Every finding on record at Collingswood Rehabilitation and Healthcare Center

Based record review and staff interviews, it was determined that the facility failed to ensure resident's representative were provided with written notice of transfer and bed hold policy. This was evident for 3 (Resident #55, #161, and #164) of 5 residents reviewed for hospitalization during the annual survey. The findings include: 1) A record review conducted on 07/28/26 at 2:14 PM found that Resident #55's original admission date was on 05/20/24. The resident's medical diagnoses include Cerebral Palsy, neurocognitive delay secondary to serine deficiency, functional paraplegia, resultant prolonged respiratory failure with tracheostomy and PEG placement, and cardiac arrests. Further review showed that on 6/28/26, Resident #55 was transferred to a nearby Medical Center ICU. Documentation notes revealed that the chief complaint originated from the Collingswood facility after nursing home staff found that the resident was being apneic. Emergency Medical Technicians transported the resident via stretcher, and the resident's representative was notified. Although the transfer form on 06/28/26, was located and signed, the required bed hold policy notice were missing from the record. And no documentation was received after a request was made on 07/28/26 at 1:21 PM. During an interview on 07/28/26, at 3:05 PM, the Administrator stated that facility staff had omitted the bed hold notice to Resident #55's representative upon transfer. The Administrator agreed that this was a deficiency in practice. 2) On 07/28/2026 at 11:35 AM, a review of Resident #161s medical records revealed the resident was hospitalized in January 2026 and again July 2026. Further review of the electronic medical records and paper medical records failed to show evidence the resident's representative was provided with the written bed hold notice and transfer notice for either hospitalization. During an interview with the Director of Nursing (DON) #2 on 07/30/2026 at 8:40 AM, she explained that when a resident is transferred to the hospital, the assigned nurse or unit manager notifies the resident's family or representative. She stated that the nurse, unit manager, or business office may discuss the bed hold policy with the resident's representative. The bed hold notice and transfer notice may be mailed to the representative or provided to the representative upon arrival at the facility. The DON #2 acknowledged that the facility did not have a consistent process for issuing bed hold and transfer notices. The surveyor requested documented evidence that Resident #161's representative received the bed hold and transfer notices for January 2026 and July 2026 hospital transfer. On 07/30/2026 at 11:55 AM, the Administrator #1 and Regional Nurse #17 acknowledged that the facility failed to complete the notice of transfer for Resident #161's hospitalization in January 2026 and July 2026. They also confirmed that the resident's representative was not provided with required written bed hold notice for either hospitalization. 3) On 07/30/2026 at 12:35 PM, an anonymous interview revealed Resident #164 was transferred to the hospital on 7/4/2026, but the Resident's representative was not provided a bed hold notice and was unable to go back to the same room they were in prior to the hospitalization. On 07/30/2026 at 12:53 PM, an interview with the Director of Nursing revealed when a resident (who was unable to make their own medical decisions) was transferred to the hospital, a bed hold notice would be provided to the Resident's representative. The surveyor requested documentation of the bed hold notice for the 7/4/2026 hospitalization. On 07/31/2026 at 8:37 AM, the Director of Nursing informed the surveyor they were unable to find documentation of the bed hold notice for the 7/4/2026 hospitalization. The surveyor reviewed the concern and she indicated that she understood.

Based on record review and staff interviews, it was determined that the facility staff failed to timely implement and revise nutritional interventions to address a resident's needs. This deficient practice was evident for 1 (Resident #112) of 6 residents reviewed for nutrition during the annual survey.The findings include:On 07/27/2026 a review of Complaint Intake #3039494 revealed allegations that Resident #112 had significant weight loss.On 07/28/2026, at 12:18 PM, a review of Resident #112's medical record revealed the resident was admitted to the facility in July 2025 with multiple diagnoses, including dementia. The resident's weight remained relatively stable at 139 pounds (lbs.) through March 2026 while consuming 75-100% of a controlled carbohydrate diet (CCHO) and 100% of a nutritional supplement twice daily.A review of the medical record revealed a dietary progress note dated 02/19/2026, indicating that Resident #112's family requested the resident's diet be changed to a diabetic, heart-healthy diet.The resident weighed 138.01lbs on 02/04/2026, and 128.02lbs on 05/04/2026, reflecting a greater than 7% weight loss over three months. On 06/10/2026, the resident weighed 122.05lbs reflecting an additional weight loss greater than 5% in one month.On 05/04/2026, the facility staff updated the resident's care plan to address unplanned weight loss related to inadequate food intake due to constant wandering. An intervention was added to include snacks as ordered. The medical record failed to show that an order for the additional snacks had been implemented.Further review of the records revealed a nutrition progress note dated 06/08/2026 indicating the resident's weight loss was significant, undesirable, and unplanned. The dietitian documented that the resident was ordered Mirtazapine on 06/04/2026 and recommended adding snacks three times daily to provide additional nutritional support and to prevent further weight loss. However, the medical record failed to show evidence that an order for the additional snacks was implemented.On 07/29/2026 at 10:12 AM, during an interview with the Administrator #1 and Regional Dietitian (RD) #8, the surveyor discussed the residents' continued weight loss from February through June 2026. The surveyor noted that although the resident's care plan was updated on 05/04/2026 to address unplanned weight loss, medication was not ordered until 06/04/2026, and the diet was not changed to a regular diet until 06/11/2026. The surveyor also questioned why the care plan directed staff to provide snacks as ordered when no snack order had been implemented.Neither the Administrator #1 nor the RD #8 could explain why an order for snacks three times daily, as recommended to address the residents weight loss had not been implemented.

Based on interview and record review, it was determined that the facility failed to ensure that staff informed a Resident's responsible party of a change in condition in a timely manner. This was evident for 1 (Resident #164) of 6 residents reviewed for notification of change.The findings include:On 07/31/2026 at 11:37 AM, an anonymous interview revealed that on 06/28/2026, Resident #164 was placed back on the ventilator (a machine that would breathe for someone who could not breathe on their own) after being able to breathe on their own for approximately two months.On 08/03/2026 at 8:20 AM, review of Resident #164's medical record revealed that the resident had been off of the ventilator for approximately two months.At the same time, further record review revealed a progress note dated 06/28/2026 at 8:17 AM that indicated the resident was placed back on the ventilator due to rapid breathing and a high heart rate. There was no evidence in the medical record that the Resident's representative was informed of the change of condition until they had arrived at the facility late morning. On 08/03/2026 at 8:27 AM, review of Resident #164's medical record revealed a progress note dated 06/28/2026 at 7:30 AM that indicated the resident was in severe respiratory distress (life-threatening medical emergency where the body is unable to get enough oxygen), andput on full ventilator support mode.On 08/03/2026 at 8:48 AM, an interview with the Director of Nursing revealed whenever there was a resident change of condition, it was the expectation of staff that the resident representative would be notified in a timely manner once the resident was in a stable condition. The surveyor reviewed the findings and she said she would look into it and follow-up with the surveyor. On 08/03/2026 at 10:47 AM, during a follow-up interview with the Director of Nursing, she indicated that either the assigned nurse or the respiratory therapist should have contacted the Resident's representative the morning of shortly after the resident was placed back onto the ventilator. The surveyor reviewed the concern.

Based on medical record review and interview, the facility staff failed to report an injury of unknown origin of a resident timely to the State of Maryland's OHCQ. This was evident for 2 (Resident # 2, #8) out of 4 resident records reviewed for alleged injuries of unknown origin during a complaint survey. The Finding include: 1) Review of facility reported incident #2682365 on 1/5/25 at 11:35 AM revealed Resident #8's family member sent an email to the Assistant Director of Nursing (ADON) on 11/18/25 reporting they noticed a contusion on Resident #8's right upper arm while visiting on 11/14/25. Upon investigation, the facility interviewed Staff #2, the Geriatric Nursing Assistant (GNA) who was assigned to care for Resident #8 on 11/14/25. Staff #2's written statement revealed Resident #8's family member reported to her that they noticed a skin issue on Resident #8 at approximately 2:30 PM on 11/14/15. She prepared to check the resident, but the family member indicated that the resident was asleep and asked Staff #2 to not disturb him/her. Staff #2 indicated that she did not check the resident and unintentionally forgot to report this to the nurse before leaving for the day. In an interview on 1/6/25 at 12:13 PM Staff #2 confirmed this information. She confirmed that she did not report the information to anyone. The facility did not report Resident #8's injury of unknown origin to the state facility until 11/18/25 when the family member emailed the ADON. This was 4 days after a potential injury was identified by the resident's family and reported to Staff #2. 2)On 12/8/25, the Office of Health Care Quality received a Facility Reported Incident (FRI) report (MD2687438) which reported the alleged injury of unknown origin of Resident #2. The FRI investigation stated that Resident #2 was observed on 12/5/25 with a bruise to the right thigh. The investigation was unable to discover how the resident received the bruise. Review of the FRI investigation on 1/6/26 at 8:15am revealed Resident # 2's right thigh injury was observed, reported and treated on 12/5/25 by nursing staff. When nursing staff reported the injury of unknown origin to Dementia Unit Manager #3 on 12/5/25, Dementia Unit Manager #3 failed to report Resident #2's injury to the Director of Nursing or Administrator. Administration didn't become aware of Resident #2's injury of unknown origin until 12/8/25 causing a late reporting of the injury to OHCQ. During the surveyor's interview with Dementia Unit Manager #3 on 1/6/26 at 1:32pm, he/she admitted failure to contact the Administrator or Director of Nursing regarding Resident #2's injury on 12/5/25 after nursing staff made them aware of the injury. When Dementia Unit Manager #3 reviewed nursing staff paperwork on Resident #2's injury on 12/8/25, he/she realized that the injury was considered an injury of unknown origin and reported the injury to the Director of Nursing. Interview with the Administrator on 1/6/26 at 1:45pm, the surveyor expressed concern that the Dementia Unit Manager #3 failed to report Resident #2's injury of unknown origin on 12/5/25. The Administrator confirmed that the facility reported Resident #2's injury of unknown origin late. The injury was reported to OHCQ on 12/8/25.

Based on record review and interview with staff it was determined the facility failed to ensure each resident's medical record was complete and accurately documented. This was evident for 1 (Resident #5) of 3 residents reviewed for Quality of Care during the complaint survey.The findings include: The facility's investigative documentation related to Facility Reported Incident #2677827 was reviewed on 1/6/26 at 1:05 PM. The documentation revealed Resident #5, who was his/her own decision maker, failed to inform staff and left the faciity on [DATE] at approximately 2:00 AM. Staff initiated proper protocol and later determined the resident had returned home safely. Further review of the documentation revealed Resident #5 was presented with a notice of non-coverage on 11/21/25 which indicated the resident's last date of insurance coverage (LCD) for his/her stay in the facility would be 11/22/25. The notice included the resident's right to appeal the discharge. The resident signed the notice. Review of the resident's medical record on 1/6/25 at 1:45 PM revealed a Social Services (SS) Progress note dated 11/21/25 1:24 PM by Staff #9 the Social Services Assistant. The note indicated she received the notice for LCD of 11/22/25 and the resident would discharge on [DATE]. Her documentation indicated that the resident was ready to go home and would go home on Saturday (11/22/25) instead of Sunday (11/23/25). The note included that SS would set up home health and the resident indicated s/he could go home in a taxi. An interview was conducted with Staff #9 on 1/7/25 at 10:47 AM. She was asked to explain how she was involved in Resident #5's discharge and what steps were taken to discharge him/her. She indicated that she provided the cut letter to Resident #5 and she called his/her family member who was involved in Resident #5's care. She indicated that she informed them of the discharge date . The family member indicated they wanted to appeal and wanted to talk to Resident #5 about it. She added that the family member thought Resident #5 needed more time before leaving the facility. Staff #9 indicated that she notified staff that there would be an appeal and Resident #5 would be staying and that she later told Resident #5 that his/her family member wanted him/her to stay and they would call him. Resident #5 indicated okay. She confirmed that she did not document the updated discharge plan information in Resident #5's medical record. Staff #5 the Regional Director of Operations and the facility Administrator were made aware of these concerns on 1/7/26 at 1:30 PM.

Based on review of facility reported incident investigations and interview it was determined the facility 1) failed to thoroughly investigate an allegation of abuse and 2) injuries of unknown source. This was evident for 1 (Resident #3) of 2 residents reviewed for abuse, and 1 (Resident #7) of 3 residents reviewed for injury of unknown source during the complaint survey. The findings include: 1) On 1/5/26 at 2:43 PM, an initial review of a facility reported incident, 2663799, alleged Resident #3 had been abused. The self-report documented on 11/7/25, around 1:15 PM, Resident #3 gave the Unit Manager (UM) a handwritten note that alleged s/he had been abused by staff during care on his/her 2nd day of admission. The resident did indicate what shift the alleged abuse occurred or identify any staff. Resident #3 was admitted to the facility on [DATE], indicating the alleged abuse occurred on 11/5/25, At that time, a brief review of the medical record revealed Resident #3 was admitted to the facility on [DATE] following an acute hospitalization. The resident was alert and oriented and had multiple diagnosis with complex medical needs. Review of the facility's investigation revealed a copy of a handwritten note from Resident #3 alleging that on the 2nd day of his/her admission to the facility, the resident was beaten up during bath time. No staff or shift was identified In the note. On 1/6/26 at 9:50 AM, a continued review of the facility's investigation documents found no documentation to indicate that after staff became aware of Resident #3's allegation of abuse, an interview had been conducted with Resident #3 about his/her allegations. In addition, no documentation was found to indicate the facility conducted interviews related to the allegations with residents who resided on the unit. Instead, a statement was obtained from the resident representative for Resident #10, Resident #11, and Resident #12. A brief review of the medical record revealed documentation that Resident #10, Resident #11 and Resident #12 were cognitively impaired and not interviewable. No documentation was found in the facility's investigation to indicate why residents were not interviewed during the facility's investigation of the allegation. On 1/6/25 at 3:50 PM, Assistant Director of Nurses (ADON) was made aware there was no evidence the resident was interviewed regarding his/her allegation of abuse, and no resident interviews were included in the facility's investigation. The ADON acknowledged the concerns and offered no further comments at that time. Review of staff interview statements obtained from staff who worked with Resident #3 on 11/5/25 revealed a statement from the nurse and GNA who worked the 7 AM to 3 PM shift, and the nurse and GNA who worked 3 PM to 11 PM shift. No documentation was found to indicate staff interviews were obtained from the nurse (Staff #13, RN) and the GNA (Staff #12) assigned to care for Resident #3 during the 11 PM to 7 AM shift on 11/5/25. In addition, no written statement was found from Staff #10, RN, UM, the nurse who received the handwritten note with the allegation of abuse from Resident #3. On 1/6/25, at approximately 4:00 PM, a typed document with the heading Incident statement regarding [Resident #3] was reviewed. The document stated when social services went to visit Resident #3 regarding an incident s/he reported to staff, the resident declined to talk about it and declined to write a statement. The statement was undated and was followed by an unclear signature. The statement did not identify the author of the statement, who from social services went to speak with the resident, or what incident the writer was referring to. On 1/6/25 at 4:32 PM, the NHA was made aware that no documentation in the facility's investigation and the resident's medical record to indicate Resident #3 was interviewed about his/her allegation of abuse and the concerns with failing to obtain staff and resident interviews was discussed with the NHA. The NHA acknowledged the concerns and stated that when the social worker, who is no longer at the facility, asked Resident #3 what happened, the resident didn't want to talk. 2) On 1/7/26 at 10:51 AM, a review of facility reported incident 2680766 alleged Resident #7 had a right wrist fracture that was an injury of unknown source. The facility's initial self-report documented that on 11/28/25, at approximately 2:30 PM, while the nurse and GNA were providing the resident incontinence care, Resident #7, displayed a facial grimace upon movement of his/her right arm. The physician was notified, and a stat x-ray of the resident's right wrist was ordered. On 11/28/25, an x-ray of Resident #7's right wrist revealed a suspected hairline fracture to right wrist. On 12/2/25, Resident #7 was sent to the hospital for an orthopedic evaluation where an X-ray of the resident's right wrist was completed and revealed there was no fracture. Review of Resident #7's medical record revealed the resident was admitted to the facility in mid-October 2025 with multiple diagnosis & complex medical needs. The record documented Resident #7 had severe cognitive impairment and ventilator (machine that helps you breath) dependent. Review of the facility's investigation documents revealed 3 employee statements related to the alleged injury of unknown source. There was a statement from Staff #14, RN, and Staff #15, GNA, the staff who were providing care to Resident #7 on 11/28/25 when the resident was observed with a facial grimace with right arm movement, and an interview from Staff #16, GNA who was not assigned to the resident, but assisted with the resident's care on 11/28/25. There was no other documentation found to indicate interviews were conducted with staff who had worked with the resident on any preceding shift or day. In addition, there was no documentation found to indicate that any residents had been interviewed in response to the allegation of an injury of unknown source. On 1/7/26 at 2:01 PM, the concerns with failing to interview staff and failing to interview residents when investigating an injury of unknow source was discussed with the NHA and the Regional Director of Operations. The NHA acknowledged the concerns and offered no further comments a that time.

Based on a tour of the kitchen, staff interview and observation, it was determined that the facility staff failed to label stored food items to ensure safety and prevent contamination which could lead to unsafe food and potential illness. This has the potential to affect all residents.The findings include:During the initial tour of the kitchen on 07/31/2025 at 0740 AM these items were found in the walk-in cooler: Box of blue berries box of 4 pks not labeled with received by date or used by date. Box of oranges with no received by dates. Biscolli cheese received by date of 5/29/2025 with no used by date. Found in the deep freezer: Box of chicken thighs - not labeled. 2 Logs of Sysco Fire River farm ground beef sitting on 2nd shelf and 1 log by itself on cart all without labels.The Dietary Aide (Staff #62) was interviewed on 7/31/2025 at 7:58 AM. The surveyor showed him/her the unlabeled items and the items without a used by date. He/ She stated that the unlabeled items should have had a received by date label, and the items that were opened should have had a used by date label. During a follow up tour of the kitchen on 07/31/2025 08:31 AM, the regional director of dining services, Staff # 63 accompanied surveyor and was made aware of the following items of concern:- a box of [NAME] tortilla not opened without a received by date label- single bag of hoagies not opened without a received by date label- Broccoli in a bag in refrigerator without any labels- bag of cube like sausages in the refrigerator not labeled- 3 lamb patties in a bag - no labels of receipt or use by date- 7 sticks of gold and sweet butter out of an original container - not labeled 08/05/2025 at 7:35 AM surveyor revisited kitchen and informed the food service director, staff #28 about the areas of concerns. Staff #28 stated that he would re-educate his staff on proper labeling of food items.

Based on resident and staff interviews, review of Resident Council Minutes/facility documents, and observation, it was determined that the facility failed to: address grievances from the Resident Council meeting, inform staff and residents of the Grievance Process (including how to file concerns or grievances), and have resolutions to grievances/concerns to include notifying residents regarding a resolution. This was evident for 5 of 6 months of Resident Council meetings reviewed the recertification/complaint survey. The findings include: On 08/06/2025 at 1:54 PM, a review of Resident Council Minutes from January 2025 through July 2025 revealed the following unaddressed concerns:-In January 2025, review of Resident Council minutes revealed a resident's concern regarding staff's unwillingness to provide restroom assistance. There was no evidence that this concern was addressed or that the resident was informed of a resolution.-In February 2025, persistent concerns regarding staff members not responding to a resident's call light and exhibiting impatience during toileting or transferring. There was no indication that the facility addressed these concerns or informed the resident of any resolution.-In April 2025, multiple concerns were unaddressed regarding several issues, including extended call light wait times during weekends and night shifts, the need for improved staff bedside manners, functionality of call lights, and difficulties obtaining necessary supplies or receipts from the facility.-In June 2025, the concerns included: - - Staff Conduct: Loudness during shift changes was a recurring complaint. - - Housekeeping & Environment: Concerns were raised regarding unchanged bedding, filthy shower areas, and housekeeping failing to sweep under residents' beds. Additionally, rooms were reported to have inconsistent air conditioning (either too hot or too cold), and a resident reported a clogged toilet. - - Resident Care & Activities: There were staffing shortages in Activities, leading to cancellations. Furthermore, residents and their family members felt compelled to assist with personal care, such as putting residents to bed or making beds due to concerns about staff timeliness and reliability.-In July 2025, the concerns included slow maintenance response times, extended call light wait times during night shifts, weekend understaffing, poor bedside manner, and non-functional air conditioning units in some rooms leading to high temperatures. Additionally, residents' clothing continued to go missing.A review of Resident Concern forms, provided to the Surveyor by the Facility Administrator on 08/07/2025 at 2:30 PM, revealed five forms from a second Resident Council meeting held in July. Four of the five forms lacked a resident identifier, one form stated it would be addressed at the next scheduled meeting, and for all five forms, there was no evidence that the resolution had been communicated to the resident.On 08/07/2025, at 11:00 AM, during a scheduled resident council meeting that the surveyor held with seven residents present, several concerns were raised regarding concerns not being addressed and a lack of awareness on how to obtain a concern/grievance form. Four of the residents reported that the following concerns had been expressed in previous resident council meetings but had never been addressed by the facility:-Resident #66: Reported call lights not being responded to for over an hour, concerns that have been voiced in previous Resident Council meetings have not been addressed. -Resident #31: Stated a black pant and shirt have been missing for two months with no resolution, and that broken glasses reported three weeks prior remain unfixed.-Resident #23: Reported that facility concerns are not addressed, night shift staff are loud, nothing is done to rectify this, and he has to take his own laundry down to laundry, with clothes often going missing.-Resident #13: Corroborated the issue of slow call light response by stating, Oh yeah we have that problem.During a facility tour and interview with Staff #46 on 08/07/2025, at 12:19 PM, it was observed that there were no visible postings of detailed information on how to file a Grievance or that provided the contact information for the Grievance officer. Staff #46 indicated that residents are instructed to request a Concern form from the nurse. Staff #46 stated that these forms are stored in a clear, upright document holder on a desk in the back office, behind the nurses' station. On 08/07/25, at 12:24 PM, during an interview, Staff #11 stated that if a resident had a concern, he/she would either write a concern form or give it to the resident to write. However, during the interview, Staff #11 had to ask Staff #44 where these forms were kept. During an interview with the Director of Nursing on 08/07/25 at 1:09 PM, the DON stated the facility's Administrator is the Grievance Officer and the Social Worker also serves as the Grievance Officer. During an Interview with the Facility's Social worker on 08/07/2025, at 1:29 PM, he/she stated that information regarding grievance forms are included in the admission packet.During an interview with the Facility's Administrator on 08/08/2025, at 10:26 AM, the Administrator stated the facility had completed a performance improvement plan in July of 2025 because they noticed no concern forms were being generated from the Resident Council meetings from January through July of 2025. She continued to state the Grievance Process as:1. Grievance Initiation:-Method 1: Grievance FormResidents inform a nurse, who notifies the Social Worker (SW). A grievance form is submitted to the relevant department with a 48-hour resolution goal. If unresolved, the Administrator intervenes. Forms are located at the front desk and nursing units.-Method 2: Compliance LineResidents/families can call the compliance line. Complaints are taken, and an email is sent to the Administrator.2. Resolution & Notification:Residents/families are notified of the resolution via phone. Compliance line resolutions are not formally logged.3. Resident Awareness:Residents learn how to file a grievance through the compliance line number, informing staff/Ambassadors(a staff member assigned to the resident who visits with the residents), or via family members.4. Staff Awareness:Staff know grievance forms are at the front desk and on units.On 08/08/2025, at 10:35 AM, a review of the Facility's admission packet revealed no written explanation of the Grievance Process for residents or families of the resident.On 08/08/2025, at 10:41 AM, the Surveyor's concerns were shared with the Administrator regarding unaddressed grievances from the Resident Council. Staff and residents are reportedly unaware of where to locate grievance forms or the Grievance process. Consequently, undocumented grievances are not addressed, nor is notification sent to residents regarding a resolution.

Based on medical record review and interview, it was determined that the facility staff failed to have an emergency dialysis access ports/shunts clamps in rooms as ordered for residents on dialysis. This was evident of 5 (Resident #66, #42, #103, #109, and #124) of 5 residents on dialysis rooms checked during the recertification/complaint survey. The findings include: A dialysis Arteriovenous (AV) fistula is a connection between an artery and a vein to make it possible to receive dialysis. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job. In the event there is continuous bleeding from the AV fistula, clamps can be applied to the puncture site to effectively control the bleeding. Review of Resident #66's medical record on 07/31/2025 at 10:43 AM revealed that resident received dialysis on Mondays, Wednesdays, and Fridays.Further record review on 08/04/2025 at 9:18 AM noted that resident had orders to monitor left arm AV fistula dialysis access site for signs/ symptoms of infection, drainage, bruising, and bleeding every shift, and as clinically indicated, and keep clamp at bedside at all times.On 8/4/2025 at 10:17 AM, the surveyor did not observe a clamp in the resident's room. The surveyor asked resident if he/she was aware of a clamp in his/her room for any bleeding emergency from her AV fistula. Resident stated that he/she did not see a clamp in the room. During an interview with Staff #13 on 8/4/2025 at 10:32 AM, she/he stated that an emergency clamp should be in the rooms of the resident's receiving dialysis. Staff #13 went to the medication room to locate a clamp and returned and stated that she/he could not find one.An interview was conducted with DON on 08/04/2025 at 12:13 PM. The DON stated that residents on dialysis is assessed before and after dialysis which includes obtaining vital signs, checking the AV site to ensure its functioning, and checking off the dialysis check sheet. Surveyor asked if an AV fistula emergency clamp should be in the room, the DON stated, yes, a clamp should be in the room. On 08/04/2025 at 11:31 AM, the surveyor checked the rooms of residents who were also receiving dialysis and had orders to keep clamp at bedside at all times.Resident # 42 -no clamp in roomResident# 103- no clamp in roomResident # 109- no clamp in roomResident # 124- no clamp in roomA follow up interview on 08/05/2025 at 7:34 was conducted with the DON who stated that the clamps were now placed in the rooms. Surveyor informed DON that this was a concern because the clamps were missing and were placed in the rooms after the surveyor's intervention. DON agreed with the concern.

Based on review of Employee files and interviews, it was determined the facility failed to have a process in place to ensure Geriatric Nursing Assistance (GNA) received at least 12-hours of In-Service training annually. This was evident for 3 (GNA #53, #54, and #55) out 5 reviewed for training. The findings include:On 08/08/2025 at 8:00 AM in review of GNA's training files revealed the following:1) In review of Employee # 53 Employee Training hours file, revealed Employee # 53 only received a total of 1.73 hours of training for the year of 2024.2) In review of Employee #54 Employee Training hours file, revealed Employee # 54 only received a total of 11.53 hours of training in a 2 year period for the years of 2023 and 2024.3) In review of Employee #55 Employee training hours file, revealed Employee #55 only received a total of 6.43 hours of training in a 2 year period for the years of 2022 and 2023. During an Interview with the Facility's Human Resource Director on 08/08/2025 at 8:46 AM, the Director stated that Employee's Annual 12 hour training for GNA's is completed through Relias upon hire and then annually.During an interview with the Facility's Staff Developer/Educator on 08/08/2025, at 10:00 AM, the Staff Developer stated that he/she runs weekly reports. If tasks are not completed, he/she will call staff to ensure completion. The expectation is that annual training will be completed before the end of the year, with a final check in November.On 08/08/25, at 12:22 PM, the Facility's Staff Developer/Educator confirmed that Staff Members #53, #54, and #55 had not completed the required 12-hour training. This issue was subsequently communicated to the Facility's Director of Nursing around 1:00 PM on the same day.

Based on observation of the soiled utility and laundry rooms, interviews staff, and documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. This was evidenced by 1) soiled linens and residents' outfits were not bagged in plastic bags in the laundry room, and 2) Precaution signage for residents who required care were not appropriately placed. This was evident in four of four laundry bins and two (Resident #36 and #71) of the 63 residents reviewed for precaution signage during the recertification/complaint survey.The findings included:Transmission-Based Precautions (TBP) is a set of infection control measures used in addition to standard precautions when patients are known or suspected of being infected with pathogens that can be transmitted through specific routes. These precautions are designed to prevent the spread of infection and are implemented based on the mode of transmission of the infectious agent.Enhanced Barrier Precautions (EBP) is an infection control strategy focused on preventing the spread of multidrug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes.EBP and TBP require the use of Personal Protective Equipment (PPE) such as gloves, gowns, masks, and/or eye shields, depending on the type of infection and risk of exposure, to prevent the spread of infections.1)During a tour of the facility laundry room on 8/05/25, at 12:21 PM with Staff #29 (Housekeeping Director), it was observed that four full bins contained used linens (3 bins) and residents' clothing (1 bin). However, they were not bagged. Staff #29 stated that they were currently overloaded, which is why all the bins were full. She also confirmed that all contaminated (used) linens or residents' clothing should be placed in plastic bags and tied before being transferred from each unit to the laundry room. Staff #29 confirmed that these items were not properly bagged and added, We have trained the nursing aides several times, but it still happens.During an interview with the Infection Preventionist (IP) on 8/05/25 at 2:41 PM, she confirmed that all contaminated linens and clothing should be bagged before transferring to the laundry room. The surveyor shared the observation; IP validated the concern.2) On 8/05/25, at 12:45 PM, the surveyor toured each unit to compare the precaution signage on residents' rooms with the list of EBP orders. During the tour, it was found that Resident #36 and Resident #71, who were on the EBP order list, did not have signage posted on their room doors.At 1:00 PM on 8/05/25, a medical record review of Resident #36 and Resident #71 revealed that Resident #36 had an EBP order for hemodialysis access, and Resident #71 had an EBP order for tracheostomy and gastrostomy.During an interview with the Director of Nursing (DON) on 8/05/25, at 2:38 PM, the DON stated that residents' precaution status should be posted by the Infection Preventionist (IP).In an interview with the IP on 8/05/25, at 2:41 PM, she stated that the contact precaution signage was posted by the unit manager.On 8/06/25, at 9:54 AM, the IP and Staff #33 (Regional Infection Preventionist) offered a different explanation for the missing signage: Resident #36's precaution signage had fallen off the door, and the unit staff was about to put it back. Since Resident #71 had just completed contact precautions due to loose stool, the facility staff was about to replace the EBP signage. The surveyor informed the IP and Staff #33 that the surveyor had been on the unit for more than 15 minutes, but no staff members were observed managing the residents' precaution signs. The IP and Staff #33 validated the concerns that the facility failed to appropriately manage residents' precaution signage.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure 1) a baseline care plan was completed and 2) a BLCP summary, including a current list of medications, was provided to the resident and/or resident representative (RP). This was evident for 3 (Resident #54, #160, #2) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. On 7/31/25 at 12:15 PM Resident #2's medical record revealed that he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP.On 7/31/25 at 1:16 PM review of Resident #54's medical record revealed that he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP.On 7/31/25 at 1:48PM review of Resident #160's medical record revealed that he/she was admitted to the facility on [DATE]. Further review of the medical record failed to reveal a BLCP.On 8/1/25 at 12:25 PM the Director of Social Services (DSS #1) and Regional Director of Social Work #2 were interviewed about BLCP's. DSS #1 stated when we have a new admission, we do our 48 hour meeting where everyone goes in and introduces themselves to the resident/family. During the interview she stated the BLCP is initiated by nursing, but when we have the Care Navigation Meeting and the corresponding Initial Guide, we print out their care plan and give it to them as their BLCP. When asked who gets a copy of the BLCP, DSS #1 stated the resident and family. DSS #1 was interviewed on 8/5/25 at 8:14 AM. During the interview when asked if the BLCP provided to the resident/RP includes a list of current medications and dietary instructions, she stated yes, we do give them a list of the orders including medications and goals. The surveyor requested a copy of the BLCP for Resident #160 and Resident #54 and evidence from the medical record that it was provided to the resident or RP. On 8/5/25 at 10:05 AM the surveyor requested to the DSS #1 a copy of the BLCP for Resident #2 and evidence from the medical record it was provided to the resident or RP. On 8/5/25 at 10:36 AM the DSS #1 stated that she did not have any of the above documentation the surveyor had requested.

Based on family interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure residents were free from accidents by failing to properly educate staff on how to operate a Hoyer lift, and by failing to maintain supervision of residents from the locked dementia unit. This was evident for 3 (Resident #4, #95, #20) of 7 residents reviewed for accidents during the facility's recertification survey.The findings include:The Health Care Decisions Act, which became effective [DATE], applies in all healthcare settings. In Maryland a patient is presumed to have capacity until two physicians certify that the individual lacks the capacity to make healthcare decisions or a court has appointed a guardian of person to make health care decisions. The form in the medical record titled, Physician's Certification of Incapacity to Make an Informed Decision, documents that a physician has examined a resident on a specific date and time and based on that examination finds the resident is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment related to his/her medical condition and is incapable of making an informed decision about the provision, withholding, or withdrawing of the following treatment because of a condition which is then listed on the form. 1) During the initial tour of the facility on [DATE] Resident #4 was determined to be non-interviewable and a review of the clinical record revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 which showed low level of cognitive functioning. As a result, Resident #4's family was interviewed on [DATE] at 12:53 PM. Resident #4's Mother stated that on [DATE] the resident wanted to go outside. The staff (one Geriatric Nursing Assistant (GNA) Staff #51 and a Respiratory Therapist (RT) (Staff #52) got the resident into a Hoyer lift sling that was too big for the resident. When the sling was lifted it caused the resident's chin to tuck into the chest. This blocked the airway. Mother said the resident was turning purple and she yelled for staff to lower the resident down. The GNA, Staff #51, could not or would not lower her. The RT who was at the air unit started to shout to lower the resident. The GNA, Staff #51, still did not lower her. The door was open and the nurse practitioner who was across the hall saw what was happening. She stood up and shouted to lower the resident. The nurse practitioner and another RT came into the room. They started to assist the GNA in getting the resident down. The Hoyer lift appeared to be stuck. They eventually got it to lower the resident, and when they did the resident no longer had a pulse. CPR was started and after 2-4 minutes the resident started to breathe again. The facility told the mother that they had ordered an appropriately sized sling. The facility had not been able to explain to the family what exactly happened, but they speculated it was the battery. The mother of Resident #4 was interviewed again on [DATE] at 1:30 pm. The surveyor asked if the large size sling has been used since [DATE]. She replied No, they ordered a new but smaller one. This surveyor asked to review the incident for clarification. The mother said that Staff #51 operated the lift by herself. GNA placed sling under the resident. Asked the mother of Resident #4 to go on other side of bed and help apply the four hooks. The mother did and was on that side of the bed when the GNA had the sling lift the resident up and out of the bed. Resident was now in the air and between the foot of the bed and the wall. RT was behind the wheelchair which was located at the resident's feet. Resident started to turn purple secondary to the sling bringing the resident's chin to chest. RT yelled for the GNA to lower the resident. The GNA could not so the RT told her to get the other RT. The GNA turned and left the room. Second RT and Nurse Practitioner entered room. They were able to get resident out of the sling and into the bed. CPR was started and about 20 seconds later, the resident started to breathe again. Mother repeated that Staff #51 operated the lift by herself, and mom has not seen her since [DATE]. The nurse practitioner (Staff #3) was interviewed on [DATE] at 8:43 AM. She was asked about the incident on [DATE]. She said she was sitting at her desk and saw that the resident was in the lift and agitated. The resident shimmied down the sling and had some issues. Staff had some problem with getting the lift down, but she was not sure what exactly was wrong. We got her disconnected. We had to bag her because she was in respiratory distress. There were two Respiratory Therapists and a Geriatric Nursing Assistant (GNA) in the room. Mom was at the bedside and the GNA was operating the lift. The GNA did not leave the room and stayed with the resident. One RT managed the [NAME] bag (Artificial Manual Breathing Unit). She said she could not feel a pulse, so she began chest compressions and the resident quickly recovered. They tried to reconnect the resident to the vent but could not. This surveyor asked if the sling was the appropriate size. Staff #3 said she was not sure if the sling was the appropriate size. She stated that the resident was at a pretty good angle, 45 degrees. She added that the resident's arms and legs were underdeveloped, so she was not sure if that had anything to do with it. Staff #3 said she could see the resident from the hall waving their arms and legs. The Respiratory Therapist Director (Staff #15) was interviewed on [DATE] at 12:19 PM. When asked about the incident, she said the family wanted to put the resident in a geri-chair to go to the living room for activities. Staff needed a Hoyer lift and while the resident was in the air, the resident's trach (tracheotomy opening) became blocked. The resident comes off of the ventilator during the day. The resident was being transferred from the bed to the wheelchair and was off of the vent. Resident became cyanotic (bluish or purplish discoloration to skin) while in the lift. Resident got CPR and was put back on the vent. 911 was called but did not take the resident to the hospital. RT did not directly help with the lift but that was not their job. Their main job was to make sure the airway was patent. This surveyor interviewed Staff #27 on [DATE] at 11:30 AM. She said a private company oversees the Hoyer lifts. She does not remember the Hoyer lift on the first floor having an issue, but it was most likely a rundown battery. This surveyor interviewed the Director of Nursing (DON) on [DATE] at 5:12 PM. This surveyor reviewed the incident with her. She acknowledged the review and the findings. She said she understood that the Hoyer lift did not lower. DON stated she would like this surveyor to review their investigation into the incident. The DON provided the investigation binder on [DATE] at 10:00 AM. This surveyor reviewed the investigation binder at 10:15AM. Review of the investigation binder revealed: Resident #4's mother told the facility staff that she wanted the resident to attend activities in the common area. She assisted the GNA in getting the resident up. Mom assisted with hooking the resident up. The RT (Staff #52) was holding the wheelchair. The GNA then lifted the resident up. Mom noticed the resident was agitated, curled in the sling and their face started to change in color. She shouted to put the resident down. The GNA (Staff #51) pressed the button, but it would not go down. RT told the GNA to get help. Staff #3 then entered the room. Staff #51 stated on [DATE] that the mom kept asking for the resident to be taken out of the room. Staff #51 was hesitant because she had never used the Hoyer lift before. Once she saw the resident change color, she tried to lower resident but was not sure she was pressing the right button. She said she tried to lower the sling bag down to the bed, but it would not lower. She said she does not recall if she was pressing the right button because she was so upset. She says at that point another RT and the Nurse Practitioner came into the room and raised the bed to meet the resident. They started to work on [the resident] so she stepped out of the way while this was happening. Staff #52 said in her statement that when she entered the room the resident was already in the Hoyer lift. She placed the venturi mask (type of mask used to deliver precise amount of oxygen to the resident) on the patient at 40% FIO2 (fraction of inspired oxygen/concentration of oxygen) from oxygen support. During the transfer she noticed the resident had become cyanotic. Staff #52 said she immediately instructed the GNA to return the resident to the bed and get a second RT into the room. Once in bed the resident was noted to be unresponsive and without a pulse. Staff #3 was called into the room, and she initiated chest compressions. At the same time, Staff #52 said she began to bag the resident. EMS was called. Before they arrived, the resident regained consciousness. Staff #3 determined that the resident did not need hospitalization. The facility administration responded to the incident by ensuring staff members were educated on several topics including: family cannot help with a Hoyer lift, staff need to know what button does what and to check the battery before use. The resident was assessed and there were no negative outcomes from the incident. 2) On [DATE] at 7:48AM Resident #95 was observed by the surveyor and Assistant Director of Nursing (ADON) off the unit, unattended with no staff member nearby, sitting in his/her wheelchair by the elevator. The surveyor recognized him/her as a resident from the locked dementia unit. The surveyor observed the Assistant Director of Nursing's (ADON) face, and it appeared she did not seem to recognize this. The ADON asked Resident #95 where he/she was going, and the resident stated up. The ADON stated there was not an up [as the 2nd floor was the highest floor in the building]. Shortly after, the ADON again asked Resident #95 where he/she was going and again the resident stated up. The elevator doors opened, and the resident started to say he/she was going to dialysis. The surveyor then asked the ADON if residents from 2 [NAME] should be unattended and going to dialysis independently. The ADON stated that no, residents from 2 [NAME] do not go to dialysis unattended. She told Resident #95 that she was going to take him/her back to the unit and speak to the nurse. On [DATE] at 7:52 AM the ADON (and surveyor) approached Licensed Practical Nurse (LPN #49) and she inquired about Resident #95. LPN #49 stated the lady came from dialysis to take him/her. The surveyor asked who she was, and LPN #49 stated she would go get her. While waiting for the nurse and transporter to arrive, the surveyor asked the ADON if it was the expectation that dialysis staff or any staff should leave a resident from 2 West, the locked dementia unit, unattended and the ADON stated no and that she did get him/her [Resident #95] back. The surveyor shared the concern that occurred after surveyor intervention. On [DATE] at 7:55 AM Dialysis Transporter #48 came through the double doors onto the unit [2 West] and down the hallway to the nursing station where the ADON and surveyor were standing. When asked if she left Resident #95 unattended in the hallway off the unit by the elevator Dialysis Transporter #48 stated, Yes, I came past you two, went straight down [and off the unit] and went to pick up Resident #36. These are my last two to transport down [to dialysis] and if I can kill two birds with one stone then that's what I'll do. That's what I normally do. After Resident #95 and Dialysis Transporter #48 left for dialysis, the ADON stated, I did not recognize her. The surveyor asked who her was and the ADON stated Resident #95. The surveyor shared they did, which is why they asked the ADON about Resident #95 being off the unit and by the elevator alone. The ADON verbalized understanding. The surveyor asked the ADON to pull Resident #95's paper chart and during a dual observation with the ADON, the surveyor flipped to two certificates of incapacity with the following dates and times: [DATE] at 12:30 PM and [DATE] at 3:00 PM. When asked if it was safe for a resident diagnosed with dementia and two certificates of incapacity to be off the locked unit and unattended the ADON stated no. On [DATE] at 8:46 AM review of Resident #95's medical record revealed a care plan, I have impaired cognitive function and/or impaired thought processes r/t dementia, disease process. Date Initiated: [DATE] 3) On [DATE] at 8:04 AM while the surveyor and ADON are standing at the nurse's station on 2 West, Resident #20 walked over, reached over the nurse's desk, and opened a drawer. He/she then started moving objects around while looking inside the drawer. The ADON did not seem phased, nor did she intervene in any manner. The resident stated he/she was looking for the remote. At this point, the ADON walked from around the front of the nurse's station to behind the nurse's station and handed him/her a remote. He/she explained that one was not to the right TV. The ADON found and handed him/her another remote. As the resident was walking away, the surveyor asked the ADON who that resident was, and she identified him as Resident #20. When asked if residents should be reaching over the nurse's station desk, opening drawers, and rummaging through them, the AODN stated, No, it is not the expectation, but he/she did ask afterward. She then stated we usually have. and dragged the paper shredder box over to the opening at the desk, blocking entrance to the nurse's station. In a dual observation with the ADON, she opened the drawer that the resident had opened, and it had several packs of batteries, a lanyard, and plastic cutlery. The surveyor stated yesterday when we spoke, you had stated that hand sanitizer is not on the unit because it could be a safety risk if ingested. Could batteries, if ingested, a lanyard or plastic cutlery be a safety risk to a resident? The ADON stated, they could be while simultaneously opening the drawer and moving the contents into the adjoining room off the nurse's station. On [DATE] at 8:07 AM in a dual observation with the ADON it was observed that Resident #20 had two certificates of incapacity r/t psychosis and cognitive impairment. The surveyor asked if someone who had cognitive impairment and psychosis on a locked unit should have access to a drawer with batteries, a lanyard, and plastic cutlery and she stated no as she removed all items from the drawer.

Based on medical record review and staff interviews it was determined the facility failed to implement wound consults timely which resulted in residents not receiving wound care treatments. This was evident for 2 (Resident #63 and #127) of 7 residents reviewed for pressure ulcer/injury during the recertification/complaint survey. The findings include:1) On 08/01/2025, at 8:44 AM, a review of Resident #63's medical record revealed a wound progress note from 02/11/2025, at 5:43 PM. This note, signed by a wound Nurse Practitioner, documented a Stage 4 sacral wound. Recommended treatments included daily (and as needed) cleansing of the wound with wound cleanser, application of Dakins moistened fluffed gauze, and Zinc Oxide Paste to the periwound to the base of the wound, secured with bordered foam and an ABD pad.Continued review of Resident #63's Treatment Administration Record (TAR) revealed a physician's order for sacral wound care. The order, effective from 7:00 AM on 02/07/2025 to 7:08 AM on 02/13/2025, prescribed daily cleansing with normal saline, application of Medihoney, and covering with gauze secured by a border gauze dressing during the day shift. The record was blank, with no treatment administered, on 02/13/2025.Upon further review, Resident #63's TAR showed a physician order start date of 02/14/2025, at 7:00 AM. This was three days after the wound Nurse Practitioner's recommendation to cleanse the wound with wound cleanser, apply Dakins moistened fluffed gauze, Zinc Oxide Paste to the periwound and base of the wound, and secure with bordered foam and an ABD pad, with daily and as-needed changes. An X on the date of 02/13/2025 indicated that this treatment was also not administered on that day. Therefore, the TAR reflected that the resident did not receive any wound care on 02/13/2025. 2) On 08/01/2025 at 9:45 AM, Resident #127's medical record was reviewed. A wound progress note, dated 06/24/2025 and signed by the wound Nurse Practitioner, indicated that the resident had a reopened wound on their left heel. The recommended treatment included daily cleansing with wound cleanser, application of Calcium alginate to the wound base, and securing it with bordered foam, with changes as needed.Continued review of Resident #127's Treatment Administration Record (TAR) showed a physician's order for left heel apply skin prep, abdominal pad, Kerlex every day and evening shift with a start date of 06/21/2025, at 3:00 PM, and a discontinuation date of 06/25/2025, at 1:05 PM. This order was left blank on the day shift of 06/25/2025 and marked with an X on the evening shift.Further review of Resident #127's Treatment Administration Record (TAR) showed that a physician's order for wound care on the left heel, including cleansing with wound cleanser, pat dry, application of calcium alginate, and securing with bordered foam daily and as needed, had a start date of 06/26/2025 at 7:00 AM. This was two days after the wound recommendations were made. Additionally, an X on 06/25/2025 indicated that the resident did not receive wound treatment on that day. Therefore, the TAR reflected that the resident did not receive any wound care on 06/25/2025.During an interview with the Director of Nursing (DON) on 08/05/2025, at 10:39 AM, the DON explained the wound care recommendation process. The Wound Nurse Practitioner discusses recommended wound treatments with the Unit Manager and/or charge nurse, and these recommendations are then sent to the Primary Care Physician for approval. The DON stated that this process is expected to be completed on the same day a treatment recommendation is received. Concerns were validated with the DON regarding delays in residents' wound care recommendations, which resulted in missed wound treatments.

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to notify the resident's physician and/or responsible party (RP) following an accident/change in condition. This was evident for 1 of 3 residents (Resident #160) reviewed for urinary catheters during the facility's recertification survey. The findings include:An indwelling urinary catheter, often referred to as a Foley catheter, is a flexible tube inserted into a patient's urethra (the tube that carries urine from the bladder to the outside of the body) and remains in place to collect the urine into a drainage bag. Urinary catheters can be ordered for several reasons such as urinary incontinence (leaking urine or unable to control when you urinate), urinary retention (being unable to empty your bladder), during and/or after a surgery, or related to other medical conditions such as a spinal cord injury. However, urinary catheters are associated with an increased risk of urinary tract infections (UTI) as well as other adverse events and should be used only when clinically indicated and ordered by a physician.In an interview with Resident #160's RP on 7/31/25 at 2:04 PM, they stated when they came yesterday Resident #160 was feeling bad. During the interview they stated, yesterday something happened, right now he/she is not going to the bathroom on his/her own. He/she has a Foley catheter, and we do not know what happened, maybe he/she disconnected the catheter, but it got disconnected. On 7/31/25 at 1:48PM record review revealed Resident #160 was admitted [DATE] with a Foley catheter and diagnoses including, but not limited to, obstructive and reflux uropathy, neuromuscular, dysfunction of bladder, other specified disorders of bladder, cognitive communication deficit, and unspecified dementia. Further review of the medical record revealed the following care plan: Focus: I have an indwelling urinary catheter r/t urinary retention. Date Initiated: 07/26/2025. Goal: I will be free from catheter related trauma and infections through the review date. Date Initiated: 07/26/2025. Interventions/Tasks: Monitor/record/report pain/discomfort due to urinary catheter. Date Initiated: 07/27/2025. Monitor for signs and symptoms of UTI, such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report abnormal findings to Practitioner, Document findings and interventions. Date Initiated: 07/26/2025On 8/4/25 at 4:01 PM in an interview with Licensed Practical Nurse (LPN #17) when asked about the incident with Resident #160 and his/her Foley catheter, she stated she emptied his/her Foley catheter around 6:00 AM. During the interview she stated she went to change the other bed [resident] in Resident #160's room at almost 7:00 AM and saw Resident #160's Foley catheter on the floor. When asked if she notified anyone, she stated she let the morning nurse, LPN # 4, know that the patient had pulled out the Foley, that he/she had voided, and that she had documented the amount [of urine]. When asked if she notified any providers, she stated no because she told LPN #4 about it so he would reinsert it. When asked if she notified the resident's RP she stated, I did not tell anyone I just handed over to LPN # 4 and gave report for him to follow up. Resident #160's medical record was reviewed on 8/1/25 at 9:52 AM. The review revealed a progress note from 7/29/25 6:02 AM that documented, Resident is post admission remains in bed sleeping foley intact and draining well amount 500ml (milliliters) amber urine obtained no complaint voiced out. However, the review failed to show that a provider was notified by LPN #17 after Resident #160's Foley came out.On 8/5/25 at 7:34 AM the Director of Nursing (DON) was interviewed. During the interview when asked what the expectations were if during their shift a nurse found a foley on the floor and no longer inserted into a resident, she stated notify the provider and family member to let them know it came out and what we are going to do. The facility's policy entitled Indwelling (Foley) Catheter Insertion, Male Resident was reviewed on 8/5/25 at 8:41 AM. The review revealed the following statement: Notify the physician of any abnormalities (i.e. pain, bleeding, obstruction, etc.).

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to provide appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for 1 of 2 residents (Resident #160) reviewed for urinary catheters during the facility's recertification survey. The findings include:An indwelling urinary catheter, often referred to as a Foley catheter, is a flexible tube inserted into a patient's urethra (the tube carries urine away from the bladder to outside the body) and remains in place to collect the urine into a drainage bag. Urinary catheters are associated with an increased risk of urinary tract infections as well as other adverse events and should be used only when clinically indicated and ordered by a physician. Urine output is an important clinical indicator and can provide insight into a patient's status and guide their care. Normal urine output is approximately 0.5 to 1.0 mL/kg/h (milliliters/kilogram/hour). Therefore, an average, healthy male with a body weight of 70 kg (154 pounds) should produce around 35-70 mL of urine per hour or 840-1,1680 mL per 24 hours. Anuria is the absence of urine production, or less than 50 mL of urine output in a 24 hour period. It is a serious condition that requires prompt medical attention. A lack of urinary output even when a resident has a catheter could be caused by several different problems. However, troubleshooting by replacing the catheter should only be performed under the guidance of a physician.A voiding trial with a Foley catheter involves assessing a patient's ability to urinate after the catheter has been removed. The trial can be either active, where the bladder is filled with fluid before removal of the Foley, or passive, where the bladder is allowed to fill naturally after removal. The purpose is to determine if the bladder is functioning normally and if the catheter can be safely discontinued. On 7/31/25 at 1:48 PM review of the medical record revealed Resident #160 was admitted on [DATE] with a Foley catheter and diagnoses including, but not limited to, obstructive and reflux uropathy (a blockage that prevents urine from flowing freely through the urinary tract and the backward flow of urine), neuromuscular, dysfunction of the bladder, cognitive communication deficit, and unspecified dementia. Further review of the medical record revealed he/she weighed 154 pounds on admission and had the following care plan: I have an indwelling urinary catheter r/t [related to] urinary retention (the inability to completely empty your bladder). I will be free from catheter related trauma and infections through the review date. Monitor/record/report pain/discomfort due to urinary catheter. Monitor for signs and symptoms of UTI, such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report abnormal findings to Practitioner, document findings and interventions. In an interview with Resident #160's responsible party (RP) on 7/31/25 at 2:04 PM, they stated when they came [to visit Resident #160] yesterday, Resident #160 was feeling bad. During the interview they stated, Yesterday something happened, right now Resident #160 is not going to the bathroom on his/her own. He/she has a Foley catheter, and we do not know what happened, maybe he/she disconnected the catheter, we do not know, but somehow it got disconnected. They [nursing] reconnected it and then waited about 6 hours to see if he/she would void. They also stated in the interview that they [facility staff] had inserted the catheter, and it was wrong because the urine was not coming out. It was almost an emergency and Resident #160 almost had to go to the hospital. The RP shared that they were saying to the staff that Resident #160 needed to go [to the hospital], but they [facility staff] said wait, let's see. So, an emergency nurse [Nurse Practitioner (NP#3)] came from another floor. She noticed the catheter was not in properly, inserted the catheter further, and then the urine came out, and it was like 2 gallons. The RP stated Resident #160 does not complain, and the only time he/she has been in pain since being here [facility] was when he/she was having the issue with his/her catheter. On 8/1/25 at 9:17 AM review of the medical record revealed a SBAR (situation, background, assessment and recommendation) Communication Form written by LPN #4, the day shift [7-AM-3PM] nurse, dated 7/29/25 at 10:35 AM that documented, The resident's [#160] Foley catheter was found detached in bed and the resident is not able to explain how it came off. This writer and the night nurse could not find a Foley catheter size 14 fr [French, the size (diameter) of the tubing] which was there on admission and instead inserted size 16fr which did not work. Further review of the SBAR Communication Form revealed NP #41 ordered a voiding trial for one day and further stated that if the resident did not void in the next 8 hours, to reinsert a 14 fr catheter. According to the SBAR, NP [#41] stated that he would come tomorrow to check on the patient. Continued review of the medical record revealed LPN #4 documented NA on his shift for the order, Measure urinary output every shift document output in 'mls' (milliliters).In an interview with the Director of Nursing (DON) on 8/8/25 at 1:44 PM, she stated an order from a physician is required for Foley catheters; however, review of the orders failed to reveal an order for a 16 fr Foley catheter and no evidence could be found that the physician ordered a 16 fr Foley catheter for Resident #160, which is a larger sized catheter. Continued review of the medical record revealed that the next progress note regarding this incident was not until 7/29/2025 at 10:48 PM. The progress note was written by the evening (3PM-11PM) nurse, LPN #16, and stated, Resident is alert and verbally responsive. He/she refused twice in order to have the foley catheter replaced. He/she later accepted the foley to be replaced. Foley intact, no drainage noted at this time. There was no documentation of the first two insertion attempts by LPN #16. The facility's policy, Charting and Documentation was reviewed on 8/5/25 at 8:59 AM and revealed, The following information is to be documented in the resident's medical record: a) objective observations; b) medications administered; c) treatments or services performed; d) changes in the resident's condition; e) events, incidents or accidents involving the resident; and f) progress toward or changes in the care plan goals and objectives. Further review revealed, Documentation of procedures and treatments will include care-specific details, including: a) the date and time of the procedure/treatment was provided; b) the name and title of the individual(s) who provided care; c) the assessment date and/or any unusual findings obtained during the procedure/treatment; d) how the resident tolerated the procedure/treatment; e) whether the resident refused the procedure/treatment; f) notification of family, physician or other staff, if indicated; and g) the signature and title of the individual documenting.In addition, the policy stated, Documentation in the medical record will be objective, complete and accurate.'The night nurse, LPN #17, was interviewed on 8/4/25 at 4:01 PM. During the interview when asked about the incident with Resident #160 and his/her Foley catheter, she stated she emptied his/her Foley catheter around 6:00 AM. During the interview she stated that she went to change the other resident in Resident #160's room a little before 7:00 AM and saw Resident #160's Foley catheter on the floor. She stated that during report she let the oncoming day shift nurse [7PM-3PM], LPN #4, know the patient had pulled out the foley, that he/she had voided, and that she had documented the amount. When asked if she notified anyone, she stated she let the day nurse, LPN # 4, know that the patient had pulled out the Foley, that he/she had voided, and that she had documented the amount [of urine]. When asked if she notified any providers, she stated no because she told LPN #4 about it so he would reinsert it. When asked if she notified the resident's RP she stated, I did not tell anyone I just handed over to LPN # 4 and gave report for him to follow up. When asked if she tried to reinsert the Foley catheter, she stated, No, because it was 7AM. There was no documentation in the medical record from LPN #17 such as this event, incident, or accident involving the resident or progress towards or changes in the care plan goals and objectives as outlined in the facility's policy. On 8/4/25 at 9:06 AM in an interview with LPN #4 (the day shift nurse on 7/29), he stated the night shift nurse, LPN #17, found the Foley had come out. He contacted NP # 41 who said wait 8 hours to have a voiding trial and if Resident #160 does not void, we need to reinsert the Foley catheter. When asked if he inserted a Foley on his shift, LPN #4 stated no. He said he gave report to the evening [3PM-11PM] nurse, LPN #16, and that LPN #16 was the nurse that was able to insert the Foley. In a second interview with LPN #4 on 8/4/25 at 9:31 AM, he came back to the surveyor and stated, Let me do some clarification. During the second interview, he stated he came in for his 7AM- 3PM shift [on 7/29] and received report from LPN # 17 that she had found the Foley off Resident #160 and could not put it back and asked him to insert one. Additionally, LPN #4 stated that between 8 and 9 AM he went to reinsert the Foley and placed it but could not see any urine coming and so he notified NP #41 over the phone. He stated, Before I left the room to call NP #41, the catheter was outside of the resident because I could not fully put it in. The surveyor shared the concern that earlier this morning when asked if he inserted a catheter on this resident during his shift, he had said no. LPN #4 stated, That is because I got confused. When asked if he documented any urine output for this resident during his shift, he stated no. LPN #4 stated that LPN #16 inserted a Foley on 7/29 at 4PM but he was not present for that; however, when he returned to work on 7/30 for his day shift [7AM- 3PM], LPN #17 said Resident #160 was still not voiding properly. LPN #4 also stated that and at that point he could see abdominal distension [on Resident #160] and you could see he/she was in pain and was not feeling good, so he called NP #41 who told him to send the resident to the ER.He then said that we [facility] have a policy that we tell a supervisor before a resident goes out, so he told Staff Developer/Educator #60 and she informed the in house NP who came around 8 or 9 AM and did a bladder scan. He stated the in house NP saw there was greater than 999 mL, he had gotten a Foley, that she played with the Foley and also irrigated it, and then the urine started flowing. LPN #4 stated that the catheter the in house NP removed was the catheter that LPN #16 had inserted on 7/29 at 4PM. On 8/4/25 at 11:06 AM in an interview with NP #41 when asked if he was familiar with Resident #160, he stated, The newer resident? I know there was an incident where he/she pulled out his/her Foley. During the interview, he stated one of the nurses contacted me that the resident had pulled his/her Foley out. He said it was a male nurse named [LPN #4]. NP #41 stated he was only contacted once by LPN #4. When asked if he documented when he spoke to LPN #4, he stated if they are calling him on the phone, sometimes he does not document it because he gets a lot of calls from staff, so he does not always document every time he talks to them. When asked what time he spoke with LPN #4 he stated, Honestly, I'm not sure when I had the phone conversation with LPN #4. When asked if he ever ordered a voiding trial for Resident #160, he stated, We talked about ordering a voiding trial because his/her discharge orders said they tried but we already knew he/she had retention and they had tried multiple times at the hospital and failed, so they wanted him to see a nephrologist. So, the short answer is no.On 8/4/25 at 3:29 PM in an interview with LPN #16 he stated when he came to work on 7/29/25 for his evening shift, LPN #4 indicated that the foley was out. He had a foley on the desk and asked him if he could replace it. During the interview he stated he did not know the details of when it came out and that his evening shift Monday everything was fine with the foley. When asked if during report he asked LPN #4 if the resident had any urine output for the shift, he LPN #16 stated no. He stated he went and tried to replace the foley around 3:45/4:00 PM and Resident #160 said, I'm fine, I'm fine and was sitting on his/her bed. When asked if he documented that, LPN #16 stated, No, I did document that. I did not think it was a medical emergency. The second time I tried to replace the foley was after dinner around 6:00/7:00 PM and he/she refused again and was getting more agitated. When asked if he documented that, LPN #16 stated, I did not document it individually, I just summarized when the foley was inserted. When I went back the third time he/she was lying in bed and told Resident #160 he was here to insert a foley and he/she did not resist and let me. When asked what time he was able to insert the Foley, LPN #16 stated, I know it was definitely after 7:00 PM that I inserted it. When asked if he used any form of communication to contact any providers at any point of his shift he stated, No, I did not. To my understanding, it was not an immediate concern that the resident had not voided. When asked if he would consider a resident not voiding for an entire 8.5 hour shift a medical emergency he stated yes. When asked if it would be important information to know if the resident had voided at all during his previous shift, he stated, Yes, I would want to know if the resident had voided at all as the oncoming nurse. When asked if he asked the off going nurse, LPN #4, if Resident #160 had voided on his [7AM-3PM] shift he stated no. When asked if he had asked LPN #4 if the resident had voided and he was told he/she had not, would you have taken different steps and he said, Yes, LPN #4 had told me the resident had not voided I would have assessed him. I did assess him/her, and he/she did not have any discomfort, and his/her abdomen was not distended, but I should have inserted the Foley earlier. On 8/4/25 at 8:42 AM in an interview with NP #3 he stated she went in to see Resident #160 once last week for an issue with his/her Foley catheter. During the interview she stated she was asked to come to the resident's room by nursing. She stated she believed he/she had recently been hospitalized for retention issues, so he/she had this catheter with a leg bag. When she walked in, LPN #4 was trying to insert a new catheter. He had inserted a new catheter and said it was not flowing back so she just manipulated it, advanced it a little, and urine came out. She stated the patient definitely had retention, we did a bladder scan, and his/her abdomen was firm. But after the catheter was placed, he/she had immediate resolution of the abdominal distension and retention. She stated Staff Developer/Educator #60 and her both responded to the request for assistance, and we brought the bladder scanner with us. LPN #4 had inserted it and was securing the balloon. She stated she did the bladder scan and said it was greater than 999 mL and that she thought we got like 2 liters out or something. She readvanced the Foley catheter and twisted it around to make sure it was not lying on the bladder wall and got an immediate free flow of urine. The resident was saying he/she was not feeling good. He/she has dementia so there is a limit on how much he/she can communicate but his blood pressure was elevated. His/her spouse was present at the bedside. He/she was very concerned about him/her asking if we needed to send him/her back to the hospital because the urine was retained. He/she stated he/she agreed he/she was retaining urine and asked if I could try to relieve the urine and he/she allowed me to do so. After the free flow of urine, he/she no longer complained and his/her blood pressure reduced to his/her baseline and his/her abdomen was soft.

Based on medical record review and interviews the facility failed to provide services to maintain hearing. This was evident for 1 of 2 (Resident #3) reviewed for communication difficulty and/or sensory problems (vision and/or hearing) during the recertification/complaint survey.The findings include: On 07/31/2025, at 11:12 AM, Resident #3 was interviewed and stated that he/she had lost their hearing. Resident #3 reported requesting to see an ENT (Ear, Nose, and Throat) a month prior, but the nurse informed him/her that their insurance would not cover the visit.08/06/2025 at 8:15 AM, a review of Resident #3's medical record revealed no indication of an appointment for an ENT examination, nor any care plan addressing hearing difficulties.Further review of Resident #3's medical record progress notes revealed the following:-According to the Nurse Practitioner progress note dated on 06/30/2025, at 10:05 PM, the Nurse Practitioner assessed the resident, who reported left ear complaints and admitted to a hearing change, describing the ear as stuffy. Dark brown, dry, impacted earwax was noted in the left ear.-According to a nurse's progress note dated on 07/2/2025 at 15:37, Debrox Solution 6.5 % Instill 5 drops in left ear two times a day for earwax buildup of Left ear for 4 Days, be delivered by pharmacy. -According to a nurse's progress note dated on 7/2/2025 at 16:15, Physician was notified that Debrox was not available and said to administer when available and to reschedule for the total of 4 days therapy. Patient self RP was made aware. -According to a Physician Progress note on 07/16/2025 at 3:06 PM eardrops have not relieved blockage yet-plan to continue current medications.-On 07/17/2025 a Physician order for Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drops in both ears two times a day for earwax buildup for 4 Days.During an interview on 08/06/2025 at 1:21 PM with the DON regarding a resident's request for an ENT consultation, it was confirmed that such an appointment would be external, requiring a physician's order and scheduling by the Unit Clerk. The DON expected follow up for the resident regarding ear wax buildup and hearing loss. It was also verified that the resident had no follow-up or scheduled ENT appointment, despite their request. On 08/07/2025 at 8:57 AM, the DON stated that the resident now had an ENT appointment scheduled for 08/12/2025 at 10:00 AM. The DON confirmed that it was made only after the surveyor raised the concern.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #54) of 6 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:A care plan is developed for residents to guide the care that they receive in the facility. It should be individualized and outlines the interventions used to address the residents' needs. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team (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).A review of Resident #54's medical record was conducted on 8/4/25 at 11:46 AM. The review revealed that Resident #54 had a quarterly MDS assessment completed on 7/23/25. There was no evidence in the medical record that a care plan meeting had been held with the resident and/or responsible party (RP) and the interdisciplinary team around the time of the quarterly MDS assessment or at the time of care plan revision.On 8/4/25 at 11:53 AM a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revealed the following: The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.On 8/5/25 at 8:15 AM in an interview with the Director of Social Services (DSS #1) the surveyor requested any evidence that a care plan meeting had been held for Resident #54 after his/her most recent MDS assessment. On 8/5/25 at 9:54 AM in an interview with the DSS #1, she was unable to provide any evidence of the most recent (July 2025) care plan meeting. During the interview when asked when the most recent care plan meeting should have been held, she stated July 2025. When asked if a care plan held was held in July 2025 for Resident #54 she stated no, she did not see a July care plan meeting was held, but that she could research in her other office to see if they did. Additionally, DSS #1 was asked if she documented after care plan meetings and she stated yes, after care plan meetings we are supposed to write a social services note. We have an assessment, called a care plan review, where we write everything that happened at the meeting. The surveyor again requested any evidence that a care plan meeting was held in July. On 8/5/25 at 10:36 AM in an interview with DSS #1 she verified and confirmed there was no invitation, care plan meeting or other evidence/documentation from July 2025.

Based on a review of medical records and a staff interview, it was determined that the facility failed to provide written notification of its bed-hold policy to the resident or their representative when the resident was transferred to an acute care facility. This was evident for three (Resident #8, #66, and #154) of five residents reviewed who were transferred to an acute care facility.In Maryland, the bed hold policy for long-term care facilities is governed by state regulations and Medicaid guidelines. Nursing homes must provide a written bed hold policy to residents at the time of admission and upon transfer to a hospital or for therapeutic leave. The policy details the duration of the bed hold, the rights of residents to return to the facility, and the the cost of holding the bed. 1) On [DATE], at 1:33 PM, the surveyor reviewed Resident #154's medical records. The records showed that on [DATE], around 4:40 AM, Resident #154 was found unresponsive. Staff initiated CPR and called 911. EMTs arrived around 4:55 AM and took over the resident's care. However, there was no documented bed-hold policy for this transfer. In an interview with Licensed Practical Nurse (LPN) #8 on [DATE], at 8:01 AM, the staff member stated that the facility provides all necessary documentation to the hospital, including the change in condition form, transfer documentation, face sheet, recent orders, and a medication list. When asked whether a bed-hold policy was included, LPN #8 said, I'm not sure about it. We gave all the papers to the EMTs, not the family or residents, unless they requested it. On [DATE], at 10:48 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the bed-hold policy should be part of the electronic transfer documentation and that the business office tracks these policies, with a copy filed in the residents' chart. The surveyor requested evidence that Resident #154 or their responsible party received the bed-hold policy on the date of transfer. At 12:45 PM on [DATE], the DON confirmed that Resident #154's medical record did not contain the bed-hold policy for the transfer. The surveyor shared their concerns, which the DON validated. 2) On [DATE] at 8:30 AM a review of Resident #66's medical record was conducted and revealed that the resident was transferred from the facility to a hospital on [DATE]. There was no notice of bed hold policy found in the paper or electronic record. On [DATE] at 8:35 AM in an interview with the Unit Manager, Staff #11, he/she stated that when a resident is transferred to the hospital, a copy of the bed hold policy will be given to the resident or the resident representative. Staff #11 also stated that a copy would be in the chart, but he/she could not provide a copy of Resident #66's. On [DATE] at 8:47 AM an interview was conducted with Resident #66 who stated that he/she was not given a copy of the behold policy but recalled getting a call during her hospital stay for a payment for bed hold. The DON was interviewed on [DATE] at 7:33 AM concerning bed hold policy. The DON stated that when a resident is transferred to the hospital there is a discussion about the bed hold policy, and a copy is given to resident. Surveyor requested a copy of documentation that resident received a copy of the bed hold policy. On [DATE] 8:51AM, the DON stated that she was unable to find any evidence that a bed hold policy was given to the resident during transfer to the hospital. The DON and Administrator were made aware that this was a concern. 3) A review of Resident #8's clinical record revealed the resident was sent to the hospital on [DATE]. Evidence of the resident and/or family being given a copy of the bed hold policy and a notice of the reason for the transfer to the hospital could not be found. This surveyor interviewed the Director of Nursing (DON) on [DATE] and I requested any evidence that the two documents were provided. DON provided a post-it note saying they could not find the bed hold notice. A copy of the notice stating the reason for the transfer was not provided. This surveyor reviewed the above findings with the DON on [DATE] at 5:12 PM. She acknowledged that neither two documents were provided to the resident or family.

Based on observations and interviews with staff, it was determined that the facility failed to attend to and answer call bells in a timely manner for dependent residents (Resident #149). This was evident during a tour of the first floor when a call bell was observed to be active and was subsequently validated during the recertification/complaint survey.The findings include: During a tour of the facility on 8/08/25, at 12:50 PM, a call bell screen on the 1 [NAME] unit showed that a call bell from Room [number of the room] had been active for 113 minutes. When the surveyor asked Staff #14 (a nurse) about the screen, she confirmed that the call had been on for 113 minutes. She added, someone is working on fixing something in that room.The surveyor immediately checked the room and found only Resident #149 lying in the bed. No other staff were present, and there was no evidence of a construction procedure. The resident was vulnerable, with a tracheostomy and tube feeding. While the surveyor was in the room, Staff #26 (Geriatric Nursing Aide) entered. After Staff #26 exited the room, the surveyor interviewed him. Staff #26 stated, the resident [Resident #149] pushed the call bell by accident; he/she did not need help. The surveyor asked how Staff #26 communicated with the resident. Staff #26 stated that he was able to communicate through the resident's facial expressions since the resident was non-verbal. He also assumed the bell was pushed accidentally since it was located under the resident's elbow.In an interview with the Director of Nursing (DON) on 8/08/25, at approximately 2:00 PM, the DON confirmed that the facility had a call bell screen only on the 1 [NAME] unit (ventilator unit). She said, since we have residents who use ventilators, we have a call bell screen on the unit. We expect nurses to respond to the call bell immediately. The surveyor shared the concern from the observation, and the DON validated it.

Based on medical record review and interviews with staff, it was determined the facility staff failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without adequate supervision and failed to implement safeguards to prevent further elopements. This was evident for 1 (#1) of 3 resident's reviewed for Resident Safety. The findings include: The surveyor entered the facility on 11/29/22 at 8:28 AM. The main entrance was unlocked and there were no staff present in the lobby area or at the front desk. A staff member entered the building at 8:38 AM and identified herself as the receptionist. When asked, she indicated that she usually comes in at 8:00 AM, but was just running late today. Review of the resident's medical record on 11/29/22 at 10:51 AM revealed that Resident #1 was admitted to the locked unit of the facility on 9/2/22 from an acute care hospital with diagnoses which included, but were not limited to: Chronic Obstructive Pulmonary Disease (COPD), dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, Cognitive communication deficit, muscle weakness, difficulty in walking, need for assistance with personal care and atherosclerotic heart disease of native coronary artery without angina. His/her 5 day Admission MDS ARD 9/9/22 revealed a BIMS score of 15/15. A guardian of person and property was appointed by the court on 7/28/22 to act on Resident #1's behalf due to him/her lacking the mental capacity due to disability defined as dementia. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. An Emergency Department Clinician note, dated 8/25/22, revealed that, prior to hospitalization , Resident #1 resided at another rehab facility and attempted elopement twice. On the second occasion, he/she became aggressive, attempted to bite people, and was brought to the hospital on an Emergency Petition. The report concluded EMS (Emergency Medical Services) and police are concerned that the facility is not able to care for him/her. The Assessment/Plan section of the note included: The patient is a [AGE] year-old man/woman with dementia who is now a ward of the state coming to the emergency department after he/she was unable to tolerate his/her current nursing home. Social work was contacted who assisted in evaluating the patient and with disposition. He/She was discussed with the POA (power of attorney). There is a plan for the patient to be housed in a nursing home that is more difficult to elope from. He/She will not be able to go to his/her nursing home until tomorrow. A hospital Behavioral Health Consultation note, dated 8/26/22, indicated On the psychiatric consult in the ED patient is pleasantly confused. He/She is slightly irritable. He/She is a very poor historian. The Exam revealed: alert with adequate awareness of surroundings, poor eye contact, guarded and not forthcoming with symptoms, fully alert and oriented to all spheres, Speech impoverished, affect constricted, Mood anxious, Thought process concrete, Memory intact, Attention span and concentration intact, Fund of knowledge adequate, aware of current events, Insight limited, Judgement limited. The diagnosis identified was Dementia with behavioral disturbances, Cognitive impairment. A facility Psychiatric Progress note with an assessment date of 11/25/22 indicated: On evaluation, the patient is confused, very guarded and not a good historian in providing details of his/her medical problems or admission here. He/She continues to have paranoia, non-compliant to his/her medications (per staff) and stays in his/her room. However, comes out only for dinner or lunch. Mental Status Examination: included Attention & Concentration: Alert/Brief/Impaired/Poor Concentration/ Easily Distracted. Psychomotor Behavior: Suspicious/Guarded. Affect: Irritable/Withdrawn/Suspicious. General fund of knowledge: Poor/ Unaware of current events/Unaware of Past History/ Partial awareness. Problem Solving: Poor. Judgement/Insight: Poor. Thought Process: Blocked/Confused/Confab/Perseverative. Abnormal or Psychotic Thoughts: Persecutory. Orientation: Oriented to Person, Place, Date, and Time. Short-term memory test used and Long-term memory test used both indicated: Patient is uncooperative with MSE but expected to be impaired. Remote Memory: Fair. Poor recall. The diagnosis indicated Unspecified dementia, unspecified severity, with agitation. Complaint #MD00186060, filed with the state agency was also reviewed at that time and revealed that Resident #1 was found by police walking with a walker down [NAME] Avenue wearing hospital socks. The resident was taken to a crisis center, the facility was notified, were unaware that the resident was missing, and said they would pick him/her up. [NAME] Avenue is a busy street with 6 lanes of traffic. Review of the weather history for 11/26/22 revealed the high temperature was 61 degrees Fahrenheit at 12 noon in [NAME] County. Resident #1's medical record failed to reveal that staff documented an elopement event in the resident's record or a notification was made to the physician and or the resident's guardian. The record revealed that one Wander/Elopement Risk Evaluation was completed and dated 9/2/22. Resident #1's risk factors included: Resident currently wanders and/or has a history of wandering, is cognitively impaired, frequently paced or wandered in areas/other resident's rooms without purpose, had impaired decision making skills that decrease his/her awareness of safety, and expressed a desire to leave the center. It indicated that the resident did not currently elope and/or have a history of eloping and did not express anger at being placed in a nursing home. The summary indicated that the resident was at risk for wandering, but was not a risk for elopement. There was no evidence that another risk assessment was completed after the resident eloped on 11/26/22. However, a Plan of Care for elopement risk/wanderer had been initiated on 9/22/22 with the goal I will not leave facility unattended through the next review date. And My safety will be maintained through the next review date. The interventions to be implemented by staff to assist the resident in reaching his/her goal were: Monitor for fatigue and weight loss. And Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The plan did not include interventions to specifically address wandering/elopement risk behaviors, nor was it updated and revised after the resident had an actual elopement. Review of Resident #1's Electronic Medical Record (EMR) on 11/29/22 at 1:20 PM failed to reveal a physician order or staff documentation of behavior monitoring, such as wandering or elopement risk behaviors, resident specific interventions for staff to attempt and their effectiveness. An interview was conducted on 11/30/22 at 11:04 AM with Staff #1, a Certified Medicine Aide. She was asked and confirmed that she was working 7AM - 3PM shift on 11/26/22. When asked if anything unusual occurred with Resident #1 she thought for several seconds. She was then asked if the resident left the building. She responded I think he/she did, but I have to ask my boss. I was tending to my business, I didn't see anything, I was busy. When asked if she was aware that the resident left the building she stated oh yes, that I heard, he/she returned the same day. When asked if she knew when, he/she left she stated, According to the police they got him/her at about 10:00. She was then asked if she knew how the resident went out and replied: He/She may have followed a visitor out of the unit. When asked if the resident was on elopement precautions, she stated What do you mean precautions? We don't allow our residents to leave unless they are signed out with a family member. The door is always closed. She was asked if anything was changed in regard to Resident #1's care after the elopement. She stated No, he/she ate their lunch, was cooperating with us, telling us he/she wanted to go home. In an interview on 11/30/22 at 11:12 AM, Staff #2 a GNA confirmed that she was working the 7AM -3PM shift on 11/30/22. She was asked to explain what happened with Resident #1 on that date. She indicated that, after breakfast the resident walked out of his/her room to the hallway, but then went back in their room. Visitors for another resident, who had never visited before, came onto the unit. About 30 minutes after breakfast, she realized that Resident #1 was not in the building. She indicated that she reported this finding to the charge nurse, Staff #3, who then called the supervisor, a head count was done, the building was searched. She was not sure what time the resident returned to the facility but indicated that Staff #3 and the supervisor went to pick Resident #1 up. Staff #3, an (LPN) Licensed Practical Nurse who was listed on the assignment sheet as the charge nurse on 11/26/22, was interviewed at 11:18 AM on 11/30/22. He confirmed that he worked 7AM - 3PM shift on 11/26/22. When asked what occurred with Resident #1, he indicated that around 10:30 AM, the manager on duty came to the unit and informed him that Resident #1 was missing, that the police had called, and the manager asked if he could go pick the resident up. When asked how the resident had gotten out of the facility, he stated I strongly feel that the emergency exit was not working properly, but don't know for sure. I don't think it was properly secured. When asked if he observed the door unsecured, he indicated no. He was asked what happened when the resident returned? He indicated that the resident was hungry, it was lunch time, about 11:20-11:40 AM. We checked his/her vital signs and skin. I did a head to toe assessment, there were no bruises or anything. All he/she wanted was something to eat. He was asked where he documented this assessment findings and showed the surveyor a progress note in the EMR, dated 11/26/22 12:24 PM, that stated: Resident remain alert, confused and noncompliant with ADLS (Activities of Daily Living). Head to toe skin assessment performed, no skin issues noted, resident siting in his/her room having lunch at this time, he/she has not verbalized any pain or discomfort. The note made no mention of the resident leaving the facility. When asked why the note did not reflect that Resident #1 had eloped, he explained that the manager told him that they would take care of the documentation regarding the elopement. When asked who the manager was, he could not recall but indicated that it was not Staff #4, the supervisor on that date. When asked if anything was put into place after the elopement, he indicated that the resident was put on 1 hour checks, however, he did not think that hourly checks were still being done. He was asked if the resident was on elopement precautions at the time of his/her elopement. He stated I guess he/she's always been on elopement precautions. He/She mostly spends time in his/her room. When asked what precautions were in place for the resident, he then stated, I don't think that he/she was. In an interview on 11/30/22 at 11:29 AM, Staff #4 the Nursing Supervisor, confirmed that she was the supervisor on duty on 11/26/22 7AM - 3PM shift. She indicated that she was paged but was tied up with completing a dressing change on another resident. She stated By the time I came to get the page, the Unit Secretary said that she gave it to Staff #5 the Manager on Duty. I called her, she said it was about Resident #1, but she was handling it. I was not involved anymore. During an interview on 11/30/22 at 11:47 AM The Director of Nursing was asked if she was aware of anything happening with Resident #1 on 11/26/22. She stated, I think Staff #5 called me but when I called back, she said that it was taken care of. When asked if she was informed of what the concern was, she first indicated that she could not remember, then indicated that she was informed that Resident #1 had eloped. When asked if the resident was on elopement precautions, she indicated that she could not recall, that she would have to review his/her record. She was asked if she thought that an elopement was a significant event she stated If the resident is not alert and oriented, if they are alert and oriented, we just educate them. They want to leave on their own, they don't know that they can't. She indicated that she thought Resident #1 was alert and oriented. When asked why he/she was on the locked unit, she indicated that sometimes there aren't any beds available except on the locked unit, so residents are placed there until a bed is available. She was made aware of the above concerns and indicated that she would review the records. She was asked at that time to provide the surveyor with a copy of all facility policy and procedures related to elopement including elopement risk. The surveyor was provided with a 1 page Policy titled Wander Management and Elopement Prevention. The Policy Statement was: The facility will maintain the safety of residents who wander and/or are at risk for elopement. The Policy Interpretation and Implementation contained 9 points. 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). a. The list of identified residents will be placed in location(s) easily accessible to staff, including at the receptionist's desk, and will include the resident's name, photo, and face sheet. 2. The staff will implement a wander management system device, if recommended, as a part of the plan of care. 3. Resident care plans will include resident specific interventions to ensure safe wandering and prevent elopement. 4.- 9. Pertained to a wander management system device. There was no policy nor procedure to provide staff guidance for elopement risk assessments, monitoring of resident behavior, interventions related to elopement & elopement risk, staff actions in the event of a missing resident, including notification, reporting, documentation, and investigation, follow up once resident was located. In an interview on 12/1/22 at 9:04 AM with the DON (Director of Nursing) and Staff #4 Corporate Regional Director of Operations. Staff #4 indicated that the wander guard (wander management system) was initiated for the residents on the locked unit. When asked if the wander guard system was already in place, He indicated that it was a new system, and the facility just gotten the bands in. He confirmed that the policy that was provided to the surveyor on 11/20/22 by the DON was the only policy and procedure that the facility had related to elopement. A serious outcome was likely to occur due to the facility failing to have a system in place to accurately identify, monitor and prevent residents at risk for elopement from leaving the facility unaccompanied. Potential for serious harm includes falls, temperatures/weather, proximity to 6 lane busy roadway. The staff's failure to identify potential risks and the need to implement necessary interventions placed all wandering, confused and vulnerable residents at risk of leaving the facility unaccompanied. An Immediate Jeopardy was determined, and the facility was notified on 12/1/22 at 11:15 AM. The facility submitted a plan for removal that was accepted on 12/1/22 at 5:20 PM. The facility's plan to remove the immediacy included: Reassessing Resident #1's elopement risk, updating his/her plan of care and reeducating staff on the care plan updates. Educating facility leadership and receptionist on insuring that the main entrance is locked when staff are not present to monitor the lobby area. A check of all emergency exits in the facility by plant operations director and by an independent contractor to ensure proper security and functioning. Re-screening of all residents to identify wandering and elopement risks and revising their care plans to include a monitoring plan and preventative interventions. Licensed Nursing Staff re-education on assessing elopement risk, policy for documentation of behavior monitoring, notification policy when a resident leaves the facility, policy regarding missing residents and completion of a risk reporter (incident report) for any unusual occurrence, and root cause analysis. Nursing Staff re-education on the care plan policy including resident specific interventions for monitoring, Elopement book location and updates, Wander guard policy. Maintenance and Nursing Staff re-education on checking emergency exit doors each shift to ensure secured and functioning per manufacturer recommendations. Interventions will be monitored as part of the facility's morning clinical meeting Monday through Friday for 3 months. QAPI (Quality Assurance, Performance Improvement) Committee will review audit findings monthly and will determine need for continued auditing. On 12/2/22 and 12/5/22, the facility's action plan and implementation of interventions were reviewed. Interviews with multiple staff, review of facility documentation including education, policies and procedures on Wandering and Elopements, Behavioral Assessment, Intervention and Monitoring, Emergency Procedure - Missing Resident, Accidents and Incidents - Investigating and Reporting, Comprehensive Person-Centered Care Plans and Change in a Resident's Condition or Status, as well as observation of the main entrance and secure unit doors and wander guard system, and staff practices confirmed that the above removal plan was implemented by the facility by 12/2/22 and the IJ was removed on 12/2/22 after validation that the plan was implemented.

Based on staff and family interviews, and review of medical record documentation, it was determined that the facility's staff failed to cohort, isolate and monitor residents on a dedicated observation unit for 14 days upon admission. As a result, the facility failed to properly prevent and contain the spread of COVID-19 between residents with a COVID-19 negative status, an unknown COVID-19, and a COVID-19 positive status. This concern was evident with 6 of 14 residents reviewed related to cohorting practices, and included Residents #5, #10, #11, #12, #13, and #14. The findings include: CMS defines cohorting as the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents. On 03-23-2020, the Maryland Department of Health (MDH) issued guidance on Preparing for and responding to COVID-19 in Long Term Care and Assisted Living Facilities. According to the guidance for admissions and readmissions facilities should: a. Create a dedicated observation area (this could be a separate unit/wing if possible or dedicated rooms in one area) to house non COVID-19 positive residents being admitted or readmitted from an outside facility. b. If a new resident screens negative, they should be admitted to this observation unit/area for 14 days. They can mix with other residents in this unit/area but not with other residents in the facility. c. After 14 days on the observation unit, if the resident does not ever screen positive, they can be released to mix with the general population. According to the Centers of Disease Control (CDC) guidance, published on 04-30-2020, nursing homes should, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. On 05-26-2020 at 2:00 PM, an interview with the Director of Nursing revealed that the facility initially designated rooms 265-270 and 272-279 on 2 West as observation unit rooms for new admission and readmissions. On 06-05-2020, a review of the facility's COVID-19 protocol, dated 04-06-2020, revealed the new admissions/readmissions were to be treated as if the residents are positive for COVID-19. The facility ' s protocol required staff to cohort new admissions and readmissions in a separate wing or unit opened as a step-down unit for a 14-day observation period. On 06-08-2020 at 1:40 PM the facility's Administrator was interviewed. The Administrator reported that on 04-24-2020 the entire 2 West was opened for new admissions. When asked about the facility's process for admitting residents to an observation unit, the Administrator explained that some residents already living on 2 West were not moved to other designated units due to lack of bed availability, and they remained in their rooms on 2 West. The administrator also stated that after the 14 days observation period newly admitted residents in 2 West remained in the observation unit if there were no rooms available in designated negative units. The facility did not ensure residents admitted remained in designated observation areas for 14 days prior to mixing new admissions and readmissions with the residents in the general population with other residents, for example: 1. On 05-27-2020 at 3:00 PM, an interview with Resident #5's family member revealed the resident was admitted to the facility on [DATE] to a room on 2 West (276-2). Two (2) days later, Resident #5 was moved to a room on 1 West (185-1). The family member stated the facility did not cohort Resident #5 correctly based on the Maryland Department of Health guidelines for new admissions and caused Resident #5 to be exposed to COVID-19. Resident #5 tested positive for COVID-19 on 04-23-2020. On 05-27-2020, a review of the medical record for Resident #5 revealed the resident was admitted from a hospital to the facility on [DATE], and was placed on the facility's observation unit on 2 West in a semi-private room (bed 276-2), without a roommate. At the time of admission to the facility on [DATE], the hospital reported that Resident #5's last COVID-19 test was negative. The day after admission, Resident #5 was moved to a general population unit on 1 West (bed 185-1) in a semi-private room. Prior to placing Resident #5 into bed 185-1, Resident # 1 had been Resident #14's roommate in bed 185-1. On 06-02-2020, clinical record review revealed that on 04-14-2020 Resident #1, the previous occupant of bed 185-1, was transferred to a hospital on 04-14-2020 for low blood pressure; and then two days later on 04-16-2020 the hospital notified the facility that Resident #1 had tested positive for COVID-19 in the hospital. On 4-16-2020 Resident #14 who had been roommate to both Resident #1 and Resident #5, was tested for COVID-19 and the result received for Resident #14 was COVID-19 positive on 04-22-2020. After having shared a room with Resident #14, the facility tested Resident #5 for COVID-19 on 04-23-2020 and when results were received on 04-27-2020, Resident #5 was also found to be COVID-19 positive. On 06-02-2020, a review of the facility's admission and daily census records revealed that on 04-15-2020, the day Resident #5 was moved to room [ROOM NUMBER]-1 (a semi-private room with roommate Resident #14) there were a minimum of five beds available on the designated observation unit (beds 273-1, 275-1, 275-2, 277-1, and 278-1). Nonetheless, Resident #5 was not isolated on the observation unit and was instead moved into the shared room with Resident #14. 2. On 05-27-2020, medical record review revealed that Resident #13 was admitted to the facility on [DATE] from a hospital. The resident was not placed on the observation unit but rather was initially placed in room [ROOM NUMBER]-1 (on 1 East). More than a week after admission, on 05-15-2020 Resident #13 was moved to the observation unit on 2 West, room [ROOM NUMBER]-1. On 05-28-2020, Resident #12 was admitted to the same semi-private room (room [ROOM NUMBER]-2) with Resident #13. Resident #12 had not started 14 days of observation and Resident #13 had not completed 14 days of observation but they were not isolated from each other. Resident #12 was Covid-19 negative before admission. Resident #13 was tested for COVID-19 on 05-21-2020 and reported positive on 05-30-2020, two days after Resident #12 had been admitted to the same room. 3. On 06-04-2020, a clinical record review of Resident #10 revealed the resident was admitted from a hospital on 05-29-2020 to a semi-private room in 2 West (room [ROOM NUMBER]-1) with Resident #11. A clinical record review of Resident #11 revealed Resident #11 was a general population resident who had been in room [ROOM NUMBER]-2 since 11-07-2019. However, a 14-day observation period had not elapsed before Resident #10 was assigned to a room with a general population resident. The facility staff failed to isolate newly admitted residents in the observation unit for 14 days and monitor them closely before moving them to non-COVID rooms. The facility staff allowed newly admitted residents to reside in rooms with other residents in the facility prior to the end of a 14-day observation period. Without a clear process to ensure new residents were isolated, COVID negative Residents were exposed to both residents with unknown COVID-19 status residents with COVID positive status.

Based on surveyor observation, review of the clinical records and staff and resident interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. This finding was evident in 1 of 32 residents selected in the stage 2 reviews (#101). In addition, safety concerns were found on 2 of 4 units. The findings include: 1. On 02-08-16, facility reported incident #MD 972 was investigated and was substantiated. The findings included the following deficiency that resulted in actual harm to resident #101. Surveyor review of the clinical record for resident #101 revealed the resident was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. The resident was immobile and required extensive to total assistance with activities of daily living. A Hoyer Lift was required to transfer resident #101 to and from resting places. A Hoyer Lift is an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, using hydraulic power. Sling lifts are used for patients whose mobility is limited. The facility uses the Invacare Reliant 450 Hoyer Lift. The manufacturer advises that users perform safety checks before lifting the person. In addition, two persons are required for transfer - one staff member to operate the lift and the other to physically support and guide the resident while on the sling during the transfer. On 2-8-16, surveyor review of the clinical record revealed that, on 1-4-16 at 11 AM, resident #101 fell out of the Hoyer Lift while being transferred from the dialysis Gerichair to his own wheelchair. There were two Geriatric Nursing Assistants (GNA's) involved in the transfer and there were no other witnesses. As he was being lowered in to the wheelchair, resident #101 fell to the floor. On 2-8-16 at 1:45 PM, surveyor interview with the GNA (staff #7 ) revealed that she was asked by another GNA to assist with the Hoyer Lift transfer of resident #101. Staff #7 reported that the other GNA handled the Hoyer Lift, while she handled the sling and the resident. Staff #7 reported that, during the transfer, while resident #101 was at the wheel chair level, he made a jerking movement of his head and fell out of the sling. He hit his forehead when he landed in a prone position on the floor. After falling, resident #101 was not observed to have lost consciousness and remained alert and oriented until he was transferred to the hospital by Emergency Medical Services. Surveyor review of the investigative report revealed that resident #101 had a bleed in his brain and a cervical spine fracture. On 2-10-16 at 3:00 PM, during surveyor interview (during a conference call) with the director of nursing (DON), Assistant DON, administrator and staff #7 it was revealed that staff #7 did not have her hands on resident #101 when he jerked his head and fell out of the sling. The second GNA was not available for interview. On 2-8-16 at 11:30 AM, interview with the Director of Nursing (DON) revealed that, immediately after the incident, she had inspected the Hoyer Lift, including the sling and straps. No defects were found in the equipment. On 2-9-16 at 2:00 PM, surveyor interview with the DON and the administrator revealed no further information. 2. During the initial tour, observation was made, on 02-04-2016 at 3:10 PM, of an unlocked and unattended Team B medication cart on the 1 West Unit. Two residents were noted in the hallway in close proximity to the cart. The cart remained unattended from 3:01 PM to 3:15 PM. During this time, the medication cart was not approached by facility staff. During this 15 minute time period, the medication cart was left unattended. At 3:15 PM, the surveyor walked up to the medication cart and opened the drawer. The medication cart's interior revealed lancets, razors, alcohol pads, heparin vials, and various prescription medications. Unit manager #4 walked over to the medication cart at 3:16 PM. At that time, the surveyor asked if she was aware that the medication cart was left open and unlocked. Unit manager #4 stated I did not realize it was left unlocked. Review of the facility's medication storage policy that was given to the surveyor stated Only licensed nurses, the consultant Pharmacist or designee, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Surveyor interview with unit manager #4, on 02-04-2016 at 3:32 PM, did not reveal any new information. 3. On 02-04-2016 at 11:10 AM, during the initial tour on the 2 East unit, surveyor observation revealed that rooms 219, 221, 242 and 246 were undergoing renovations. Surveyor observed that all the residents were out of the rooms. The beds, including the floor, were covered with thin plastic sheeting. Surveyor observation revealed three individuals who appeared to be painters and non caregivers in room 219, 221 and 242. However, observation revealed that the door to room 246 was left wide open with no attendant. Closer observation revealed two five gallon buckets with no lids containing a white substance which appeared to be paint on a wheeled cart and another one with a lid in the room. Surveyor observation revealed two cognitively impaired residents wandering and pacing the hallway with one peeping and gazing at the uncovered white substance in room 246. On 02-04-2016 at 11:12AM, surveyor approached the nursing station on 2 East and alerted the administrative assistant who was sitting at the nursing station at the time, about the imminent danger. Surveyor also notified the administrator on 02-04-2016 at 11:32 AM. However, the two five gallons with white substance were not removed from room 246 until 12:10 PM when the administrator came to address the issue. On 02-04-16 at 12:15 PM surveyor interview with administrator did not reveal any new information.