Every finding on record at Coffman Nursing Home

Based on observation, interview and review of complaint #2585549 and other pertinent documentation it was determined that the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety as evidenced by failure to ensure: items were labeled and covered adequately; the refrigerator was in good working order; dishes were completely dry before storage; sanitary storage of bulk items; hair nets were worn by staff preparing food items; and cooling logs were maintained. These deficient practices have the potential to affect all resident's who are able to consume food by mouth. The findings include: Review of complaint #2585549 revealed concerns in the kitchen in regard to expiration dates not being noted by all employees, a lack of concern for cleanliness at the facility and the safety of residents health.On 7/30/26 between 8:30 - 9:00 AM surveyor completed the initial tour of the kitchen. A follow up kitchen observation was made on 8/3/26 between 5:04 - 5:40 PM. 1.During this initial tour on 7/30/26, Surveyor observed in the refrigerator near the tray line an uncovered container on the top shelf, which was partially filled with what appeared to be water. [NAME] #13 reported the container was there to collect water because it leaks. Later during the initial tour Staff #18, who identified himself as the previous interim Dietary Manager, indicated that a work order was already submitted regarding the leak.During the follow-up tour of the kitchen on 8/3/26 surveyor again observed an open container collecting water on the top shelf of the refrigerator near the tray line.2.Further observation of the refrigerator near the tray line revealed a bag that did not have a label but contained what [NAME] #13 identified as turkey. [NAME] #13 then disposed of the unlabeled bag of meat. 3.On 7/30/26 at 8:45 AM surveyor continued the initial tour of the kitchen and was now accompanied by the Dietary Manager (DM #11). Surveyor observed on a metal cart, a tray with tulip dessert cups nested together in piles of four to five. Three out of three of these cups observed were found to have water inside the cup. DM #11 then proceeded to instruct staff to put these cups on drying racks, informing the staff that this is wet nesting. Continued observation on 7/30/26, revealed on the same cart as the tulip dessert cups, four trays of soup bowls stacked one on top of each other. On each tray was a layer of soup bowls with the open side facing down on the flat tray. Observation of three of the bowls on the top tray of bowls revealed two of them with water, and the third had a small bit of debris. DM #11 confirmed that these bowls were considered clean and ready to be used.During the follow up tour of the kitchen on 8/3/26, surveyor again observed soup bowls in the clean storage area that were resting open side down on a flat tray. Two out of three of the bowls observed were found with water inside the bowl. DM #11 removed the top tray of bowls, surveyor then checked four of the bowls on the next tray of bowls and found one out of four with water.On 8/3/26 at 5:39 PM during the follow-up kitchen tour, coffee cups were observed near the drink station. They were noted to be stored open side down on flat surface. Three out of three cups checked revealed wetness inside the cup. DM #11 then pulled the tray of cups from service. 4. Continued observation of the kitchen during the initial tour on 7/30/26, revealed a bulk container of bread crumbs with the scoop sitting in the bread crumbs. Adjacent to the bread crumbs was a container of flour, which also had a scoop sitting in the flour.Staff #18 reported the scoops were supposed to be hanging on a hook within the containers.Review of the HACCP [Hazard Analysis Critical Control Points] plan, provided by DM#11 on 8/3/26, revealed: Dry bulk items, such as rice , sugar and flour are stored in seamless containers with tight fitting lids and are clearly labeled. Scoops should not be left in food bins.5. During the initial tour on 7/30/26, observation of a floor drain in the food prep area revealed a black tube that extended into the drain almost reaching the grate at the bottom of the open drain. Staff #18 was present during this observation and reported it has been like that since he has been at the facility but indicated he could cut the tubing off. Staff #18 was heard informing other staff that they need an air gap.Surveyor also observed during the initial tour a pipe draining into the floor drain under the dishwasher that extended below the rim of the drain.During a follow up tour of the kitchen on 8/3/26 at 5:04 PM surveyor observed the tubing that drained into the drain in the food prep area was now shorter and allowed for an air gap. Observation of the pipe draining into the floor drain under the dishwasher remained the same. Surveyor then reviewed the concern regarding failure to have an air gap for one of the pipes draining into the drain under the dishwasher with DM #11.6. During the follow up tour of the kitchen on 8/3/25, [NAME] #14 reported that she sometimes cooks large pieces of meat that need to be cooled down, such as a turkey breast. She reported she does not keep a cooling log but was able to verbalize an appropriate plan in regard to the time frame and temperature goals of cooling.On 8/05/26 at 11:18 AM, when asked if she expected the cooks to keep a cooling log, the Registered Dietitian (RD #10) reported she had never worked in a company in Maryland where they have kept a cooling log and that she did not know if the company expects them to keep a cooling log.Review of the HACCP [Hazard Analysis Critical Control Points] plan, provided by DM#11 on 8/3/26, revealed in the section addressing cooling: Record hourly cooling temperatures on the cooling log sheet.7. On 8/3/26 at 5:30 PM, during the follow-up kitchen tour, surveyor reviewed a report from the local county health department dated 3/18/26. This report included the following: complainant states that staff in kitchen are not wearing beard nets. Results of investigation during inspection, members in kitchen were not wearing beard nets. Management was notified of the complaint and instructed to ensure beard nets are worn at all times in the kitchen. According to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. On 8/3/26 at 5:33 PM surveyor observed Staff #13 in the kitchen preparing drinks in cups. Staff #13 had a beard and was not wearing a beard net. He had on a cap covering his head. When asked if there was anything else he should be wearing he verbalized beard net. He was later observed with a beard net on.8.On 8/05/26 at 12:36 PM surveyor, with Nurse #7, observed the nourishment room located across the hall from the nursing station. The following items were observed in the refrigerator:a.A plastic container with some kind of salad per Nurse #7. There was no date, no name or other identifying information on the container.b.A dinner tray from the dining room, with a meal ticket that indicated it was from Sunday 8/2/26. A cup with fruit salad was observed to be uncovered on this tray.c.An approximately 5 inch deep and 8-inch-long container with what appeared to be chicken. There was no date, no name or other identifying information on the container.d.A partially eaten beef sandwich that was wrapped in aluminum foil. There was a room number but no date on this item.e.A plastic bag that held a small container of green beans. The bag included a name and a date of 7/25/26.Nurse #7 disposed of these items at the time of the observation. She reported items should be thrown out after 72 hours and referenced a sign on the side of the refrigerator. When asked who is supposed to clean out the refrigerator, Nurse #7 reported that the kitchen does this, but she did not know when it was last completed.On 8/5/26 at 12:48 PM when asked who was responsible for cleaning out the nourishment room refrigerator, the Nursing Home Administrator (NHA) reported either nursing or dining, both but ultimately the dining team. Surveyor then reviewed the above listed observations from the nourishment room refrigerator.Review of the Foods Brought by Family/Visitors policy, with a Revision date of March 2022, revealed: Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the 'use by' date. The nursing staff will discard perishable foods on or before the 'use by' date.The policy failed to define how the 'use by' date was determined.Nursing Home Administrator confirmed, on 8/05/26 at 1:32 PM, that the policy for Food Brought by Family/Visitors is dated March 2022. She also reported that the expectation is to throw out food after 72 hours.On 8/5/26 at 12:54 PM surveyor reviewed the concerns with the NHA regarding the above observations made in the kitchen during the survey.

Based on record reviews and interviews, it was determined that the facility failed to keep a resident's environment free from accident hazards. This was evident for 1 (Resident #59) of 4 residents reviewed for accidents.The findings include:Resident #59 was admitted into the facility in late 2025 for routine healing of a closed fracture. A complaint related to intake #2680375 indicated concerns that included faulty medical equipment (resident bed).A review of Resident #59's medical record was conducted on 7/31/26 at 1:37 PM. During the review, the resident's discharge summary from the hospital prior to admission to the facility indicated that the resident had surgery due to a fractured right ankle and had instructions not tobear weight on the right lower extremity.Further review of Resident #59's medical record also revealed a progress note with an effective date of 11/28/25 at 6:54 AM that indicated the resident had to put weight on his/her non-weight-bearing lower extremity to prevent a fall due to the mattress sliding off the bedframe. Theprogress note also indicated that a work order was submitted to fix the resident's bed.The Maintenance Supervisor (Staff #1) was interviewed on 7/31/26 at 2:31 PM. During the interview, Staff #1 reported that the facility used TELS (TELS is an electronic platform used by many healthcare facilities for building management, work orders, and tracking service requests) to report and track building or maintenance requests. Staff #1 was asked to print the work orders report for November 2025.On 7/31/26 at 2:47 PM, the work orders report was provided and reviewed with Staff #1. The review revealed work order #10491 dated 11/26/25 that indicated concerns with Resident #29's mattress moving/sliding off the bedframe. Work order #'s10495 and 10496 were both dated 11/28/25 and had indicated the same concerns with the resident's bed. When Staff #1 was asked what maintenance staff did after the work order requests were made on the dates above, he reported that he would review the documents/comments in TELS, print, and report back to the surveyor.On 7/31/26 at 3:04 PM, Staff #1 provided documentation printed off from TELS and confirmed that all 3 work order numbers (10491, 10495, and 10496) were made in reference to Resident #59's mattress sliding off the bedframe, with the initial request made on 11/26/25. Staff #1 reported that work order requests were reviewed by maintenance staff several times each day. However, based on the documents, the concern with the resident's bed was not addressed till 11/28/25.During an interview with the Director of Nursing (DON) on 7/31/26 at 3:28 PM, the concern was discussed that the facility failed to address Resident #59's concern with his/her mattress moving/sliding off the bedframe promptly, which resulted in the resident having to put weight on a non-weight-bearing foot to prevent a fall when the mattress slid off the bedframe on 11/28/25. The DON verbalized understanding and acknowledged the concern.

Based on record review, interviews, and observations, it was determined that the facility failed to ensure that meals were delivered to residents at an appropriate and palatable temperature. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen. The findings include:A review of complaint #316959 contained a statement that, “The meals are cold and half-cooked”. A subsequent review of the facility's food committee meeting notes revealed that residents had voiced concerns about the presentation, taste, and temperature of foods. A review of the food service temperature logs was completed. The review failed to show food service line temperature records for dinner on 3/6/25, breakfast, lunch, and dinner on 3/13/25, dinner on 3/20/25, dinner on 3/27/25, lunch and dinner on 5/1/25, dinner on 5/20/25, dinner on 5/21/25, dinner on 6/14/25, dinner on 6/15/25, dinner on 6/16/25, and dinner on 6/18/25. The review also revealed two undated food temperature log forms, which also lacked records of food temperatures for lunch and dinner. Continued review of the food temperature policy showed a statement: “Foods will be served at proper temperature to ensure food safety. If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and [discard] out-of-temperature range foods.” However, earlier log reviews failed to show that the required food temperatures were consistently obtained before serving residents. During an interview on 7/15/2025, Resident #1 reported, “The food is always cold.” The resident also added that the liners, which were to be placed between the plates holding the food and the plastic covers to keep the food warm, were rarely present. During a meal observation on 7/17/2025, another Resident, #56, reported that the food was served cold. While observing the dinner tray line on 7/22/2025, at 5:15 PM, the surveyor requested a test tray. The tray contained Manicott Alfredo, Spinach, Wheat roll, butter, salt, pepper, vanilla pudding, 2% milk, Ice water, and Chocolate ice cream. The dietary manager was present and obtained the food temperatures, which showed 57 degrees for the milk. Staff indicated that the acceptable temperature range for the milk should have been less than 41 degrees and verbalized understanding of the concern. In a subsequent interview, the dietary manager reported that to address the concerns about food temperatures, he had ordered additional food liners for the food warming systems. However, his department had just been fully staffed, and he had yet to train them to use the liners. On 7/23/2025 at 12:30 PM, the Nursing Home administrator was informed of the food concerns and verbalized understanding.

Based on observations and interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards and guidelines. This deficient practice has the potential to affect all residents.The findings include:An observation of the facility's walk-in refrigerator on 7/15/25, at 8:14 AM, with staff #18, the dietary manager, present, revealed nine cabbages with a grayish substance growing on them. He indicated that the cabbages had gone bad and discarded them.Continued observation revealed a bag of broccoli with a label stating, Best if used by 7/8/25. Staff confirmed that it had expired and removed it for disposal.Further observation noted a bag of shredded cheese with an open date of 7/14/25 but had no use by date.The observation also showed an opened and halfway used [NAME] buttermilk ranch dressing labelled with a received date of 3/20/25. However, the label did not indicate the open or use-by date.An observation of the facility's walk-in freezer revealed a container of prepared spaghetti sauce with a date of preparation listed as 5/29/25. It did not have a use-by date. Staff #18 said it should have been used within 4 weeks and took it out to discard. He also said he was aware of the labeling issues, so he had initiated a Performance Improvement Plan (PIP) to address this issue.A subsequent observation of the nutrition room refrigerator on the nursing unit with staff #20, a licensed practical nurse, showed a carton of thickened orange juice with a use-by date of 4/30/25. Staff #20 indicated it had expired and discarded it after the surveyor's intervention. She also noted that the dietary staff were responsible for stocking and disposing of expired food items from the nutrition room refrigerator.In an interview on 7/21/25 at 2:48 PM, Staff #21, the Culinary Operations Manager, said she had provided training to the dietary staff regarding labeling, dating, and rotating perishable food items after the surveyor's intervention.

Based on observations and interviews, it was determined that the facility failed to provide a home-like environment for residents. This was evident in three of the three hallways reviewed for the environment.The findings include:During an observation on 7/17/2025, at 12:34 PM, in the 200 hallway, six tiles between room [ROOM NUMBER] and the nurses' station were noted to be cracked.Continued observation of the 300-hallway showed that room [ROOM NUMBER] had eight cracked tiles. Additionally, two tiles under the head of the first bed had bubbles, and six tiles to the right had black discoloration. The observation also found that the trim guard was detached from the bathroom door post, and the P-trap under the bathroom sink was rusted in room [ROOM NUMBER].Further observation showed six cracked tiles between rooms [ROOM NUMBERS]. Then, in the 400 hallway, four tiles between rooms [ROOM NUMBERS] were broken.An observation of the unit shower room revealed two cracked tiles behind the door.During an environmental tour on 7/21/25, at 10:14 AM, Staff #5, the Maintenance Director, confirmed all the findings and stated that they would address them.

Based on a record review, observations, and interviews, it was determined that the facility failed to serve residents meals according to a predetermined menu that reflected their preferences. This was evident in four out of four dining observations during the survey.The findings include:1) A review of the facility's food committee meeting notes was done. The notes revealed that the residents voiced concerns and grievances, including the dietary staff consistently not serving their meals according to their preferences on the meal tickets.A dining observation on 7/17/2025 at 5:35 PM, in the 300 Hall, showed Resident #56 eating dinner in the room. On the Resident's meal tray was a ticket that listed all the food items to be on the tray: sloppy joe on Bun, xplain potato chips, steamed corn, salt and pepper, chocolate pudding, 2% milk, Ice water, vanilla ice cream.However, continued observation failed to show that Resident #56's tray contained vanilla ice cream, salt, and pepper. The Resident's Representative was present and said, We don't always get everything on the ticket.2) An observation of dinner in the 300 Hallway included Resident #11, eating dinner in his/her room. The observation noted from the Resident's meal ticket was that s/he was to receive a red inner lip plate, a sloppy joe on a bun, mashed potatoes, cream-style corn, salt and pepper, chocolate pudding, ice water, cranberry juice, chocolate ice cream, 2% milk, and low-fat yogurt.However, the observation failed to show that Resident #11 received milk and low-fat vanilla yogurt on his/her tray. The resident stated that s/he did not receive milk or yogurt and added that s/he had requested cottage cheese with his/her meals but did not receive it at times.In an interview on 7/17/2025 at 6:05 PM, staff #17, a dietary aid, confirmed concerns about missing food items on the trays for Residents #56 and #11. And added that missing food items on the residents' trays were dependent on which dietary staff member loaded the meal cart.3) An observation of breakfast on 7/18/2025 at 8:00 AM showed that Resident #40 was eating breakfast in the room. The resident's tray contained corn flakes, scrambled eggs, hash brown patty, special cup, special spoon and fork, special yellow plate, dry wheat toast, butter, salt and pepper, grape jelly, creamer, cranberry juice, 2% milk, coffee, and Prune juice. However, the Resident's meal ticket listed the following items: corn flakes, scrambled eggs, hash brown patty, [NAME] anti-spill cup, small built-up utensils, yellow-lipped plate, dry wheat toast, butter, salt and pepper, grape jelly, creamer, cranberry juice, 2% milk, coffee, Prune juice, and banana. The Resident stated, They missed my banana.4) While observing the dinner tray line on 7/22/2025 at 5:15 PM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #52, which listed the following food items to be served: Manicott Alfredo, Spinach with garlic butter, Wheat roll, butter, salt, pepper, chocolate pudding, 2% milk, Ice water, and a Chocolate ice cream cup.However, continued observation failed to show that Resident #52's tray contained chocolate pudding. The dietary manager was present and was made aware of the concern that Resident #52's tray did not contain chocolate pudding, and he confirmed the concern.In an interview on 7/23/2025, at 11:12 AM, the dietary manager confirmed the concerns and verbalized understanding.

Based on observations, review of policies and medical records, and interviews it was determined that the facility failed to ensure staff maintained standard and enhanced barrier precautions (EBP) while providing care; and failed to ensure the infection prevention and control policies and procedures were reviewed and revised at least annually. This was found to be evident for 3 (Resident # 3, #37 and #29) out of 40 residents included in the sample.The findings include: 1a) An observation made on 7/16/2025 at 9:31 AM noted a sign outside Resident #3's room that indicated that the Resident was on EBP and required staff to wear gowns and gloves during high-contact care activities. Enhanced Barrier Precautions (EBP) are infection control measures designed to reduce the transmission of infections in healthcare settings, including nursing homes. EBP involves wearing gowns and gloves during high-contact care such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with infections, MDRO colonization, indwelling devices, or wounds. A review of Resident #3's record showed that s/he was on EBP due to having a wound. The review also included an EBP care plan for Resident #3. The care plan had recorded that “Staff will don[wear] gown and gloves for all high contact Resident care activities”. However, during a subsequent observation of morning care for Resident #3, staff #6 and #7, both geriatric nurse aids (GNAs), wore gloves but did not wear gowns, despite the posted EBP requirements. In an interview on 7/16/25 at 9:50 AM, both GNA #6 and #7 stated that Resident #3 did not have a wound and therefore were not required to wear a gown during high-contact resident care. Both staff members confirmed seeing the EBP signage outside the resident's room, but indicated it needed to be removed because Resident #3 did not have a wound. A subsequent interview on 7/17/2025 at 11:18 AM, with staff #8, a licensed practical nurse, revealed that Resident #3 had a wound that required daily treatment, and staff needed to gown up before providing high-contact resident care. In an interview on 7/17/2025 at 11:59 AM, Staff #11, the infection preventionist (IP) nurse, indicated that she was made aware of the concern regarding not wearing a gown before providing high-contact care to Resident #3. The IP nurse indicated that steps would be taken to address the concern. 1b) Review of Resident #37's medical record on 7/15/25, revealed the presence of a stage 3 pressure ulcer on the resident's heel. A Stage 3 pressure ulcer indicates there is full thickness skin loss. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with pressure ulcers. On 7/17/25 at 9:59 AM the surveyor arrived at the resident's room and observed Nurse (Staff #1) completing Resident #37's dressing change. There was a sign posted outside of the resident's room indicating Enhanced Barrier Precautions were in place for this resident. The nurse had already removed the old dressing and was in the process of cleaning the wound when surveyor arrived for the observation. Surveyor noted that Nurse #1 was not wearing a protective gown while completing the dressing change. On 7/17/2025 at 10:13 AM, after the dressing change was complete, the surveyor asked Nurse #1 what was her understanding of EBP? The nurse responded she was not 100 % sure, indicated the infection control nurse would know more and then stated: “I was suppose to wear a gown, wasn't I?” On 7/17/25 at 11:59 AM the Infection Preventionist (IP) Nurse (Staff #11) reported that EBP was reviewed with the staff within the last month or two. The Infection Preventionist Nurse confirmed that any resident with a pressure ulcer would require the use of gown and gloves during high contact care. The Surveyor then reviewed the observation from this morning of the nurse performing a dressing change without wearing a gown. 1c) On 7/17/25 at 08:16 AM, during the observation of medication administration with Nurse#1 for Resident #29, Nurse #1 was observed preparing and priming an intravenous (IV) line and pump without donning gloves. Nurse #1 handled the IV equipment and tubing without adherence to standard infection control precautions. On 7/21/25 at 4:09 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's infection prevention and control policies and the facility's annual review process. The DON stated that there was no evidence the infection prevention and control program had been reviewed in the past year, and no documentation could be provided to demonstrate that policies, procedures, and standards had been evaluated or revised based upon the current facility assessment or resident population. The policies presented were generalized, templated forms with dates ranging from 2017 to 2023 and lacked facility-specific identifiers based on the facility assessment. On 7/23/25 at 12:47 PM, the DON confirmed again that the facility was unable to provide evidence that a review or revision of the infection prevention and control policies had occurred to ensure alignment with current standards or the facility's specific assessment.

Based on a record review, observation, and interviews, it was determined that the facility failed to provide an assistive device for eating to a Resident. This was evident in one of four dining observations during the survey.The findings include:On 7/15/25, at 8:14 AM, a review of a report provided by the dietary manager for Residents who require special utensils during meals was completed. The review showed that Resident #40 required “a [NAME] anti-spill cup, a yellow-lipped plate, and small built-up utensils [special fork and spoon with built-up handles to aid people with a weakened grip]” for every meal. However, during dinner observation on 7/17/25, at 5:35 PM, Resident #40 was eating dinner in his/her room and did not have his/her weighted utensils. Staff #6, a geriatric nurse aid, was present and stated that she had given Resident #40 regular utensils because the weighted utensils had not been received from the dietary staff. In an interview on 7/17/25 at 6:05 PM, Staff #17, a dietary aid, confirmed that Resident #40 did not receive his/her weighted utensils on the meal tray and stated that she would notify her supervisor of the concern. During an interview on 7/21/2025 at 8:11 AM, Staff #19, an occupational therapist, reported that Resident #40’s weighted utensils were to help limit spillage and gather food during meals due to decreased fine motor strength and coordination. However, earlier observations failed to show that staff provided utensils to the resident during mealtime.

Based on record review and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 1 (#8) of 5 residents reviewed for unnecessary medications and 1 (#40) of 2 residents reviewed for the Preadmission Screening and Resident Review (PASSR) screening.The findings include: The MDS (Minimum Data Set) is a complete assessment of the Resident that provides the facility with the information to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need.Active diagnoses documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that directly relate to the Resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.1) A review of Resident #8's medical record included an order audit report that showed an attending provider's order for Resident #8 to receive an antipsychotic medicine for mood and behavior, effective 3/14/25. And the diagnosis for the medicine was Dementia with other behavioral disturbance.Further review included MDS assessments for Resident #8 dated 3/26/25 and 6/24/25. The MDSs recorded in section I0020B and I8000A that Resident #8 had an active diagnosis of Dementia without behavioral disturbance.In an interview on 7/22/2025 at 4:28 PM, Staff #13, the MDS Coordinator, reported that she missed it when Resident #8's diagnosis of Dementia was updated with behavioral disturbance. Staff #13 added that she would correct the MDS assessments.2) A review of Resident #40's MDS assessments dated 12/25/24, 3/25/25, and 6/23/25 showed a documentation of Psychotic disorder as one of the Resident's diagnoses in section I. Further review of the record did not reveal supporting documentation for the diagnosis.In an interview with Staff #13, it was indicated that to code an active diagnosis on the MDS assessment, it should have been documented in an attending provider's note within the last 60 days and treated over the previous 7 days preceding the assessment date, including the assessment date itself.However, earlier record review did not show that Resident #40 was treated for Psychotic disorder during the last 7days to the assessment date, and the attending providers' notes for the past 60 days did not show the diagnosis.During a subsequent interview on 7/22/2025 at 4:40 PM, staff #13 confirmed that Resident #40's MDSs dated 12/25/24, 3/25/25, and 6/23/25 were recorded inaccurately and that she would correct them.

Based on interviews and a review of medical records, it was determined that the facility failed to ensure an interdisciplinary team (IDT) care plan meeting was conducted for a resident. This was evident for one Resident (#48) who was reviewed for care planning.The findings include: A care plan guides each resident's care based on their specific needs. Care plans must be created within 7 days of the admission MDS and updated quarterly or as needed.The Minimum Data Set (MDS) assessment is a federally mandated tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected is used in the Resident's care planning decisions.The facility must have care plans developed and revised by an interdisciplinary team (IDT), including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable).In an interview on 7/15/2025 at 2:50 PM, Resident #48 was asked if s/he participated in his/her care plan meetings and responded that s/he was not aware of any care plan meeting.A review of Resident #48's medical record revealed that s/he had been residing in the facility since June 2025. The review also noted an admission MDS assessment for Resident #48, dated 6/30/25, and completed on 7/1/25. However, the review failed to indicate that a care plan meeting took place following the completion of the MDS assessment.During an interview on 7/22/2025, at 8:01 AM, Staff #4, Social Services Director (SSD), reported that IDT care plan meetings were scheduled for Residents based on their MDS schedules. The SSD stated that she missed scheduling a care plan meeting for Resident #48 because the date for his/her MDS had been changed.Later that day, the SSD reported that a care plan meeting had been scheduled for Resident #48 after the surveyor's intervention.

Based on review of medical records and complaint 316958, and interviews it was determined that the facility failed to ensure a resident received care in accordance with professional standards of practice. This was found to be evident for one (Resident #23) of five residents reviewed for unnecessary medication.The findings include:1)Review of Resident #23's medical record on 7/17/25 revealed the resident has resided in the facility for more than 8 months. The resident was admitted with an implanted port in place and orders to access the port once a month to complete a flush with saline and heparin (a medication used to prevent blood clots). A port is a medical device that is surgically implanted under the skin that allows health care providers easy access to a vein. A port can be used for access to give medications, intravenous (IV) fluids, blood transfusions or for obtaining blood samples. Flushing the port lowers the risk of clots and blockages.Review of the nursing progress notes revealed that on 2/3/25 a nurse from the pharmacy completed the flush. This note was completed by the facility Nurse (Staff #1).Further review of the medical record revealed that in the beginning of March 2025 the order to flush the port once a month was still in place. However, review of the Licensed Nurse Administration Record (where the nurse's document the medications they administer to the resident) revealed a blank in the area for staff to document the flush when due on 3/3/25 and a notation that the order was discontinued on 3/3/25. Review of corresponding progress notes, completed by Nurse #1 revealed a notation: port flush changed to every 3 months, last flushed on 2/3/25.Further review of the medical record revealed an Implanted Port Infusion Protocol and Orders form, dated 3/3/25, that included orders to flush the port with saline and heparin once every 3 months. Nurse (#1) had signed the form. On 7/17/25 at 2:09 PM an interview with Nurse #1 revealed that an infusion nurse had completed a training with the staff in regard to completing the flush and referenced her note from February. Nurse (#1) went on to report that the nurse who conducted the training had recommended the flush be completed every 3 months rather than every month.No documentation was found to indicate the physician or nurse practitioner were notified of this recommendation when it was made in February. The surveyor discussed the concern with the DON on 7/22/25 at 4:53 PM, that the staff had received education in February but no documentation was found to indicate the physician was notified about the recommendation to change the order until the next month when Nurse #1 identified that the order should have been changed.Since a flush was completed on 2/3/25, and the order was changed in March to every three months then the next flush would be due in May. Further review of the Licensed Nurse Administration Record revealed a flush was completed on 4/3/25, which was a month before it was due.On 7/17/25 further review of the Licensed Nurse Administration Record revealed a current order was in place to complete the flush once every three months and that it was due to be administered on 7/3/25. In the area to document administration the nurse (Staff #9) documented a 9 which indicates Other/See Progress Notes.There was a corresponding progress note written by Nurse #9 on 7/3/25 at 11:28 PM. Review of this note revealed the nurse had attempted to access the port with the needle, but the needle would not fully access, there was no blood return and was unable to flush. The note also documented that the on-call nurse was made aware and that the night shift nurse had also attempted.Further review of the progress notes revealed a note completed by Nurse #10 on 7/3/25 at 11:44 PM. This note revealed the following: This RN attempted access without results. Resident screaming and waving [his/her] arms during access attempt. Attempts and educating resident and talking with resident were without results. DSD [dry sterile dressing] applied.On 7/17/25 further review of the medical record failed to reveal documentation to indicate the port flush was completed after the unsuccessful attempts on 7/3/25. No documentation was found to indicate the physician or nurse practitioner was notified that the nursing staff was unable to complete the flush as ordered.On 7/17/25 at 11:20 AM Nurse (Staff #12) reported she was aware the resident has a port and that staff flush it, but she was unsure how often and stated that she had never completed the flush. The surveyor then reviewed the concern that the record review revealed the flush was due on 7/3 but that progress notes indicated nursing staff could not access the port, no documentation was found to indicate any follow up or if the port has been flushed in the two weeks since. Nurse #12 stated: the doctor should have been notified.On 7/17/25 at 12:15 PM the surveyor informed the Director of Nursing (DON) that no documentation was found to indicate the port was flushed since it was due on 7/3/25. The DON indicated she would check if there was any documentation to indicate the port was flushed.On 7/17/2025 at 12:28 PM the DON confirmed there was no documentation to indicate the port was flushed or that the physician or nurse practitioner was notified. DON reported she was going to have staff contact the doctor today.2) Continued review of Resident #23's medical record revealed an order, in effect since October 2024, for acetaminophen (also known as Tylenol) 325 mg tablets, give 2 tablets every 6 hours as needed for generalized pain or fever over 100 degrees. This is a PRN (as needed) order and requires an assessment be completed to determine if the acetaminophen was actually needed or not. Acetaminophen is a medication used for pain relief as well as a fever reducer. Review of complaint 316958 revealed an allegation that the Certified Medication Aides (CMA) were completing pain assessments.The Director of Nursing reported, on 7/15/25 at 11:52 AM, that the medicine aides do give the PRN Tylenol, but only after the nurses complete the assessment.CMA (Staff #14) reported, on 7/22/25 at 11:50 AM, that in regard to PRN medications they communicate with the nurse who will assess the resident and then tell them to go ahead and administer the medication. CMA #14 also reported that she would document why the medication was given.CMA (Staff #15) reported, on 7/22/25 at 1:01 PM, that she has to report all the pain to the nurse. If the pain is below 5 the nurse will say give the Tylenol. She went on to report that she does follow up with the patient and documents the follow up. And that if the medication does not work she documents that and tells the nurse.Review of the Medication Administration Record (MAR) revealed documentation that on 7/16/25 at 1:34 PM a dose of the PRN acetaminophen was administered to the resident by CMA #15. The pain level was documented as a 5 (on a scale of 1-10). Review of corresponding progress notes revealed that at 1:34 PM CMA #15 documented c/o [complaint of] shoulder pain; and at 2:32 PM CMA #15 documented that the PRN administration was effective and follow up pain scale was 0. No documentation was found in these notes, or elsewhere in the medical record, that the nurse was made aware of the resident's report of pain or that the acetaminophen was administered.Further review of the medical record failed to reveal documentation to indicate the resident had reported pain of any type in the month of July prior to the shoulder pain on the 16th. No documentation was found by a licensed nurse addressing the report of shoulder pain on July 16th.Nurse #1 reported on 7/23/25 at 10:30 AM, that if a CMA told her of a resident's report of pain, she would speak with the resident, offer position change, or an ice pack prior to instructing the CMA to give the prn Tylenol. Offering a position change or an ice pack are what is known as non-pharmaceutical interventions (NPI) that can help relieve pain without the use of medication. It is generally expected that staff offer NPI prior to the administration of prn pain medication.During the 7/23/25 interview, when asked about documentation of a report of pain by the CMA, Nurse #1 indicated she would include this information on the 24-hour report. She then showed the surveyor a binder with 24-hour report documentation. Review of this binder with Nurse #1 failed to reveal an entry for Resident #23 on 7/16/25.Further review of the electronic medical record on 7/23/25 at 10:37 AM with Nurse #1, revealed that Nurse #1 was assigned to care for the resident during the day shift of 7/16/25. Nurse #1 reported that it would be unusual for this resident to report pain, and denied recalling being told about shoulder pain, and indicated she would have documented about it if she was aware.On 7/23/25 at 10:52 AM the surveyor reviewed the concern, with the DON, that the CMA had documented shoulder pain, which was a new and unusual complaint. And that a nurse had not been informed of this report of shoulder pain.

Based on medical record review and interviews it was determined that the facility failed to ensure the residents were free from unnecessary antibiotics. This was found to be evident for one (Resident #54) out of five residents reviewed for unnecessary medications.The findings include:Review of Resident #54's medical record revealed the resident has resided at the facility for more than one year. Review of the primary physician (Staff #16) progress note, signed on 5/16/25 at 10:30 AM revealed the resident was seen that day for a sick visit, patient had a cough with phlegm and that he was waiting on chest x-ray results. The physician assessed the resident as having bronchitis and possible pneumonia. The plan included: Will start Levaquin 500 mg p.o.[by mouth] daily for 7 days; Waiting for chest x-ray if antibiotic needs to be changed; [Discussed] with staff continue to monitor closely.Review of the chest x-ray results, dated 5/16/25 at 4:25 PM, revealed: No active cardiopulmonary disease.Review of the May 2025 Medication Administration Record (MAR) revealed the resident received 500 mg of levofloxacin (also known as Levaquin) for 10 days from May 16 through May 25. The first dose was administered on 5/16/25 at 9:00 PM.On 7/22/25 at approximately 4:15 PM an interview was conducted, in the presence of the infection preventionist nurse (Staff #11), with physician #16. Surveyor requested clarification regarding the Waiting for chest x-ray if antibiotic needs to be changed statement in the 5/16/25 progress note. The physician reported that if the resident had pneumonia then he would have extended the treatment or ordered IV [intravenous] antibiotics. The physician reported that he talks to the nursing staff and gives verbal orders which the nurses then put into the medical record. When asked about the discrepancy of the number of days for the antibiotic treatment, the physician said he thinks it was a misunderstanding. The physician went on to confirm that the order for the antibiotic should have been for 7 days.Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. Review of the facility's Antibiotic Stewardship policies revealed they were last revised in December 2016. On 7/23/25 at 3:15 PM the surveyor reviewed with the Director of Nursing the concern related to the administration of an antibiotic for 10 days rather than for 7 days.

Based on observation and staff interviews, it was determined that the facility failed to ensure that drugs and biologicals were stored in areas that are secure against unauthorized access. This was evident in 2 (the 200 hall and the 300 hall) out of 3 rooms being used to store medications, as observed during the completion of the medication storage and labeling task for the annual recertification survey.The findings include:On 7/18/25 at 11:08 AM, the clean utility supply room located at the end of the 300 hall was observed to be unlocked and accessible. The room contained over the counter (OTC) medications and biologicals, including, but not limited to: vitamin A&D ointment, saline enemas, iodoform packing strips, hydrogel wound dressing, calcium alginate dressings, Silvasorb (Silvadene) for wound care, COVID-19 test kits, razors, and direct care supplies.At 11:28 AM, Nurse #1, was observed in the hallway and was asked whether the door to the clean utility room was normally secured. Nurse #1 stated they did not have a key to the door and further stated, The other clean utility closet does not stay locked, referring to the clean utility room on 200 hall, and then demonstrated that the door to the clean utility room on 200 hall opened freely and was not equipped with a lock or keypad where similar OTC medications and biologicals were stored with direct care supplies. At 11:47 AM, a handwritten sign was observed taped to the 300 hall clean utility room door stating, See the nurse for the key. The 200 hall clean utility room door remained open and accessible.On 7/18/25 at 1:35 PM, during an interview with the Director of Nursing, she was informed of the observations on the 200 hall and 300 hall and acknowledged the deficiency.

Based on observation and interview it was determined that the facility failed to maintain the daily posted staffing information in a readily accessible format. This practice has the potential to affect all residents.The findings include:On 7/23/25 at 12:38 PM observation on the nursing unit, with the Director of Nursing (DON), revealed staffing information posted on a large white wipe board for the current day shift. The information on the wipe board included the number of hours worked for registered nurses, licensed practical nurses, certified nurse aides (including geriatric nursing assistants and certified medicine aides) and the current resident census. There was separate paper documentation, also posted, that included the specific staff room assignments but failed to include the actual hours worked for nurses and aides. Surveyor then reviewed the concern with the DON that the posting of the actual hours worked is only on the wipe board and that the regulation requires this information to be readily available and kept for 18 months. DON reported the hours worked information was kept on other reports, not on the saved posted assignment sheets.

Based on complaint, review of the facility policies and a closed medical record, as well as staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury. This was evident for 1 (Resident #6) of 6 residents reviewed during a complaint survey. The findings include: A review of complaint MD00183144 on 03/22/24 revealed an allegation that Resident #6 had fallen and was not assessed or treated for 6 hours. A review of the facility Change in a Resident's Condition or Status policy on 03/22/24, revealed that: 1) The nurse will notify the resident's attending physician or the physician on-call when there has been an accident or incident involving the resident. Under #4 of the policy: Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. A review of Resident #6's closed medical record on 03/22/24 at 11 AM revealed that Resident #6 had been admitted to the facility for rehab after being treated at the hospital for a fall and subsequent neck surgery. Upon admission to the rehab facility, on 04/22/22, Resident #6 was noted with: not being steady on his/her feet, having numbness in the hands and feet, requiring a maximum assist of 2 staff members while ambulating with a walker. Resident #6 was also receiving the anticoagulant medications, Eliquis, orally, twice daily for blood clot prevention. Further review of Resident #6's closed medical record revealed that on 06/13/22 at 3:30 am, RN #7 was alerted to Resident #6's room by Resident #6 calling out for help. Upon entering the room, RN #7 observed Resident #6 lying on the floor beside the bed. RN #7 documented that Resident #6 was unable to give a response as to how he/she fell . RN #7 also documented that Resident #6 was observed with new bruising and skin tears to the extremities. In an interview with the complainant #1, for complaint MD00183144, on 03/25/24 at 10:24 am, complainant #1 stated that he/she was not notified until 9 am on 06/13/22 that Resident #6 had fallen and had injuries. In an interview with Resident #6's attending physician on 03/26/24 at 10:38 am, Resident #6's attending physician stated that he/she was not immediately notified of Resident #6's fall with injuries until later in the morning on 06/13/22. Resident #6's attending physician also stated that Resident #6 was receiving an oral anticoagulant at this time. Resident #6's attending physician stated that upon notification of Resident #6's 3:30 am fall on 06/13/22, Resident #6's attending physician instructed the nursing staff to send Resident #6 to the emergency room for evaluation and to rule out bleeding in the brain. Resident #6 was later readmitted to the facility with no indication of bleeding on the brain.

Based on observation, interview and review of relevant documentation, it was determined that the facility failed 1) to ensure that clean dishes were stored in a manner to prevent contamination; 2) maintain a cleaning schedule for the ice machine 3) ensure bulk food items were labeled and dated and 4) failed to ensure the temperature of the nourishment refrigerator was monitored. These practices have the potential to affect all the residents in the facility. The findings include: 1) On 4/14/22 at 9:44 AM surveyor observed a tray of coffee cups sitting open side down on a tray. Per surveyor request, when the certified dietary manager (CDM #8) picked up two of the cups, water was noted to be present inside the cup. The CDM removed the tray from the clean area and indicated they should have been dried on the drying rack prior to being put in the clean area. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganism can grow. On 4/21/22, a revisit to the kitchen was conducted between 11:25 AM and 12:15 PM. Surveyor observed a tray in the clean dish storage area with three brown coffee cups stored upside down. Observation of the inside of the cups revealed water inside one of the cups. The CDM was alerted to the observation. Additionally a blackish residue was noted inside the cup when it was wiped with a paper towel. The CDM reported they have hard water which may be the cause of the residue. Surveyor reviewed the concern that the wet nesting had been identified during the initial kitchen tour. Further observation of the clean dish storage area revealed a tray of cups stored upside down. The CDM identified these as clean cups. A random observation of one of the red cups revealed a white residue with a fuzzy appearance. One of five additional cups observed from the tray was also found to have water inside the cup. Additional observation of plastic pans stored in food prep area and identified as clean by the CDM revealed at least one container with a small bit of water and a crack in the plastic. Observation of the metal pans identified as clean by the CDM revealed at least one pan with whitish/bluish spot with fuzzy appearance on the bottom of the pan. CDM removed these items from clean area. Surveyor reviewed the concern that wet nesting had been identified on first day of survey and again today, as well as the other issues with the cleanliness of the dishes. The CDM indicated he would inservice the staff. 2) Further observations during the kitchen revisit on 4/22/22 revealed a significant amount of dust built up on the air vent on the ice machine. Observation of the ceiling of the inside of the ice machine revealed the presence of several small black spots. This observation was confirmed by the CDM. The CDM was unable to provide information regarding a cleaning schedule for the ice machine or when it was last cleaned. 3) Further observations during the kitchen revisit on 4/22/22 revealed in the food prep area two plastic storage containers. One contained dry yellow substance (like cornmeal), and another with dry white substance. Neither container was labeled with either contents or date. CDM was unable to definitively identify contents of either container, but indicated the yellow looked like potatoes and the white was possible sugar. CDM removed both containers and indicated would discard. 4) On 4/22/22 at 1:44 PM, observation of nourishment refrigerator, located in the nourishment room on the nursing unit, with the Assistant Director of Nursing (ADON) revealed the temperature was currently an acceptable 40 degrees. The refrigerator contained facility provided snacks and some resident food items which were labeled. Observation of the Freezer and Frig Temps log found on the door of the nourishment refrigerator revealed it was dated [DATE] and only had temperatures documented on two dates in February. Behind the [DATE] log sheet, sheets dated March 2022 and April 2022 were also found. Review of these two logs failed to reveal documentation of any temperatures for either month. The ADON acknowledged the concern regarding the failure to monitor the temperature of the refrigerator and freezer and reported that dietary was responsible for checking the temperature. On 4/25/22 at 3:51 PM, surveyor reviewed the kitchen concerns with the Director of Nursing and with the Administrator at approx 4:15 PM.

Based on observation and staff interview, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to store insulin pens and glucometers in a way that reduced the risk of bloodborne pathogen exposure, 2) failing to have a process in place to screen and educate visitors regarding infection control procedures for visiting, 3) failing to review and update Infection Prevention and Control policies and procedures on an annual basis. 4) failing to follow hand hygiene procedures during medication administration, 5) failing to properly store resident care equipment, and 6) failing to ensure daily COVID symptom assessments were being completed. This was evident during the annual survey and had the potential to affect all residents, staff, and visitors. This was also evident during an observation of 1 of 2 certified medication aides administering medications for 1 (#39) of 3 residents, and for 2 (#9, #19) out of 2 residents reviewed for respiratory care The findings include: 1) On 4/20/22 at 9:21 AM, an observation was made of the top drawer of the medication/treatment cart's top drawer which revealed that all the resident's insulin pens were placed in one section and were laying on top of each other. Secondly, each resident had an assigned glucometer, however they were laying in a row and touching each other. An interview with the Infection Control Preventionist (ICP) #13 on 4/26/22 at 10:00 AM revealed that she had been unaware of the storage of the glucometers and insulin pens and agreed that this practice was not acceptable. 2) On 4/16/22 at 8:30 AM upon entry to the facility, an observation of the lobby area where staff, visitors, volunteers, and vendors were screened before entering the facility revealed that a receptionist was sitting at the desk but had not actively been involved in the screening process. Reviewing some of the forms completed by people entering revealed temperatures of 91.9, 92.4, 95.9, 95.6, 93 degrees in Fahrenheit. There had been no instructions regarding the infection control practices that should be followed by visitors and vendors. Furthermore, throughout the survey, multiple observations of this area revealed that a receptionist was not always at the desk, therefore, at times there had been no one monitoring the screening process to ensure it had been completed and to ensure that visitors knew the infection control measures to follow. An interview with the ICP #13 on 4/26/22 at 10:00 AM, revealed that the facility was not monitoring the screening process for visitors and was relying on the honor system that each visitor had screened properly and knew the infection control measures to follow. The ICP #13 had agreed that the temperatures taken had not been within a normal range. 3) A review of the facility's infection control policies and procedures revealed no evidence that the facility had reviewed and updated them annually. During an interview with the ICP #13 on 4/26/22 at 10:00 AM, she reported that she knew the policies and procedures needed to be reviewed and updated, but had not instituted a process to ensure they had been. 4) On 4/21/22 at 9:30 AM, during an observation of medication administration by 2 surveyors, CMA (certified medication aide) (Staff #6) was observed dispensing medications into a medication cup for Resident #39, which were crushed and mixed with applesauce. CMA #6 was then observed pouring a beverage for Resident #39 into a cup, placing a plastic lid on the cup, then with his/her bare hands, pinched the tip of the straw and inserted the straw through the opening of the plastic lid. The CMA did not sanitize his/her hands prior to touching the resident's straw. 5) On 4/21/22 at 9:35 AM, during an observation of medication administration, an observation was made of Resident #39's bathroom. At that time, a turquoise-colored fracture pan (small bed pan) was observed on the floor, next to the toilet commode. On top of the fracture pan was a white specipan (a plastic, container with measurements used to collect urine or stool). The fracture pan, and the specipan were not covered or bagged and were not stored properly to prevent the transmission of disease and infection. Following the medication administration observation, CMA #6 was made aware of this finding and confirmed the finding. The Assistant Director of Nurses was made aware of the above findings on 4/21/22 at 11:20 AM. 6) Review of Maryland Department of Health (MDH) Amended Directive and Order Regarding Nursing Home Matters, dated 1/13/2022, revealed the following: Each nursing home resident shall be evaluated daily to check for COVID-19 by the nursing home's clinical staff. The evaluation shall include vital signs as well as the identification of new or worsening signs or symptoms. Review of the CDC website page for Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 2/2/2022 revealed the following: Actively monitor all residents upon admission and at least daily for fever (temperature greater than or equal to 100.0* F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. Review of the CDC website page for Symptoms of COVID-19, updated 3/22/2022, reveal the following symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. 6a) On 4/25/22, a review of Resident #19's medical record revealed the resident was admitted to the facility in February. Review of the medical record failed to reveal documentation of COVID 19 screenings for March 4, 5, 6, or 11, 2022 or for April 20, 2022. Further review of the medical record also failed to reveal documentation of vital sign assessments for these dates. On 4/25/22 at 3:53 PM, surveyor reviewed that no daily COVID 19 screens could be found for these 5 dates with the Director of Nursing (DON), who indicated she would investigate. At 4:07 PM, the DON confirmed that they had no additional documentation to indicate the assessments had been completed. 6b) On 4/26/22, review of Resident #9's medical record revealed the resident was admitted to the facility several months ago. Further review of the medical record failed to reveal documentation to indicate that a screen for COVID signs and symptoms was completed on 3/20 or 3/28/22. This concern was reviewed with the Assistant Director of Nursing on 4/26/22 at 2:38 PM. As of time of exit at 6:15 PM on 4/26/22, no additional documentation was provided regarding this concern.

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to establish when to report suspicion of a crime and mandated time frames to report those suspicions. This was evident during the annual survey and has the potential to affect all residents. The findings include: On 4/21/22 at 1:00 PM, a review of the facility's Resident Abuse and Neglect Policy, dated 5/2/18 and revised 9/20/21, revealed that the facility failed to include in the policy to report to local law enforcement any suspicions of a crime and include the required timeframes of such reports. While reviewing the concerns with the Assistant Director of Nursing (ADON) #13 on 4/22/22 at 11:38 AM, she reported she had been aware that the facility's policies and procedures needed to be reviewed and updated. On 4/26/22 at 9:18 AM, the Administrator was made aware of the concern with the Resident Abuse and Neglect policy.

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure their residents were free of abuse. This was evident during the annual survey and has the potential to affect all residents. The findings include: A review of the facility's Resident Abuse and Neglect policy, dated 5/2/18 with the last revision on 9/20/21, revealed that the facility had failed to establish a procedure for 1) staff to identify the types of abuse, 2) screening of all new employees to prohibit abuse, 3) notification of the State Agency with appropriate timeframes, 4) protecting the resident from the alleged perpetrator until an investigation can be completed, 5) conducting an investigation of alleged abuse, and 6) education of staff at least annually. In addition, the abuse policy failed to address how to identify, report, and investigate an injury of unknown origin. During a review of the concerns with the Assistant Director of Nursing (ADON) #13 on 4/22/22 at 11:38 AM, she reported that the facility needed to review and update their policies and procedures. ADON #13 reported she would further review the policies and procedures to see if additional ones existed. On 4/25/22 at 1:30 PM, the ADON #13 provided a copy of a policy titled, First Aid for Unexplained Injuries, Skin Lacerations and Bruises dated 9/25/00, with the last revision date of 5/11/15. A review of this policy revealed that it failed to address how to identify an injury of unknown origin and what the facility expected staff to do when an injury of unknown injury was identified. An interview with Social Work Director (SSD) on 4/25/22 at 9:50 AM revealed that the policy referenced above was facility's complete policy and procedure for resident abuse and neglect. The Administrator was made aware of these concerns on 4/26/22 at 9:18 AM and at that time he confirmed that the facility did not have additional policies and procedures for abuse. (Cross Reference F608 and F609)

Based on review of facility records and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 1 (#291) of 3 residents reviewed for Beneficiary Protection Notification. The findings include: The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services. On 4/20/22 at 2:28 PM, a review of the SNF Beneficiary Protection Notification Review worksheet completed by the facility indicated Resident #291 was discharged from the facility on 1/18/22 with benefit days remaining and a SNFABN form was not provided to the resident/representative. An explanation on the form indicated the resident planned to discharge on the last covered day of his/her benefit period but, instead, stayed in the facility a few days longer. A Notice of Medicare Non-coverage documented the effective date the coverage of the resident's current skilled nursing stay services would end on 1/14/22 and was signed by Resident #291's representative on 1/12/22. On 4/20/22 at 2:00 PM, the above concerns were discussed with Staff #11, who confirmed the SNFABN form was not provided to the resident/representative prior to or after the service coverage end date.

Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the appropriate care for a resident with a low oxygen level and failed to thoroughly assess a resident with a recent history of [MEDICAL CONDITION]. This was evident for 2 of 9 residents reviewed. The findings include: The facility staff failed to provide the appropriate care for a resident with a low oxygen level. 1) Resident #2 was admitted to the facility on [DATE] from an acute care hospital for rehabilitative services, with the goal of returning home. He was treated at the hospital for a low potassium level and an elevated [MEDICATION NAME] level. He has history of a previous hospitalization , about a month prior according to hospital documents found in the current resident record, for [MEDICAL CONDITIONS] (a rapid irregular heart beat), blood clot to the leg and kidney failure. His history includes [MEDICAL CONDITION] [MEDICAL CONDITION] hypertension and [DIAGNOSES REDACTED] with an ejection fraction of 25%. The resident was experiencing some confusion and agitation, which, according to the resident's psychiatrist, could be a result of his elevated [MEDICATION NAME] level ([MEDICATION NAME] is used to slow and regulate the heart beat). Due to his confusion and behaviors, he had someone sitting with him most of the time while at the facility. The resident was taken off of the [MEDICATION NAME] and placed on [MEDICATION NAME] for his [MEDICAL CONDITION] at the hospital. Resident #2 also had [MEDICAL CONDITION] and received 2 medicated inhalers and a nebulized breathing treatment twice a day. He had a physician's orders [REDACTED]. His oxygen level was to be checked every shift while receiving oxygen. A mechanical pulse oximeter is used to monitor the oxygen level by clipping it on a finger and obtaining the reading. Review of the medical record revealed that, on [DATE] at 2:56 AM, the resident's oxygen saturation was 98% on room air. On [DATE] at 6:13 AM, his oxygen saturation was 98% on 2 liters of oxygen via nasal cannula and he was requesting an inhaler for "chest tightness." The resident intermittently, on [DATE] and on [DATE], complained of "chest tightness." His oxygen saturation, with between 1 and 2 liters of oxygen, remained during this time between 90 and 100%. The physician was again notified of the resident's complaint of chest tightness on [DATE] at 2:53 PM. At that time the resident was ordered an EKG (Electrocardiogram), a decrease to his [MEDICATION NAME], which he had not received since 10 AM on [DATE], and a new [MEDICATION NAME](a [MEDICATION NAME] which dilates the blood vessels). On [DATE] at 3:18 PM, the resident is found to be cool and clammy, face flushed with oxygen saturations in the 40's, with 2 liters of oxygen on via nasal cannula. Medical record revealed that his oxygen was increased from 2 to 3.5 liters per minute. This resident had a recent history of cardiac and respiratory compromise. The facility staff failed to check the residents vital signs, which would include his heart rate and blood pressure, listen to his lung sounds, note the color of his extremities and nailbeds and identify if any [MEDICAL CONDITION] was present. They monitored him and noted 10 minutes later thathis oxygen saturation was ranging around 65% on 3.5 liters. ( According to the Mayo Clinic, below 90% is considered low and this is a dangerous condition with serious consequences if not treated promptly.) This resident was known to have [DIAGNOSES REDACTED] with an ejection fraction of only 25%, which basically means only about a quarter of [MEDICATION NAME] blood in the left ventricle of the heart is being pumped out to the body. The resident was a full code with no restrictions regarding hospitalization s according to his Maryland Order for Life Sustaining Treatment form. The emergency medical system was not activated, and an attempt to notify the resident's physician was not made until 45 minutes after the initial low oxygen level was noted. There was no response from the physician until the resident complained of chest tightness at 4:48 PM and the facility placed another call. At 4:50 PM, the physician returned the facility's phone call and gave an order to send him to the hospital. The emergency medical system (911) was not called until 5:15 PM on [DATE], 25 minutes after the order was given. The resident expired at the hospital later that evening of a possible [MEDICAL CONDITION]. It was determined that the facility failed to provide the appropriate care and services for a resident with compromised cardiac and respiratory status. As a result, a condition of Immediate Jeopardy to Quality of Care was declared at 10:15 AM on [DATE], and then abated at 1:45 PM with the submission of an acceptable plan of correction. 2) The facility staff failed to thoroughly assess a resident with a recent history of [MEDICAL CONDITION]. Resident #7 had a history of [REDACTED]. She had, previously, [DATE] to [DATE], been hospitalized for [REDACTED]. Review of the medical record revealed that since the resident returned from the hospital on [DATE], she had not had many issues documented on the night time shift. On [DATE] at 1:40 AM, the resident was medicated with a [MEDICATION NAME] (an antianxiety medication) by her request for feeling "nervous." Later that night at 2:34 AM the resident had audible wheezing and complained of SOB (Shortness of Breath). She had oxygen on at 1 liter/minute via nasal cannula with a oxygen saturation of 92%. The staff administered her a medicated nebulized breathing treatment which was not effective. Her physician was notified and ordered Intramuscular (by injection in to the muscle) [MEDICATION NAME] to be given which is a diuretic. It was administered at 2:50 AM, and by 3:24 AM, the resident had improved. According to the medical record, after the incident on [DATE], the resident was anxious about becoming SOB and was requesting her antianxiety medication nightly. On [DATE] at 5:15 AM, the resident again starts to complain of SOB and receives a medicated nebulized breathing treatment and the physician was notified, [MEDICATION NAME] is given one time by mouth and the resident responds well. The resident had no complaints during the nights of [DATE] and [DATE], according to the medical record. On [DATE], the resident complained, after going to the bathroom at 2:30 AM, felt flushed and something was wrong with her and she can not sleep. Her oxygen saturation was 93%. The nurse documented that she spoke with her and the resident had fear so she was administered a [MEDICATION NAME]. No lung sounds were checked or vital signs taken for this resident that stated something was wrong with her, and had had recent episodes of [MEDICAL CONDITION] compromise. At 4:25 AM, the resident complained of SOB and had audible wheezing. Her oxygen saturation level was 93% on 2 liters of oxygen and she was administered a medicated nebulized breathing treatment. No physician notification was made at this time even after the resident had experienced similar events on [DATE] and [DATE]. Then, at 4:38 AM, the resident requested [MEDICATION NAME] and was told by the nurse, according to the medical record, the wheezing had stopped, try and relax and let the medication work. Nine minutes later the resident was complaining she can not breathe and is "perspiring on face," wheezing in lungs and oxygen saturation 85%. The physician is notified and the resident was transferred to the hospital emergently. The facility staff failed to complete a thorough resident assessment for a resident with compromised respiratory status and failed to notify the physician of a change in the resident's condition.

Based on review of the medical record, administrative records, and staff interview, it was determined that the facility staff failed to adequately supervise and protect a resident from an accident with injury. This was evident for 1 of 9 residents reviewed during a complaint survey. The findings include: Resident #4 suffered from severe dementia and the effects of a cerebral vascular accident (stroke), and required extensive assistance from the nursing staff for all aspects of her care except eating. The resident had a history of [REDACTED]. Review of Resident #4's medical record and facility incident report revealed that the resident was left unattended on the toilet and subsequently fell to the floor from the toilet and was sent to the hospital. The fall resulted in a right hip fracture that required surgery. According to nursing documentation, the resident was a falls risk, and had a tab alarm on so that the staff could be alerted when the resident attempted to get up. Review of the MDS (Minimum Data Set) revealed that the resident was not steady and was only able to stabilize with staff assistance due to impairment on 1 side, both upper and lower extremities. Per the facility policy " no resident that has an alarm is to be left unattended in the bathroom." In conclusion, the facility staff left a resident unattended in the bathroom, which resulted in an injury requiring surgery.