra articular fluid; acute mild angulation - slight angle; impacted - the bone fragments are driven into each other; fractured distal femur - the end of the thigh bone closest to the knee. The facility staff failed to safely position the resident and left the resident's bedside; this resulted in the resident falling out of bed, fracturing her left femur, and pain.

Based on medical record review and interview, the facility staff failed to follow the plan of care and prevent injury (Resident # 10). This is evident for 1 of 43 residents selected for review in the stage 2 sample. The findings include: Review of Resident # 10's medical record on 12/17/12 at 10:23 am revealed the facility staff conducted the annual MDS (Minimum Data Set) assessment and coded Section G 0110 B Transfers as 4/3 (Total dependence with 2 person physical assist). Review of the physicians orders dated 10/1/12 revealed orders "transfer/mobility Hoyer lift and 2 assist". A Hoyer (brand name) lift is mechanical lift used to transfer a resident from the bed to chair and back. A Hoyer lift uses a sling that supports the entire weight of the resident when the resident is dependent or cannot assist with the transfer. Further review of the medical record revealed on 10/9/12, the GNA providing care to the resident failed to follow the physician's orders [REDACTED]. A stand lift is used to transfer residents between two seated positions (edge of bed to a wheelchair) and is designed to support the upper body weight of the resident requiring the resident to be able to bear weight. During the transfer, the resident suffered a fall and was transported to the hospital via 911 for further evaluation. The resident suffered fractures to the left arm and left leg. Surveyor interview with the Administrator and Director of Nursing on 12/17/12 at 1:35 PM, confirmed the GNA failed follow the physician's orders [REDACTED].

Based on medical record and facility incident investigation review, as well as review of and interview by the surveyor of facility staff interviews, it was determined that the facility staff failed to transfer the resident with the assistance of 2 persons, as ordered by her physician. This resulted in pain and a fracture of the resident's left tibia (shin bone). This was evident for 1 of 10 residents selected for review. On 3/25/11, the surveyor interviewed the Assistant Administrator (staff #1) and the Director of Nursing (nurse #2). The surveyor requested the facility staff investigation report and the closed medical record for resident #1. The surveyor reviewed resident #1's closed medical record . The resident was admitted to the facility on [DATE]. Her date of birth was 11/14/1907. Her [DIAGNOSES REDACTED]. Osteoporosis is the thinning of bone tissue and loss of bone density over time. Osteoarthritis is caused by the breakdown of the cartilage that cushions the ends of the bones, causing them to rub together. The physician's orders [REDACTED]. On 12/28/10 at approximately 10 AM, the resident was transferred by 1 facility staff person instead of the physician ordered 2. She immediately complained of pain in her left leg. Her leg was X-rayed and she was diagnosed with [REDACTED]. The surveyor reviewed the resident's medical record for information that would have been in place on 12/28/10, the date of the transfer resulting in the pain and fracture. The physician order [REDACTED]. On 12/28/10 at 10:35 PM, the Xray interpretation signed by the radiologist and the final report faxed to the facility at 22:37 (10:37 PM) noted an acute fracture involving the proximal tibia with minimal displacement. There was associated soft tissue swelling and diffuse osteopenia. Osteopenia is a condition where bone mineral density is lower than normal. This fracture, or break, is in the upper part of the shinbone (tibia).According to the American Association of Orthopedic surgeons: these fractures may result from a low-energy injury, such as a fall from a height, or from a high-energy injury, such as a motor vehicle accident; and the soft tissues (skin, muscle, nerves, blood vessels, and ligaments) also may be injured at the time of the fracture. On 12/28/10 at 16:30 (4:30 PM), the progress notes indicated that the resident was transferred to the hospital. The resident was transferred to the hospital for stabilization of the fractured left leg and a change in her respiratory status. On 12/30/10, according to the medical record, the resident's family called the facility to inform them that the resident had passed away the preceding evening at the hospital. On 3/25/10, the surveyor reviewed the facility staff investigation initiated on 12/28/10. The date and time of the incident was 12/28/10 at 10:00 AM. The resident was assessed to be alert and coherent. The surveyor reviewed the facility staff investigation which included interviews with facility staff rendering direct care for the shifts preceding 12/28/10 at 10 AM. There were no significant resident changes or events noted. The resident and her roommate were also interviewed. The resident was described to make a twisting motion with her hand when she was asked what happened to her leg. Her roommate, resident #8's documented interview noted that she heard her roommate yell around 10 AM. According to the nursing assignment sheet and facility staff investigation and interviews, GNA #5, was assigned to and rendered care to the resident on 12/28/10. The facility staff investigation revealed that at approximately 10 AM, GNA #5 transferred the resident by herself, from the bed to the wheelchair. GNA #5 was interviewed and this was documented in the facility investigation. She was noted to state that the resident complained of pain to the left leg when she was transferring her from the bed to the chair. She added that the resident kept stating that her leg was broken. GNA #5 was further noted to state that the resident started to scream after she was transferred. GNA #5's documented interview added that after the resident was transferred from the bed to the wheel chair she (resident #1) started screaming that her leg was broken and that "they bent it backwards". GNA #5 was noted to state that she then wheeled the resident to the dayroom and reported the complaint to the nurse, nurse #7. Nurse #7 assessed the resident and an Xray was ordered. The Xray was positive for a fracture; an acute fracture involving the proximal tibia with minimal displacement. The facility staff investigation documented a second interview with GNA #5. The documented interview noted that when GNA #5 transferred the resident from the bed to the chair she lifted her and pivoted her with the resident's legs supported by hers. The chair did not have leg rests and she lifted the resident's legs to put them on the leg rest and that was when she (resident #1) screamed out in pain. GNA #5 then wheeled the resident to the day room and went in. On 1/3/11, according to the facility staff investigation, staff #1 met with GNA #5. Staff #1 documented that after completion of the facility staff investigation she believed the injury occurred during the resident transfer on 12/28/10 and noted that GNA #5 accepted responsibility. The facility staff investigation concluded, per Staff # 1, that GNA #5 was responsible for transferring the resident by herself and the resulting pain and fracture. On 3/25/11 at 1:35 PM Staff #1 and Nurse #2 were interviewed by the surveyor and the facility investigation conclusion was reviewed; they stated that the information was accurate and failed to provide additional information. The facility staff failed to transfer the resident with the physician ordered assistance of 2 persons. This resulted in pain and a fracture of the resident's shin bone, tibia.