Every finding on record at Complete Care at Hagerstown

Based on interview, record review, and observation, the facility failed to ensure advance directive documentation was maintained and readily accessible in the resident's medical record for1 (Resident #17) of 1 residents reviewed for advance directives. The findings include: On [DATE] at 1:43 PM, Staff #20, Licensed Practical Nurse (LPN), stated the facility does not maintain hard-copy medical records on the nursing units and that resident records are maintained electronically in PointClickCare (PCC). When asked where advance directive documents other than the MOLST (Medical Order for Life Sustaining Treatment) would be located, Staff #20 stated they would be found within the Miscellaneous section of the electronic medical record.On [DATE] at 3:16 PM, Staff #14, Social Services Designee, stated the facility maintains hard-copy MOLST forms in binders located on each nursing unit's crash cart. Staff #14 further stated Resident #17 had an advance directive naming a medical and financial Power of Attorney, as documented in the admission social service assessment completed by Staff #14.On [DATE] at 3:31 PM, review of Resident #17's electronic medical record revealed documentation indicating the resident lacked decision-making capacity, as evidenced by a capacity evaluation signed by the facility's Medical Director. The resident was admitted to the facility on [DATE] with hospital discharge orders dated [DATE] identifying the resident as No CPR - A2 and a facility order summary indicating Do Not Resuscitate, Do Not Intubate dated [DATE]. Despite confirming the existence of an advance directive, Staff #14 was unable to provide documentation of the advance directive within the resident's electronic medical record.On [DATE], during a joint review of the electronic medical record with Staff #13, Licensed Social Worker, and Staff #14, the surveyor and both Staff #13 and #14 were unable to locate the resident's advance directive in the Miscellaneous section of the electronic medical record or elsewhere within the record.On [DATE] at 3:45 PM, Staff #14 returned and provided a paper copy of Resident #17's advance directive. Review of the document revealed it had been printed from hospital records, as evidenced by the hospital web link and hospital liaison credentials printed on each page. There remained no evidence that the document had been incorporated into the facility's electronic medical record.On [DATE] at 9:20 AM, follow-up review of Resident #17's electronic medical record revealed the previously existing MOLST identifying the resident as No CPR had been removed and replaced with a Full Code MOLST. At that time, there were still active orders in Resident #17's electronic medical record for both Full Code and Do Not Resuscitate/Do Not Intubate. On [DATE] at 9:25 AM, there was still no evidence that Resident #17's advance directive had been uploaded or maintained in the electronic medical record.On [DATE] at 10:40 AM, during an interview, the Assistant Director of Nursing acknowledged concerns regarding the appropriate maintenance and availability of Resident #17's advance directive documentation.

Based on interviews and record reviews, it was determined that the facility failed to follow resident grievance requirements by failing to provide the resident with a written grievance decision that included the required investigation findings and outcome and failed to follow its own grievance policy and procedure. This was evident for 1 (Resident #19) out of 7 residents investigated for potential abuse related to Facility Reported Incident (FRI) #3017272.The findings include:The Brief Interview for Mental Status (BIMS) is a standardized cognitive assessment used in long-term care to measure a resident's orientation, attention, and short-term memory. A score of 15 is the highest possible score and indicates that a resident is cognitively intact.Resident #19 had a BIMS score of 15, indicating intact cognition. The resident's medical record documented diagnoses that included respiratory failure and other medical conditions requiring nursing care, including medication administration by licensed nursing staff.On 7/13/26 at 10:30 AM, the surveyor conducted an interview with Resident #19 regarding concerns associated with Facility Reported Incident (FRI) #3017272 (Cross-Reference F684). During the interview, Resident #19 expressed additional concerns that were not included in the original FRI investigation. The resident stated that they previously received a double dose of thyroid medication and reported several close calls involving multiple nurses nearly administering incorrect medication dosages. The resident stated that they planned to speak with the unit manager to request additional staff training regarding medication administration and that they now feel they must stop nurses and ask them to verify medication dosages before administration.Resident #19 stated that a previous unit manager (Nurse #33), who is no longer employed by the facility, confirmed the medication error and added instructions in all capital letters to the Medication Administration Record (MAR) in an attempt to prevent future medication errors. The resident further stated that they recently had another medication change and that staff continued to have difficulty administering the correct dosage of their stool softener medication.Resident #19 stated that the repeated medication concerns became so concerning that they filed an official grievance with the facility in June 2026. The resident reported that Nurse #33 assisted them with completing the grievance.The surveyor asked Resident #19 to explain their understanding of the grievance process. The resident replied, The grievance process is going to the unit manager and that goes to the leadership during 'stand up meetings' and then goes up the chain.The surveyor asked whether anyone from upper management had responded to the grievance. Resident #19 stated that the only response they received was from Nurse #33, who informed them that the medication instructions had been changed to all capital letters. The resident stated that they never received communication from the Nursing Home Administrator (NHA), never received the investigation findings in writing, and were only informed that the medication instructions had been revised in an attempt to prevent future medication errors.On 7/13/26 at 12:47 PM, the surveyor reviewed the facility grievance log. The log documented that Resident #19 reported a medication error on 6/20/26 and that an investigation was initiated on 6/23/26. Under Investigation Findings, the entry stated, nurse education provided. Under Resolution/Actions Taken, the entry stated, nursing updated medication order. The grievance was documented as resolved on 6/26/26.Review of the facility policy titled Resident and Family Grievances, implemented and revised 4/5/23 (no policy number), stated, in part:e. The grievance official, or designee, will keep the resident appropriately apprised of progress toward resolution of the grievance.g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the grievance official will issue a written decision to the resident or resident representative at the conclusion of the investigation. The written decision will include, at a minimum:-The steps taken to investigate grievance.- A summary of the pertinent findings or conclusions regarding the resident's concerns.- A statement indicating whether the grievance was confirmed or not confirmed.- Any corrective action taken or to be taken by the facility as a result of the grievance; and- The date the written decision was issued.On 7/13/26 at 2:03 PM, the surveyor interviewed the NHA, who confirmed that he serves as the facility's grievance official. The NHA stated that grievances are reviewed during the daily morning meeting, assigned to appropriate staff members for investigation, and entered into an electronic grievance tracker accessible by the NHA and social services department. He stated that updates are discussed during daily stand down meetings and the tracker is updated each day. When asked how grievance outcomes are documented, the NHA stated that the facility completes a Resident Concern/Compliment Form documenting the grievance and basic information related to the concern.The surveyor directed the NHA to Resident #19's grievance and asked what he knew about the complaint and its outcome. The NHA stated that he did not believe it was an actual medication error but would need to review the grievance before responding. He stated that the grievance had been assigned to Nurse #33, who no longer works at the facility.The surveyor asked whether he follows up with residents after grievances are investigated. The NHA replied, Yes, I do. I speak to them in person or call them. When asked whether residents are ever provided the investigation findings in writing, the NHA responded, No, I don't. Is that a new requirement? The surveyor advised the NHA to review the federal grievance requirements and the facility's grievance policy. When asked whether he recalled following up with Resident #19, the NHA stated that he believed Nurse #33 had followed up with the resident.On 7/13/26 at approximately 3:30 PM, the NHA provided the surveyor with the Resident Concern/Compliment Form related to Resident #19's grievance.The form documented:Brief Description: Stated [s/he] received wrong dose of Synthroid. Could tell by pill color.Department Head Response: Additional instructions added to orders in large print of dose. New order added to acknowledge dosing regimen.The form documented that the resident was notified on 6/26/26 of the change to the medication order print (now all capital letters). The document did not indicate whether the investigation determined that a medication error occurred, did not include the documented grievance log finding of nurse education provided, did not summarize the investigation findings or conclusions, and did not include documentation that Resident #19 received a written grievance decision from the grievance official or designee.On 7/14/26 at 11:45 AM, the surveyor reviewed Resident #19's Medication Administration Record (MAR). The MAR included an order for Levothyroxine Sodium Oral Tablet 125 mcg (generic Synthroid) with directions written in all capital letters: !!! TWO TABLETS!!! ONE HOUR BEFORE MEAL ON EMPTY STOMACH MONDAY THROUGH SATURDAY!!! TWO TABLETS!!!On 7/14/26 at 1:30 PM, the surveyor met with the NHA to discuss concerns identified during the survey, including the grievance process. The NHA confirmed that the facility had no additional information to determine whether Resident #19 experienced a medication error. He acknowledged that the facility's current practice was to provide grievance outcomes verbally rather than in writing. Additionally, there was no documentation supporting that nursing education had been completed despite the grievance log documenting nurse education provided, and there was no current Quality Assurance and Performance Improvement (QAPI) initiative addressing the concerns raised in the grievance. The NHA stated that the facility has begun working to revise its grievance process.

Based on record review and interview, it was determined that the facility failed to conduct thorough investigations of allegations of neglect prior to concluding the allegations were unsubstantiated for 2 (Resident #41 and Resident #70) of 2 residents reviewed with facility reported incidents. The findings include: 1. Resident #41 FRI #2994012On 7/9/26 at 1:59 PM, review of Facility Reported Incident (FRI) #2994012 revealed the facility investigated an allegation of neglect after Resident #41's daughter alleged that on 4/23/26 Certified Nursing Assistant (CNA) Staff #26 instructed the resident to go in your brief rather than assisting the resident to the toilet or providing a bedpan.Review of Staff #26's written statement dated 4/24/26 revealed that Staff #26 claimed Resident #41 requested to have a bowel movement and that Staff #26 instructed Resident #41 to notify Staff #26 after they were finished. Staff #26 stated that they were responding to multiple admissions and caring for other residents and later returned to provide incontinence care after Resident #41's family member requested assistance.Review of the facility's Resident Concern Form, completed on 4/23/26, revealed the resident's family member found Resident #41 lying in a soaked bed after Staff #26 stated the resident had just been changed. The family member requested assistance again before care was provided. The concern form further documented that Resident #41 needed to have a bowel movement during the day and was instructed by Staff #26 to go in your brief.Review of the Nursing Home Administrator's investigative note dated 4/24/26 at 12:30 PM documented that Resident #41's daughter reported Staff #26 told the resident to just go in your brief before leaving the room and later returning to provide care.Review of Staff #14's, the Social Services Designee, progress note dated 4/25/26 at 10:54 AM revealed Resident #41 had no recollection of the reported event during the interview.On 7/9/26 at 9:50 AM, a review of the facility investigation file revealed three resident interview and observation assessment forms for residents residing in the same area as Resident #41. Although each form was signed, dated, and timed by Staff #14, the interview and observation sections were left blank.On 7/10/26 at 2:50 PM, during the interview, the Assistant Director of Nursing (ADON) stated that the incomplete forms most likely indicated that licensed nursing staff were expected to complete skin assessments and observations. On 7/10/26 at 3:15 PM, the ADON provided two skin assessments intended to correspond with the incomplete forms. One assessment was completed within the required five working day investigation timeframe, one assessment was completed after the required investigation timeframe, and no documentation was provided for the third resident assessment.The facility concluded the allegation was not verified after documenting that a comprehensive investigation had been completed. However, the investigation record contained incomplete resident interview and observation forms. It lacked evidence that all resident assessments were completed within the required investigation period, preventing the facility from demonstrating that the allegation had been thoroughly investigated before reaching its conclusion.2. Resident #70 FRI #2986456On 7/14/26 at 9:50 AM, review of Facility Reported Incident (FRI) #2986456 revealed Resident #70's sister alleged neglect related to oral hygiene, hair hygiene, incontinence care, nutrition, and staffing. The investigation documented notification of the physician, local ombudsman, and law enforcement. The Nurse Practitioner, Psychiatry, Social Services, and nursing staff evaluated resident #70. The facility ultimately concluded the allegation was not verified, documenting that Resident #70 denied neglect and reported satisfaction with her care.On 7/14/26 at 10:20 AM, a review of the facility investigation file revealed the investigative documentation completed by Staff #14, the Social Services Designee, contained three resident interview and assessment forms for residents residing on the same hallway as Resident #70. One resident assessment could not be associated with an identifiable resident. The remaining two residents had documented Brief Interview for Mental Status (BIMS) scores of 15/15. Although all three forms were signed, dated, and timed, none contained completed interview or observation documentation.Because the resident interview and observation forms for both investigations were incomplete, the facility could not demonstrate that residents in the same area were interviewed or assessed for potential knowledge of or exposure to the alleged neglect before concluding that the allegations were unsubstantiated.On 7/14/26 at 10:40 AM, during an interview, the ADON acknowledged concerns regarding the lack of a thorough investigation related to the allegation of neglect for both Resident #41 and Resident #70. The ADON acknowledged that signed, dated, and timed resident interviews and assessment forms were included in the investigation records without completed interview or observation documentation, and that the facility could not demonstrate the investigations had been completed thoroughly before concluding the allegations were unsubstantiated.

Based on medical record review and interview it was determined that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment. This was found to be evident for one (Resident #5) out of five residents reviewed for unnecessary medications.The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of Resident #5's medical record revealed an order for Risperdal 0.5 mg, one tablet at bedtime for delusional disorder, was in effect from 1/2/26 until it was discontinued on 7/7/26. Risperdal is an antipsychotic medication. Review of the May 2026 Medication Administration Record revealed the resident received this antipsychotic medication, as ordered, daily in May. Review of Resident #5's medical record revealed an MDS assessment with a reference date of 5/15/25 that documented in section N0415A that Yes the resident was taking an antipsychotic medication. However, in section N0450A, in response to a question about receiving an antipsychotic medication, staff documented 0. No- Antipsychotics were not received. Based on this response questions about gradual dose reductions (N0450 B.C. and D.) were then skipped. Further review of the medical record revealed an order, in effect since 5/5/26, for tramadol (a narcotic pain medication) 50 mg give one tablet every 12 hours for pain. Review of the May 2026 MAR revealed this pain medication was administered, as ordered, starting on 5/5/26. Further review the MDS assessment with a reference date of 5/15/25 revealed in section J. Pain management, in response to J0100A Received Scheduled pain medication regimen? Staff documented No. On 7/09/26 at 1:20 PM when asked where she would obtain the information for MDS section N. Medications and section J. Pain management, the MDS Nurse #23 responded, It would be on the MAR. Surveyor reviewed the concern regarding the assessment for N0450A that indicated no antipsychotics were received; and J0100 that indicated no scheduled pain medication was received. MDS Nurse #23 responded that she would have to verify what the resident was receiving. On 7/09/26 at 1:59 PM MDS nurse #23 reported the two items in regard to the medications (Section N and J) were coded in error and that she would submit a modification. On 7/14/26 at 11:24 AM surveyor reviewed the concern with the Director of Nursing regarding the failure to accurately assess the use of regularly scheduled pain medications and antipsychotic medications on the MDS assessment.

Based on medical record review and interview it was determined that the facility failed to develop a comprehensive care plan. This was found to be evident for one (Resident #5) out of one resident reviewed for communication. The findings include:The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Care plans are to be reviewed and revised as necessary following an MDS assessment.Review of Resident #5's medical record revealed an MDS, with an Assessment Reference Date (ARD) of 11/12/25, that indicated the resident did not have a hearing aid at the time of the assessment. During an interview with Unit Nurse Manager (UM) #21, on 7/09/26 at 1:03 PM, she provided a copy of a Hearing Aid Delivery Receipt, dated 12/8/25, that indicated a left and a right hearing aid was delivered. On the morning of 7/9/26, review of the medical record revealed an order, with a start date of 1/2/26 for: Nurse to place hearing aids in resident's ears every morning, and remove in the evening. Store in med cart. Ensure battery door is open when placed in case.Review of the MDS with an ARD of 2/12/26 indicated that the resident had a hearing aid at the time of that assessment.Review of Resident #5's medical record revealed a Minimum Data Set(MDS) assessment, with an assessment reference date (ARD) of 5/15/26, that indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This assessment also revealed that the resident has a hearing aid.During an interview with Resident #5, on 7/6/26 at 11:03 AM, the resident reported s/he could hear ok out of one ear but indicated the hearing aid for the other ear was lost about a month ago. The resident reported having spoken to someone at the facility about this concern and thought they were going to replace it but had not heard any updates.During the 7/09/26 at 1:03 PM interview, UM #21 went on to report that she had completed the medication pass yesterday and that the box is still in the medication cart but that both of the hearing aids are currently gone.On 7/9/26 review of the resident's care plans, which had a revision date of 5/14/26, failed to reveal documentation regarding the residents need for or use of hearing aids.During an interview on 7/9/26 at 1:31 PM, surveyor reviewed the concern with the ADON that the hearing aid was included in the MDS assessment but nothing was found in the care plan to address the use of the hearing aid. On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing the concern regarding the failure to develop a care plan to address hearing aid usage.Cross reference to F 685 and F 658

Based on medical record review and interview it was determined that the facility failed to ensure care plan meetings were conducted following the Minimum Data Set Assessment completion. This was found to be evident for one (Resident #12) out of five residents reviewed for unnecessary medications.The findings include:The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Care plans are to be reviewed and revised as necessary following an MDS assessment.State regulations require a care plan meeting to be held not later than 7 calendar days after completing the assessment, but may hold the meeting sooner if agreed to by the resident, a family member or a resident's representative. Review of Resident #12's medical record revealed an Interdisciplinary Team care plan meeting was held on 12/10/25.Further review of the medical record revealed a quarterly MDS assessment with an assessment reference date (ARD) of 2/17/26. The RN assessment Coordinator signed this assessment as complete on 2/26/26. Review of the progress note written by Social Service Designee (SSD) #14 on 2/26/26 revealed that a care plan meeting was scheduled for 2/26/26 but the resident wanted to reschedule the meeting; and that the meeting will be rescheduled late next month per the resident's request. Further review of the medical record failed to reveal documentation to indicate a care plan meeting was scheduled or held in March or April of 2026.Further review of the medical record revealed a quarterly MDS assessment with an ARD of 5/20/26. The RN assessment Coordinator signed this assessment as complete on 6/15/26. Review of the progress note written by SSD #14 on 5/29/26 revealed that per the resident's request the care plan meeting was rescheduled due to a doctor's appointment.On 7/9/26 further review of the medical record failed to reveal documentation to indicate a care plan meeting was held for this resident since the meeting in December 2025.On 7/09/26 at 4:50 PM when asked if a care plan meeting needs to be rescheduled what happens, the Director of Social Services (DSS) #13 reported that another would be scheduled based on when a family and others are available. Surveyor then reviewed the concern that no documentation was found to indicate a care plan meeting was held for this resident since December. On 7/10/26 at 10:35 AM DSS #13 and the SSD #14 presented surveyor with a letter indicating a care plan meeting was scheduled for Resident #12 on 7/21/26. The SSD #14 was asked has there been a care plan meeting for this resident since December, to which SSD #14 responded: no.On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing the concern regarding the failure to ensure an interdisciplinary care conference was held following MDS assessments and that no meeting was held for this resident for more than 6 months.

Based on medical record review and interview it was determined that the facility failed to ensure staff accurately documented the provision of care. This was found to be evident for one (Resident #5) out of five residents reviewed for unnecessary medication. The findings include: Review of Resident #5's medical record revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 7/6/26 at 11:03 AM Resident #5 reported his/her hearing aid was lost about a month ago and the resident thought it was going to be replaced but had not heard anything about it. The resident indicated s/he had spoken to someone at the facility about this concern.On the morning of 7/9/26, review of the medical record revealed an order, with a start date of 1/2/26 for: Nurse to place hearing aids in resident's ears every morning, and remove in the evening. Store in med cart. Ensure battery door is open when placed in case.Review of the Medication Administration Record (MAR) revealed an area for the nurse to document about the hearing aids at 9:00 AM and 9:00 PM. Review of the June MAR revealed staff were documenting the provision and storage of the hearing aids from June 1st through June 12th. On 6/12/26 Nurse #28 documented with a check mark at 9:00 PM indicating the hearing aid was stored in the medication cart. The area to document on the morning of 6/13/26 was noted to be blank and a 7 was documented in the evening. The documentation on the evening of 6/13/26 was completed by Nurse #29. A 7 indicates Other/See Nurse Notes. Review of the corresponding nursing note revealed: Not available.Review of the Resident Concern/Complaint Form dated 6/15/26 revealed the resident reported the hearing aid was in a cup and now is missing. The Social Service Designee (SSD) #14 followed up regarding the concern but was unable to locate the hearing aid. On 7/9/26 at 1:31 PM the Assistant Director of Nursing (ADON) #6 presented with a written statement that indicated on 6/16/26 she had interviewed Nurse #28 about the hearing aids. Nurse #28 had confirmed he removed the resident's hearing aids during his evening shift and placed them in a cup on the medication cart but was unable to confirm whether the hearing aids were secured in the locked medication cart before the end of his shift.On 7/09/26 at 1:03 PM the Unit Nurse Manager (UM) #21 reported that she had completed the medication pass yesterday and that the box is still in the medication cart but that both of the hearing aids are currently gone. Further review of the MAR revealed revealed nursing staff documented that they provided the resident his/her hearing aides on the mornings of June 14, 15, 17, 18, 19, 22, 24, 25, 27, 30 and July 1, 2, and 4. Staff documented that they secured the hearing aids in the medication cart on June 15, 22, 23, 26, and July 1, 2, 3, and 7.During an interview on 7/9/26 at 1:31 PM, surveyor reviewed the concern with the ADON that staff are frequently documenting that they are providing or accepting back the hearing aids even after the hearing aids went missing. On 7/14/26 at 11:24 AM surveyor reviewed with Director of Nursing and the New Nursing Home Administrator #10 the concern regarding the failure to ensure staff accurately documented hearing aid usage.Cross reference to F 685

Based on record reviews and interviews, it was determined that the facility failed to provide necessary Activities of Daily Living (ADL) care, including timely incontinence care, for a resident. This was evident for 1 (Resident #37) of 2 residents reviewed for ADL care and investigation of a facility-reported incident (FRI #3038101).The findings include: ADLs are activities necessary for daily self-care, including bathing, dressing, toileting, personal hygiene, and continence care. Facilities are required to provide assistance with ADLs based on each resident's needs to maintain personal hygiene, dignity, and the highest practicable level of functioning. Failure to provide timely incontinence care places residents at risk for discomfort, skin irritation, moisture-associated skin damage, pressure injuries, infection, and a decline in overall quality of life.Resident #37 has a medical history that includes cerebral infarction (stroke), urinary incontinence, irritable bowel syndrome, and multiple other medical conditions requiring assistance with personal care.On 6/09/26 at 10:08 AM, the facility submitted a facility reported incident to the Office of Health Care Quality (OHCQ) which stated that Resident #37 filed a complaint that they were not changed all night (referring to incontinence care) during the 11-7 shift on 6/8/26. The facility's follow-up report to OHCQ determined that the allegation was not verified.On 7/14/26 at 9:45 AM, the surveyor reviewed the facility's investigation file and discovered the following:A skin assessment dated [DATE] indicated that the resident had new red areas to the right and left buttocks and sacrum.A change in condition note dated 6/9/26 indicated that redness to bilateral buttocks and sacrum started on 6/9/26.A statement from the Social Services Designee (Staff #14) stated that Resident #37 alleged that they had put on the call bell for assistance with incontinence care and that Geriatric Nursing Assistant (GNA #36) stated they would get someone to help them, but no one returned.A statement from GNA #36 denied that they answered Resident #37's call bell at any time during their shift.A statement from GNA #37 stated that when they entered the resident's room on 6/9/26 (time not indicated), the resident reported that they had not been changed all night and that when they requested GNA #36 obtain assistance with changing them, no one returned to the room. GNA #37 documented that the resident had redness as a result of a wet brief and reported the findings to the nurse on the floor.The surveyor reviewed the facility's investigation file and found no evidence that the facility reviewed GNA task documentation to determine whether Resident #37 received ADL care during the 11-7 shift. Additionally, the investigation did not address the skin assessment and change in condition documentation completed on 6/9/26, which identified new redness to the bilateral buttocks and sacrum following the reported concern regarding missed incontinence care.On 7/14/26 at 10:42 AM, the surveyor interviewed the Nursing Home Administrator (NHA) regarding the investigation process when a resident reports that ADL care was not provided by staff. The NHA stated that a neglect investigation would be initiated and would include speaking with the resident involved, other residents who may have been impacted or have additional information, speaking with staff, and reviewing the resident's medical record to determine if care was documented.On 7/14/26 at 12:00 PM, the surveyor reviewed GNA task documentation, provided by the NHA, which revealed that personal hygiene was provided on 6/9/26 at 12:36 AM (just after midnight), toilet transfer was documented at 12:07 AM, and turning and repositioning was documented at 12:33 AM. There was no bladder documentation during the 11-7 shift and no further documentation to show that additional turning, repositioning, or incontinence care was provided during that shift.There was also no bladder documentation on 6/9/26 during the 7-3 shift, and turning, positioning, toileting, and personal hygiene were not documented until nearly 1:00 PM, indicating several hours passed without documented continence care.On 7/14/26 at 12:06 PM, the surveyor interviewed the Director of Nursing (DON) and asked her to review the ADL documentation for Resident #37 to determine whether care was provided after midnight through the following morning. After reviewing the documentation, the DON confirmed that Resident #37 was not changed, turned, or dried after midnight until the next shift

Based on medical record review, observation and interview it was determined that the facility failed to ensure activities were provided as indicated in the resident's care plan. This was found to be evident for two (Resident #10 and #7) out of two residents reviewed for activities.The findings include:1)Review of the medical record revealed Resident #10 has a history of stroke and a diagnosis of dementia. The resident is dependent on staff for transfers and mobility.On 7/06/26 at 1:15 PM the resident was observed in her/his room with the television in front of him/her. The resident did not respond to surveyor greeting.On 7/10/26 at 2:37 PM Resident #10 was observed sitting in his/her room, the television was on and in front of the resident.Review of the 6/5/26 Minimum Data Set assessment revealed it was very important to the resident to listen to music that s/he likes.Review of the resident's current care plans revealed a plan with the following focus: [Resident] is dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The interventions section revealed the following: I enjoy the following music: Blues, jazz. I would listen to live performances and on the radio.On 7/13/26 at 11:04 AM interview with the Activity Director (AD) #11 revealed he has four activity assistants but two are currently on leave. AD reported that the goal is to have two staff on the weekends but at present there is just one. The AD was aware that Resident #10 enjoys music and reported that when they have entertainers they bring the resident to the program. In regard to documentation, the AD reported that when they document independent that is when they turn the television on in the resident's room.Review of the activity documentation for 6/14/26 through 7/12/26 revealed staff documented television as the activity on 14 out of the 23 dates that activities were documented.Review of the activity documentation for 5/13/26 through 7/12/26 failed to reveal documentation to indicate music was provided or offered to the resident during the 60 days reviewed.During the 7/13/26 interview, the AD reported that Resident #10 is usually content to watch tv but that he does have radios that people ask for sometimes.2) Review of Resident #7's medical record revealed the resident has severe cognitive deficits and a diagnosis of dementia.On 7/06/26 at 1:23 PM resident was observed in bed with the television on. The resident was heard speaking loudly but there was no staff or visitor in the room at the time of the observation.Review of the 5/13/26 annual MDS assessment revealed it was very important to the resident to listen to music he/she likes and somewhat important to participate in religious services.Review of the resident's current care plans revealed a plan with the following focus: [Resident] is dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The interventions section revealed the following: I enjoy the following music: blues, jazz, 60's, 70's; and Church is important to me. I am Baptist and can watch on tv as interested.Review of the activity documentation for 6/14/26 through 7/12/26 revealed staff documented television as the activity on 14 out of the 25 dates that activities were documented.On 7/13/26 at 11:11 AM the AD reported he schedules music activities 2 to 3 times per month and has a birthday party once a month. He confirmed there is a minister here on Sundays and someone from a Baptist church on the second Tuesday of the month.Review of the activity documentation for 5/13/26 through 7/12/26 failed to reveal documentation to indicate music was provided or offered to the resident during the 60 days reviewed. No documentation was found to indicate the resident was provided or offered to attend a religious service during this period.Review of the June activity calendar revealed there were church services every Sunday, as well as Baptist church providers scheduled on 6/9 and 6/15. No documentation was provided to indicate the resident was offered to attend these services or was visited by the religious providers.On 7/14/26 at 11:24 AM surveyor reviewed the concern with the Director of Nursing and the new Nursing Home Administrator #10 the concern regarding the failure to provide activities as indicated in the resident's care plans.

Based on medical record reviews and interviews, it was determined that the facility failed to ensure the rotation of insulin injection sites for residents receiving multiple daily insulin injections and failed to report a resident's change in medical condition to a supervisor. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications, 1 (Resident #59) of 1 resident reviewed for insulin use, and 1 (Resident #19) of 7 residents reviewed for potential abuse related to Facility Reported Incident (FRI #3017272).The findings include: 1a). Review of Resident #7 medical revealed the resident has diabetes, dementia and severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15. Further review of Resident #7's medical record revealed an order for Insulin Glargine (long acting insulin also known as Lantus) 5 units to be injected subcutaneously one time a day for diabetes. The resident also had an order for Insulin Lispro (fast acting insulin) 3 units to be injected subcutaneously three times a day with meals. Review of the facility's Administration of Injections policy, with a revision date of 3/6/26 revealed in the section addressing the procedure for subcutaneous injections includes: c. For repeated injections, rotate site. This policy was provided to the survey team by the Assistant Director of Nursing on 7/9/26. Review of the June 2026 Medication Administration Record revealed on 6/19/26 at 2:01 PM and again at 5:14 PM the resident received Lispro Insulin injections in the right arm. On 6/20/26 at 9:46 AM and again at 1:25 PM the resident received Lispro Insulin injections in the right lower quadrant of the abdomen. On 6/21/26 at 9:58 AM, 1:48 PM and 4:22 PM the resident received Lispro Insulin injections in the right lower quadrant of the abdomen. Also on 6/21/26 at 10:06 AM the resident received a Lantus Insulin injection to the right lower quadrant of the abdomen. Review of the July 2026 Medication Administration Record revealed that the resident received 11 insulin injections between 7/1/26 and 7/3/26. Of these 11 injections, 10 were documented as having been administered to the left arm. One injection, administered on the morning of 7/1/26 was administered to the right arm. On 7/5/26, 7/6/26 and 7/7/26 the resident's Lantus insulin was injected in the left lower quadrant of the abdomen. On 7/7/26 at 12 noon and again at 6:31 PM the resident's Lispro insulin was injected in the left arm. On 7/8/26 at 12:19 PM and again at 6:24 PM the resident's Lispro insulin was injected in the left arm. On 7/14/26 at 11:24 AM surveyor reviewed the concern with the Director of Nursing regarding the failure to rotate sites of insulin injections for Resident #7. As of time of survey exit at 3:10 PM no additional documentation was provided regarding this concern. 1b). Resident #59 has a diagnosis of Multiple Sclerosis (MS), which impacts mobility and requires assistance with Activities of Daily Living (ADLs). Additionally, the resident has diabetes and require insulin injections for management of their condition. Rotating subcutaneous insulin injection sites is important to reduce the risk of tissue changes, including the development of fatty lumps under the skin, which can affect how insulin is absorbed and may result in inconsistent blood glucose control. On 7/6/26 at 11:34 AM, the surveyor spoke with Resident #59 who stated that they had concerns regarding insulin administration practices by nursing staff and requested that the surveyor review how their insulin was being administered. The resident stated that they had to ask a nurse to administer an injection in a different arm. The resident stated that instead of walking around the bed to administer the injection the nurse attempted to give the injection across the resident's body. On 7/7/26 at 3:17 PM, the surveyor conducted an interview with Resident #59's spouse who stated that approximately one month ago, an agency nurse was administering an injection and the resident requested that it be given in their left arm. The spouse stated that instead of walking around the bed the nurse leaned over the bed to give the injection. The Brief Interview for Mental Status (BIMS) is a standardized cognitive assessment used in long-term care to measure a resident's orientation, attention, and short-term memory. A score of 15 is the highest possible score and indicates that a resident is cognitively intact. On 7/10/26 at 9:34 AM, the surveyor conducted a record review and confirmed that Resident #59 had a BIMS score of 15. The record review revealed that Resident #59 received insulin and had physician orders for blood glucose monitoring twice daily. The resident's care plan included interventions related to management of diabetes. On 7/10/26 at 9:47 AM, the surveyor reviewed Resident #59's Medication Administration Record (MAR) and insulin injection site documentation. The review revealed the following: Lantus Subcutaneous: -7/1/26 – Left arm -7/2/26 – Left arm -7/3/26 – Left arm -7/4/26 – Left arm -7/5/26 – Left arm -7/6/26 – Right arm Insulin: -7/6/26 – Left arm three times -7/7/26 – Left arm three times -7/8/26 – Left arm three times On 7/10/26 at 10:43 AM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) regarding the professional expectations for administering subcutaneous injectable medications. The ADON stated, We are supposed to rotate injection sites. The surveyor asked if she was aware of nurses not rotating injection sites, and the ADON stated that she was aware this was an issue. The ADON stated that Resident #59 sometimes requested a specific injection site. When asked if this should be documented, the ADON stated that it should include documentation such as, Resident requested a different location for injection, and should include education provided to the resident regarding the importance of rotating injection sites. 2). The Brief Interview for Mental Status (BIMS) is a standardized cognitive assessment used in long-term care to measure a resident's orientation, attention, and short-term memory. A score of 15 is the highest possible score and indicates that a resident is cognitively intact. Resident #19 had a BIMS score of 15, indicating intact cognition. The resident required staff assistance with Activities of Daily Living (ADLs), including bathing and showering. On 7/6/26 at 11:20 AM, Resident #19 approached a surveyor and asked to speak to them privately about a potentially abusive situation they had experienced by a Geriatric Nursing Assistant (GNA) while receiving a shower. Neuropathy is nerve damage that can reduce or eliminate sensation, particularly in the hands and feet. On 7/13/26 at 10:30 AM, the surveyor conducted a private interview with Resident #19. The resident stated that approximately two months earlier GNA #41 had been very aggressive while washing their feet during a shower. The resident explained that they have neuropathy and cannot feel below the knees. They stated, She was careless with my feet, and I didn't feel it, but the scrubbing was so aggressive that the skin between the toes on both feet split and bled. The resident stated that GNA #41 told them she would report the bleeding to the unit manager; however, no staff came to assess the injuries. The resident stated the incident occurred on a Saturday evening and they reported it during morning rounds on Monday because no one had checked their feet. The resident stated a nurse later bandaged the toes and the injuries healed. The resident stated they did not believe GNA #41 intentionally caused the injuries but believed she needed additional training because she had been very rough. On 7/13/26 at approximately 12:00 PM, the surveyor reviewed Facility Reported Incident (FRI #3017272), which included the following: -The initial report submitted to OHCQ on 5/18/26 documented that Resident #19 reported GNA on Saturday [5/16/26] gave [them] a shower which resulted in 2 toes on [their] right and left feet to bleed. -A statement written by the Admissions Director (Staff #43) on 5/18/26, reported that she obtained a statement from Resident #19 which stated During rounds this writer stopped and spoke with [Resident #19] who reported that [their] aide [GNA#41] was rough with them during their shower on Saturday 5/16/26 around 3:30 pm. The resident explained rough to be scrubbing too hard which they reports caused bleeding between their toes. -A statement obtained from GNA #41 dated 5/22/26 documented that on 5/16/26 the GNA stated I washed between [Resident #19's] toes and I saw blood. We finished the shower and returned to [their] room, saw the blood and told [them] I would report it to the nurse. -A statement obtained on 5/21/26 by GNA #44 stated that on 5/16/26 she saw bleeding from Resident #19's toes after [s/he] had been transferred into the bed. GNA #41 told GNA #44 that she was going to report it to the supervisor. -A statement obtained by Nurse #42 obtained on 5/21/26 stated I was not made aware of any alteration in [Resident #19's] skin integrity by the resident or by direct care staff. No reports were made to me [regarding the incident of bleeding toes on 5/16/26]. On 7/13/26 at 3:00 PM, the surveyor interviewed the Nursing Home Administrator (NHA) regarding the incident. The NHA stated the allegation was determined to be unsubstantiated because the resident did not believe the injury was intentional and the GNA had been being rough. When asked whether the facility addressed the fact that GNA #41 failed to report the resident's bleeding toes to the charge nurse, the NHA acknowledged that the GNA had received neglect and abuse education but did not believe any additional education had been provided regarding reporting changes in condition or providing gentle ADL care. The surveyor expressed concern that although the abuse allegation was determined to be unsubstantiated, the investigation identified that GNA #41 observed the resident's bleeding toes but failed to report the change in condition to nursing staff. The surveyor also expressed concern that the facility had not addressed the need for additional education related to safe handling during ADL care. The NHA stated the GNA would receive additional training. On 7/13/26 at 3:24 PM, the NHA informed the surveyor that GNA #41 had been removed from resident care duties and would not return until additional training had been completed.

Based on medical record review and interview it was determined that the facility failed to address the resident's needs in regard to a hearing aid. This was found to be evident for one (Resident #5) out of one resident reviewed for communication needs.The findings include: Review of Resident #5's medical record revealed an Minimum Data Set(MDS) assessment, with an assessment reference date of 5/15/26, that indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This assessment also revealed that the resident has a hearing aid. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Review of the resident's care plans failed to reveal documentation regarding the residents need for or use of hearing aids.On 7/6/26 at 11:03 AM Resident #5, when asked about ability to hear, reported s/he could hear ok out of one ear, but indicated the hearing aid for the other ear was lost about a month ago. The resident reported having spoken to someone at the facility about this concern and thought they were going to replace it but had not heard any updates.On the morning of 7/9/26, review of the medical record revealed an order, with a start date of 1/2/26 for: Nurse to place hearing aids in resident's ears every morning, and remove in the evening. Store in med cart. Ensure battery door is open when placed in case. Review of the Medication Administration Record (MAR) revealed an area for the nurse to document about the hearing aids at 9:00 AM and 9:00 PM. Review of the June MAR revealed staff were documenting the provision and storage of the hearing aids from June 1st through June 12th. The area to document on the morning of 6/13/26 was noted to be blank and a 7 was documented in the evening. A 7 indicates Other/See Nurse Notes. Review of the corresponding nursing note revealed: Not available.Review of the Resident Concern/Complaint Form dated 6/15/26 revealed the resident reported the hearing aid was in a cup and now is missing The report also indicated that Nurse #27 was unable to find the hearing aid during the morning shift. The Social Service Designee (SSD) #14 followed up regarding the concern but was unable to locate the hearing aid. SSD #14 documented that the unit manager placed the resident's on [name of audiology provider] list and that the resident was agreeable with the outcome.On 7/9/26 at 1:31 PM the Assistant Director of Nursing (ADON) #6 presented with a written statement that indicated on 6/16/26 she had interviewed Nurse #28 about the hearing aids. Nurse #28 had confirmed he removed the resident's hearing aids during his evening shift and placed them in a cup on the medication cart but was unable to confirm whether the hearing aids were secured in the locked medication cart before the end of his shift.On 7/9/26 at 12:35 PM Social Service Designee (SSD) #14 reported the resident had a hearing aid that the resident reported missing and that they are in the process of communicating with [name of audiology provider] and that the resident is on the list for audiology provider to get the hearing aid replaced. On 7/09/26 at 1:03 PM the Unit Nurse Manager (UM) #21 reported both a nurse and an aid reported there were two hearing aids when first delivered but that one went missing early on. UM #21 provided a copy of a Hearing Aid Delivery Receipt, dated 12/8/25, that indicated a left and a right hearing aid was delivered. UM #21 went on to report that she had completed the medication pass yesterday and that the box is still in the medication cart but that both of the hearing aids are currently gone. UM #21 reported there is a warranty so the hearing aids will be replaced. When asked how the audiology provider is notified, UM #21 reported we email them with the people to be seen, then it is their schedule as to when they come out here. When asked who is responsible for notifying the audiology provider, UM #21 asked if she could check and get back to the surveyor.During an interview with the ADON on 7/9/26 at 1:31 PM when asked who notified the audiology provider about the missing hearing aid, the ADON reported the audiology provider will send an email with a list of who is to be seen and then the facility can put names on an add on list for additional residents to be seen. The ADON was unable to provide information regarding how often or when the audiology provider would be coming to the facility. She confirmed that the audiology provider has not been informed of the missing hearing aids and reported that Resident #5 is to be added to the list when the facility has confirmation of the date they will be coming to the facility. She went on to report that the unit managers keep their own list and that Resident #5 is the only one to be added on for audiology. When asked where the list was kept, the ADON reported it is not a list, it is just Resident #5 and confirmed there is no specific running list for audiology. When asked if there was any reason she was unable to notify audiology that a resident needs to be seen, the ADON responded: I am not aware of a way to notify them.On 7/09/26 at 2:16 PM the Director of Nursing (DON) reported that she had provided a contact number for the audiology provider to the Social Worker sometime in the past week or two. The DON indicated the Social Worker has contacted the provider, surveyor then requested documentation to support that the provider has been contacted. Surveyor then reviewed the concern that the ADON indicated they did not have a way to contact the audiology provider and that they just wait for the provider to contact them and they provide the name as an add on. The DON reported the process should be that the UM lets the Social Worker know and if not receiving feedback from the provider they should let me (DON) know so I can escalate it. DON also reported that the provider should be coming to the facility quarterly and as needed.On 7/09/26 at 3:30 PM the DON reported that there was no documentation to indicate the audiology provider was notified of the missing hearing aid.On 7/14/26 at 11:24 AM surveyor reviewed the concerns with the DON and New NHA #10 regarding the failure to ensure the hearing aid was available and failure to ensure the audiology provider was notified of the loss of the hearing aid. Cross reference to F 656 and F 658

Based on interviews, observations, and record reviews, it was determined that the facility failed to protect a dependent resident from injury while using Hoyer lift equipment. This was evident for 1 (Resident #59) of 7 residents investigated for potential abuse related to a facility reported incident (FRI #3003045) and an anonymous complaint (#3005562).The findings include:Resident #59 has a diagnosis of Multiple Sclerosis (MS), which impacts mobility and requires assistance with Activities of Daily Living (ADLs). Resident #59's care plan identifies the use of a mechanical lift with two staff members to safely transfer the resident from bed to chair.On 7/6/26 at 11:34 AM, during the initial screening process of the survey, Resident #59 spoke with the surveyor and stated that they had concerns regarding how staff treated them and requested that the surveyor return when their spouse was visiting to further discuss the concerns.On 7/7/26 at 3:17 PM, the surveyor conducted an interview with Resident #59 and their spouse. The resident's spouse stated that while most staff in the facility are wonderful, there are some staff members who have caused concerns for the resident. The spouse described an incident in which GNA #39 struck the resident above the eye with a Hoyer Lift while attempting to transfer the resident from a chair to the bed. Resident #59 stated that GNA #39 entered the room with the Hoyer Lift and pushed it toward them, causing it to hit them above the eye. The resident stated they sustained a cut above their eye but did not develop bruising. Resident #59 stated they reported the incident immediately to facility staff. Resident #59 further stated that GNA #39 was always in a hurry and was rough while providing care. The resident's spouse stated that although they were not present during the incident, they had witnessed GNA #39 being careless and rushing several times.On 7/8/26 at 1:50 PM, the surveyor performed a record review and identified that Resident #59's care plan included the use of a mechanical lift with two staff members for transfers.On 7/8/26 at 2:07 PM, the Assistant Director of Nursing (ADON) confirmed that all residents transferred using a Hoyer lift require two staff members to be present during the transfer.On 7/8/26 at 2:30 PM, the surveyor reviewed Facility Reported Incident (FRI #3003045) and anonymous complaint (#3005562). The FRI indicated that Resident #59 alleged GNA #39 hit the resident in the head with a Hoyer lift on 5/1/26. The facility investigated the allegation and determined the allegation was inconclusive. Review of the facility investigation documents revealed the following:A note from Social Services dated 5/5/26 stated that Resident #59 felt the aide was careless but did not hit the resident on purpose.A staff statement dated 5/4/26 revealed that on 5/1/26 Resident #59 reported being hit on the head with part of the lift machine. The resident expressed frustration that GNA #39 was rushing, stating, she did everything so fast as if she were in a hurry.A statement dated 5/1/26 from GNA #39 revealed that GNA #39 brought the Hoyer lift into the resident's room and was waiting for a second GNA to assist. GNA #39 denied that the Hoyer lift hit the resident and stated that the resident yelled, you just hit me in the face. GNA #39 stated that the resident then yelled at her to get out.A statement from GNA #40 revealed that GNA #39 reportedly exited Resident #59's room and stated that the resident was upset and didn't want me back in their room due to the fact that she had hit her in the head with the Hoyer lift. GNA #40 entered Resident #59's room and observed the resident crying and upset about what had happened.A statement from the ADON (who was the Director of Nursing (DON) at the time of the incident) dated 5/4/26 revealed that GNA #39 initially reported that the incident did not occur. The ADON stated that GNA #39 later reported that when moving the Hoyer lift forward the lift swung forward and bumped [Resident #59's] forehead. The ADON further stated that GNA #39 admitted she was rushing and thinking about the next thing that she had to do and was not being careful at the time of the incident.On 7/8/26, review of the employee file indicated that GNA #39 was terminated on 5/22/26 for violation of the company code of conduct.On 7/8/26 at 12:15 PM, the surveyor conducted an interview with the ADON, who was the DON at the time of the incident. The ADON stated that Resident #59 was sitting in a chair awaiting transfer back to bed. The ADON stated that GNA #39 was bringing the Hoyer lift into the room and that the top portion of the lift was swinging as she moved it, causing it to strike the resident above the eyebrow. The ADON confirmed there were inconsistencies in the reporting of events and stated that GNA #39 initially denied the allegation but later acknowledged that the Hoyer lift struck the resident. The ADON further stated that GNA #39 admitted she was rushing and thinking about the next thing that she had to do and was not being careful at the time of the incident. The ADON confirmed that the resident was struck due to GNA #39 rushing.The surveyor discussed concerns that the resident was not protected from injury due to staff rushing while handling mechanical lift equipment. The ADON confirmed the expectation that GNA staff operate equipment carefully, do not rush while providing care, and use two staff members when operating a Hoyer lift.

Based on interview and record review, it was determined that the facility failed to ensure residents receiving hemodialysis received care and services consistent with professional standards of practice for 2 (Residents #4 and #26) of 2 residents reviewed for hemodialysis services.The findings include:Administering medications prior to hemodialysis—a treatment where a machine filters waste and fluid from the blood—can remove water-soluble drugs before they achieve a therapeutic effect. Additionally, giving blood pressure medications beforehand increases the risk of dangerous blood pressure drops, as the drug's effects combine with the machine's fluid removal process. On 7/7/26 at 3:07 PM, a review of the facility policy titled Hemodialysis revealed that physician orders for hemodialysis were to include instructions regarding medications to be administered or withheld before hemodialysis treatments. The policy further required nursing staff to communicate medication administration, including medications administered or withheld before hemodialysis, with the hemodialysis provider and document those communications. On 7/7/26 at 2:32 PM, during the medication administration task, Staff #3, a Licensed Practical Nurse (LPN), stated this was the first facility in their 34 years of nursing where residents receiving hemodialysis routinely received scheduled morning medications before leaving for hemodialysis appointments. 1 - Resident #4 On 7/6/26 at 10:20 AM, during an interview with Resident #4, they stated to the surveyor that they received hemodialysis every Monday, Wednesday, and Friday. The resident stated that nursing staff began administering all scheduled morning medications before hemodialysis appointments, approximately in the middle of the previous month. Resident #4 further stated they had routinely taken their phosphate binder before hemodialysis but had never previously received all scheduled morning medications before hemodialysis and expressed concern regarding the recent change in practice. On 7/7/26 at 2:40 PM, review of the July 2026 Medication Administration Record (MAR) and hemodialysis communication documentation revealed that Resident #4's scheduled morning medications were documented as administered immediately before hemodialysis appointments on July 1, 3, 6, and 8, 2026. The hemodialysis communication documentation contained incomplete or inconsistent departure documentation, including blank departure times on July 3 and July 6, 2026, and a departure time recorded before medication administration on July 8, 2026. On 7/7/26, Staff #3 and Staff #4, an LPN, confirmed there was no physician or consulting nephrologist order directing Resident #4's scheduled morning medications to be administered before hemodialysis and were unable to identify who had authorized the practice. A review of Resident #4's hemodialysis communication binder further revealed no documentation of medication administration to the hemodialysis provider. On 7/7/26 at 2:55 PM, a review of Resident #4's care plan identified interventions related to hemodialysis care. However, there was no physician directed intervention specifying that scheduled morning medications should be administered before hemodialysis treatments. On 7/8/26 at 3:00 PM, during an interview with Staff #7, a Nurse Practitioner, they stated they were uncertain who had directed nursing staff to administer scheduled morning medications before hemodialysis and believed the nursing staff had defaulted to the scheduled administration times in the Medication Administration Record. On 7/8/26 at 3:04 PM, Staff #7 acknowledged concerns regarding resident medication orders, hemodialysis schedules, and the facility's hemodialysis policy and acknowledged that changes were needed. 2 - Resident #26 On 7/7/26 at 2:30 PM, review of the July 2026 MAR and hemodialysis communication documentation revealed that Resident #26's scheduled morning medications were documented as administered immediately before hemodialysis appointments on July 1, 3, 6, and 8, 2026. Documentation further revealed the hemodialysis communication record was incomplete on July 6, 2026, with the resident's departure time left blank despite the nursing staff's signature. On 7/7/26 at 2:38 PM, Staff #3 confirmed no physician or consulting nephrologist order was directing Resident #26's scheduled morning medications to be administered before hemodialysis. A review of Resident #26's hemodialysis communication binder revealed documentation of the resident's weights, vital signs, and fluid intake. However, there was no documentation communicating medication administration to the hemodialysis provider. On 7/7/26 at 2:44 PM, Staff #4 confirmed there was no written order from the physician or consulting nephrologist directing that scheduled morning medications be administered before hemodialysis and was unable to identify who had authorized the practice. On 7/7/26 at 3:20 PM, review of Resident #26's care plan identified interventions related to hemodialysis care. However, there was no physician directed intervention indicating that scheduled morning medications should be administered before hemodialysis treatments. On 7/9/26 at 11:15 AM, during an interview, the Director of Nursing (DON) acknowledged concerns regarding Resident #4 and Resident #26 receiving routine scheduled morning medications before hemodialysis without an expressed physician or consulting nephrologist order. The DON further acknowledged that the hemodialysis communication documentation accompanying residents to the hemodialysis center did not document medications administered before hemodialysis treatments. On 7/14/26 at 10:40 AM, the Assistant Director of Nursing acknowledged concerns about professional standards of practice related to residents receiving hemodialysis.

Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure monthly pharmacy review recommendations were addressed by the providers in a timely manner. This was found to be evident for two (Resident #12 and #7) out of the five residents reviewed for unnecessary medications. The findings include: On 7/7/26 at 11:31 AM the Director of Nursing (DON) was interviewed in regard to the process for the monthly medication regimen review (MRR). The DON reported that once the pharmacist sends the recommendations to the facility they are given to the unit nurse managers who then meet with the physician or nurse practitioner to make any needed changes. She confirmed that there is a paper recommendation form and reported it would be scanned into the electronic health record under the miscellaneous tab. The DON also reported that she keeps a binder with the recommendations as well. Surveyor requested the binder for review. 1)On 7/7/26 at 12:40 PM review of Resident #7's medical record revealed a progress note written by the pharmacist on 3/3/26 that stated: Medication Regimen Review_See report. Further review of the medical record failed to reveal documentation of the referenced report. Review of the facility's Medication Regimen Review policy, with a revision date of 2/17/26, revealed: The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities. Written communications from the pharmacist shall become a permanent part of the resident's medical record Review of the MRR binder provided by the DON revealed a Summary Recommendation Report for Medical Director for recommendations made on 3/3/26. For Resident #7, this report revealed that the resident was currently receiving the antipsychotic medication Quetiapine 25 mg at bedtime. This report also included: Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR [gradual dose reduction] in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.If appropriate, please consider a GDR at this time to Quetiapine 12.5 mg HS [at time bedtime]. If not appropriate, please document rationale for contraindication. No documentation was found in the medical record to indicate this recommendation was addressed by the primary care provider. Review of the facility's Medication Regimen Review policy, with a revision date of 2/17/26, revealed in regard to timelines for responding to the Medication Regimen Review: Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities within 30 days. Further review of the medical record revealed a progress note written by the pharmacist on 4/2/26 that stated: Medication Regimen Review_See report. Review of the miscellaneous section of the electronic health record (EHR) revealed a Recommendations to Attending Physician/Provider form, dated 4/2/26. This form revealed the same recommendation as found in the 3/3/26 Summary Recommendation Report for Medical Director about considering a GDR of the antipsychotic medication Quetiapine. Review of the facility's Medication Regimen Review policy, with a revision date of 2/17/26, revealed: The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. Further review of the 4/2/26 Recommendations to Attending Physician/Provider form found in the EHR revealed the Nurse Practitioner (NP) #7 wrote on 4/7/26 to refer to psych. At the bottom of the form the psychiatric NP #22 documented that she agreed with the recommendation and included a hand written order to discontinue the Quetiapine 25 mg at bedtime, and a new order for Quetiapine 12.5 mg at bedtime. Review of the orders in the EHR confirmed that a new order was put in place on 4/7/26 for the Quetiapine 12.5 mg. On 7/09/26 at 3:30 PM the DON reported that she had identified a concern regarding the MRR process in June and had developed a performance improvement plan but added that it is still an ongoing issue. On 7/14/26 at 11:24 AM surveyor reviewed with the DON the concern regarding the failure to ensure the pharmacy recommendations were reviewed and addressed by the primary care provider for Resident #7. As of time of survey exit on 7/14/26 at 3:10 PM the facility had not provided documentation to indicate the primary care provider, or the psychiatric provider, had reviewed the initial 3/3/26 recommendation for the gradual dose reduction. 2) Review of Resident #12's medical record revealed a 5/5/26 Recommendation to Attending Physician/Provider form that including the following: A large, multinational observational cohort presented at the American Heart Association Scientific Sessions (2025) reported that adults with chronic insomnia who used melatonin for [greater than or equal to] 12 months had a higher hazard of incident of heart failure, higher heart failure hospitalizations, and an increased all-cause mortality over a five-year period compared with non-users. The study analyzed > 100,000 patients and found roughly a near-doubling of some adverse cardiovascular outcomes among long-term users; however, it is observational and cannot definitively prove causation. Please consider discontinuing Melatonin. NP #7 had addressed the 5/5/26 recommendation on 5/20/26 by documenting: refer to psych. Review of the psychiatric NP #22 notes revealed she saw the resident on 5/19/26 and again on 6/23/26. Notes from both of these visits included documentation that the resident was taking Melatonin for a sleep cycle disorder, trazadone for depression and Xanax for anxiety. The notes included a generic statement about a GDR not being indicated because a dose reduction would decrease the patients quality of life. Neither of these notes indicated NP #22 was aware of the pharmacist 5/5/26 report or the recommendation to discontinue the Melatonin because of the cardiac concerns. On 7/14/26 at 10:25 AM an interview was conducted with the psychiatric NP #22. In regard to the MRR recommendations, NP #22 reported that they do not always give her the paper [referencing the Recommendations to Attending Physician/Provider] but that she would include in her notes if there was a pharmacy recommendation. After reviewing her May and June notes for Resident #12, NP #22 stated: never addressed with me. Surveyor asked: did you review this recommendation, to which NP #22 responded: No. On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing the concern regarding the failure to ensure pharmacy recommendations were reviewed by the psychiatric provider, as per the primary care provider instructions for the 5/5/26 recommendation.

Based on medical record review and interview it was determined that the facility failed to ensure resident's were free from unnecessary medications. This was found to be evident for 2 (Resident #5 and #7) of 5 residents reviewed for unnecessary medications. The findings include: 1) Review of Resident #5's medical record revealed an order, in effect since 5/14/26, for oxycodone 5 mg give one tablet every 8 hours as needed for pain 8-10. Oxycodone is a narcotic pain reliever. Pain is rated on a scale from 1-10 with 10 being the worst pain. Review of the June and July 2026 Medication Administration Record (MAR) revealed an area for staff to document the resident's pain level and the time this medication was administered. On 6/11/26 at 7:04 PM the oxycodone was administered and the pain level was documented as 6. Review of the nurse's progress note revealed the follow up pain scale was 0. On 6/15/26 at 7:11 PM the oxycodone was administered and the pain level was documented as 6. Review of the corresponding nurse's progress note revealed: c/o [complaint of] of pain 6/10 and the follow up pain scale was 0. On 6/25/26 at 3:08 PM the oxycodone was administered and the pain level was documented as 3. Review of nurse's progress note revealed the follow up pain scale was 0. On 6/30/26 at 12:17 PM the oxycodone was administered and the pain level was documented as 4. Review of nurse's progress note revealed the follow up pain scale was 2. On 7/3/26 at 8:49 AM the oxycodone was administered and the pain level was documented as 5. Review of the corresponding nurse's note revealed the oxycodone was given for hip pain. The follow up pain scale was documented on 7/4/26 at 9:10 AM with pain rated at 1. On 7/5/26 at 1:28 PM the oxycodone was administered and the pain level was documented as 4. Review of nurse's progress note revealed the follow up pain scale was 0. On 7/09/26 at 11:21 AM Nurse #24 was asked about as needed pain medication administration for Resident #5. Nurse #24 reported prior to giving the medication she would massage and give the pain patch. She went on to report that today the resident had rated the pain an 8 out of 10 and that they had talked about how the pain could be controlled. When asked if she documented these interventions, Nurse #24 stated: yes ma'am. Further review of the MARs revealed an area for nursing staff to document non-pharmacological interventions used before PRN (as needed) Pain Medication. On the following dates staff documented the administration of the as needed oxycodone but no documentation was found on the MAR, or elsewhere in the medical record, to indicate non-pharmacological interventions were attempted prior to the administration of the narcotic: June 11, 15, 19, 22, 26 and July 3, and 5, 2026. Review of the Controlled Drug Sheet for the oxycodone 5 mg for Resident #5 revealed documentation that one dose was removed on 6/29/26 at 11:40 AM. Review of the June MAR and the progress notes failed to reveal documentation to indicate the resident was in pain or was requesting pain medication at that time. No documentation was found on the MAR to indicate this dose was actually administered to the resident. On 7/09/26 at 2:02 PM the Director of Nursing (DON) was asked about the expectation prior to the administration of as needed pain medication. The DON reported she would expect a full assessment and the provision of non-pharmacological interventions. She confirmed that she expected these interventions to be documented. Surveyor then reviewed the concerns regarding the as needed oxycodone being administered without adequate indication for its use and reviewed the documentation of pain being rated less than 8 but the narcotic was administered and the failure to document non-pharmacological interventions. Surveyor also informed the DON that a dose of the oxycodone was removed from the supply on 6/29/26 but no documentation was found to indicate the resident had required or requested it at that time. On 7/14/26 at 11:24 AM during a discussion with the DON she indicated there was additional documentation regarding the oxycodone 5 mg that was pulled from the supply on 6/29/26. As of time of survey exit, on 7/14/26 at 3:10 PM, no additional documentation was provided regarding this concern. 2) Review of Resident #7's medical record revealed an order, in effect since 12/5/25, for blood sugar finger sticks before meals and at bedtime. There is another order for Insulin Lispro (a rapid acting insulin), inject 3 units with meals for diabetes and to hold if blood sugar is less than 100. Review of the Medication Administration Record (MAR) revealed documentation of blood sugars (BS) at 6:30 AM, 11:30 AM; 4:30 PM and 9:00 PM. The MAR also included documentation of the administration of the Insulin Lispro at 8:00 AM, 12 noon, and 5:00 PM. On 7/08/26 at 12:51 PM Nurse 19 reported she had obtained the resident's blood sugar today prior to administering the lunch time dose of insulin. The nurse also reported that there was an order to hold the Insulin Lispro if the blood sugar was less than 100. Review of the June and July 2026 MARs revealed on the following dates the resident's blood sugar was below 100 and the staff administered the Insulin Lispro at the time of the corresponding meal: On June 8 at 4:30 PM the BS was 94.On June 10 at 6:30 AM the BS was 80.On June 14 at 6:30 AM the BS was 86.On June 15 at 6:30 AM the BS was 91.On June 15 at 4:30 PM the BS was 95.On June 25 at 6:30 AM the BS was 98.On June 29 at 6:30 AM the BS was 92.On July 2 at 6:30 AM the BS was 86. On 7/08/26 at 12:36 PM surveyor reviewed the concern with the Nurse Practitioner (NP) #7 regarding the BS being below 100 and the insulin being administered. NP #7 responded that: they are suppose to hold it. The NP also reported that the resident is followed by an endocrinologist and those are her recommendations. On 7/08/26 at 4:05 PM surveyor informed the Nursing Home Administrator of the concern regarding unnecessary medication related to multiple occasions when the resident's blood sugar was less than 100 and the insulin was administered. On 7/14/26 at 11:24 PM the surveyor reviewed the concern with the Director of Nursing regarding the administration of insulin when the blood sugar was below the parameter to hold the medication. As of time of survey exit on 7/14/26 at 3:10 PM no additional documentation was provided regarding this concern.

Based on record review and interview it was determined that the facility failed to ensure abnormal laboratory results were uploaded into the resident's electronic medical record in a timely manner. This was evident for 1 resident (Resident # 48) of 1 resident reviewed for pressure ulcer care during the annual survey.The findings include: Resident #48 was frail and elderly and was admitted to the facility in January 2026, and had multiple medical conditions which included, but were not limited to, pressure ulcer and hyperkalemia [high blood potassium]. On 7/08/26 at 1:45 PM a review of Resident #48's electronic record revealed two nurse practitioner (NP) progress notes dated the same day, 7/08/26, that were contradictory regarding treatment for the resident's high potassium level. One note was written by an on-call NP (Staff #34), who was contacted by the facility nurse by phone on the evening of 7/07/26 because the resident's Sodium Polystyrene Sulfonate [medication to lower blood potassium levels] was not available from the pharmacy. Staff #34's documentation indicated that she reviewed the laboratory results in the resident's record, a potassium level result on 6/29/26, which was normal, and that Staff #34 gave the nurse an order to hold [not give] the Sodium Polystyrene Sulfonate medication. The other NP note was written by the facility's nurse practitioner (Staff #7) on 7/08/26 at 1:33 PM and indicated that the resident had high potassium levels on 7/06/26 and 7/08/26 and she gave an order to continue the resident's Sodium Polystyrene Sulfonate and as well as another medication also used to treat high potassium levels. A review of the miscellaneous scanned documents revealed the most recent lab result in the record was for 6/29/26. On 7/08/26 at 1:57 PM an interview was conducted with the facility's Staff #7 to review the Resident #48's documentation and laboratory results in the electronic record. Staff #7 was asked where the resident's lab reports for 7/06/26 and 7/08/26 were and Staff #7 brought the surveyor to the receptionist's desk (Staff #8) to look for them. Staff #8 looked through a stack of resident documentation but said she did not have the lab reports in question. At 7/08/26 at 2:17 PM a continued interview with Staff #7, was conducted and the unit manager (Staff #16), and the Director of Nursing (DON) were asked to join the interview which was continued in Staff #8's office. The DON was informed that the resident's chart lacked the most current and accurate laboratory results and that an on-call NP had given orders based on an old laboratory result. The DON explained the system for how lab results were received and processed at the facility. She said that the local hospital processes labs for the facility, but they did not automatically transmit resident's lab results, someone at the facility had to access the hospital's portal to retrieve the results and that currently only the Assistant Director of Nursing (ADON, Staff #6) had access to do so. The DON further explained that once the lab results were retrieved (printed) they would be given to the unit manager who would in turn give them to the provider for that day (physician or NP) to review. Once reviewed, the lab result would be given to the receptionist (Staff #8) and she would then scan the lab results into each resident's medical record. The DON and Staff #16 said that the facility had been looking at this process as part of the facility's quality assurance (QA) activities, but they acknowledged that the issue they focused on was the number of staff who had access to the hospital's portal, not the process of how lab results were handled once they were accessed. They acknowledged that Resident #48's abnormal labs results were available at the facility on 7/6/26 and 7/8/26 but were not in the resident's record when the on-call provider looked for them on 7/07/26 and were still not in the resident's record at the time of the interview. Staff #16 said she had the lab results on her desk and that the facility would work on their process for how lab results were entered into resident's records. On 7/09/26 at 9:49 AM an interview was conducted with Staff #6 to review the concern that Resident #48's abnormal lab reports from 7/06/26 and 7/08/26 for were not in the resident's record, even though they were available to be placed in the record. She was also informed that an on-call provider was contacted on 7/07/26 in the evening and the on-call provider referenced the old lab report dated 6/29/26 that had a normal lab value, and that the resident's more recent abnormal lab results were not in the record for the on-call provider to review. In response, Staff #6 also reported that the facility had an ongoing ad hoc QA project for lab results but she confirmed that the focus was on the concern that only she had access to the lab results from the hospital system. She acknowledged the concern that the lab result was available but not placed in the resident's record and could not explain why the record did not contain the most recent lab results.

Based on interview and record review it was determined that the facility failed to follow up on a resident's need for oral surgery. This was evident for 1 resident (Resident #11) of 1 resident reviewed for dental care during the recertification survey.The findings include:Resident #11 was admitted to the facility in May 2024 due to his/her need for assistance with all activities of daily living. The resident had medical diagnoses that included, but were not limited to, acute and chronic respiratory failure and diabetes.On 7/06/26 at 3:26 PM an interview was conducted with Resident #11 who said s/he had a dentist visit at the facility and was told that s/he needed to have teeth pulled but that no appointment had yet been scheduled.On 7/08/26 at 1:31 AM a review of Resident #11's medical record revealed a dental consult/exam/visit note dated 2/06/26, found in the scanned documents. The dental note indicated a recommendation for referral to an oral surgeon for surgical extraction of retained roots and gave the company name and phone number to call for the referral. On 7/09/26 at 1:35 PM an interview was conducted with the Assistant Director of Nursing (ADON, Staff #6) regarding the facility's process for how recommendations by dental providers were managed. She explained that the unit manager who received the paperwork that indicated the need for follow-up would contact the facility's scheduler by email and in the communications section of the medical records software program, although it was not part of the clinical record. When asked if the scheduler received communication from the unit manager that Resident #11 needed an appointment with an oral surgeon, Staff #6 said she did not know and that the unit manager for that unit was no longer at the facility. When asked if she was aware of the resident's need for follow-up with an oral surgeon, Staff #6 said that she was not aware of it.On 7/10/26 at 10:32 AM an interview was conducted with Staff #6 who said that the resident's follow up appointment with an oral surgeon was missed until it was brought to her attention by the survey team and that it was now scheduled.

Based on interview and review of facility documentation it was determined that the facility failed to have a qualified food service director. This was found to be evident for the one out of one food service director at the facility. The findings include: During the initial tour of the kitchen on 7/6/26 at 9:28 AM, Staff #15 introduced himself as the Dietary Manager. Later during the tour, Staff #15 reported he was not a Certified Dietary Manager (CDM) but that his boss has a CDM. Staff #15 went on to report that the CDM was there two to three times a week, and there is a dietitian four days a week.On 7/8/26 at 1;44 PM the facility's registered dietitian (RD) #17 was interviewed. RD #17 reported she works four days a week. When asked about her role in the kitchen, RD #17 reported she coordinates with the Dietary Manager, talks a lot about diet texture and supplements. RD #17 confirmed that she had no oversight or management of the kitchen.On 7/8/26 at approximately 4:00 PM surveyor requested the Dietary Manager's credentials from the Nursing Home Administrator (NHA).On 7/9/26 at 10:38 AM review of the documentation provided by the NHA revealed a CDM certificate for Staff # 47. An interview with the NHA revealed that Staff #15 is the Dietary Manager and that the CDM was for Staff #47 who is a corporate person who is only at the facility 1-2 days per week. The NHA went on to report that he thought it was acceptable since they have a full time RD. Surveyor informed the NHA of the interview with RD #17 who had reported working only 4 days per week and that she had reported she has no oversight or management of the kitchen but rather coordination to ensure residents received what they should.On 7/8/26 at 2:00 PM Staff #47 reported he is at this facility once or twice per week.If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. Full-time means working 35 or more hours a week.In States that have established standards for food service managers or dietary managers, the director of food and nutrition services must meet the State requirements for food service managers or dietary managers.The state of Maryland requires in a nursing home with more than 50 beds, overall supervisory responsibilities for the food service department and food production shall be assigned to a full-time qualified dietetic service supervisor.[See S0790].Review of the definitions section of the state regulations revealed: Dietetic service supervisor means a person who: (a) Is a qualified dietitian; (b) Is a graduate of a dietetic technician program approved by the American Dietetic Association; (c) Is a certified dietary manager who has successfully completed the required course and maintains certification as required by the certifying board for the Dietary Managers Association; (d) Is a graduate of a State-approved course that provided 90 or more hours of classroom instruction in food service supervision and has experience as a supervisor in a health care institution with consultation from a dietitian; or (e) Has training and experience in food service supervision and management in a military service equivalent in content to (b) and (d) of this regulation.On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing and the New NHA #10 the concern regarding the failure to ensure the food service director was a CDM.As of time of survey exit on 7/14/26 at 3:10 PM no additional documentation was provided to indicate the RD worked full time or had managerial duties in the kitchen. No credentials were provided for Staff #15.Cross refernce to F 803 and F812

Based on observation, review of menus and medical records and interviews it was determined that the facility failed to ensure menus were followed. This was found to be evident for one out of one pureed test tray observed and has the potential to affect any resident who requires pureed texture foods.The findings include:On 7/09/26 at approximately 4:50 PM observation of dinner tray line revealed three pureed items which were identified by the cook as mashed potatoes, spinach and turkey.Review of the dinner menu for 7/9/26 revealed it included winter blend vegetables and baked macaroni and cheese. Spinach and mashed potatoes were not found on the dinner menu or the alternative menu.On 7/09/26 at approximately 5:00 PM Corporate Chef #47 confirmed the puree vegetable for dinner is spinach and he pointed to the posted menu and reported that the spinach was also served at lunch. He stated it was made at lunch. Corporate Chef #47 also reported they are serving mashed potatoes rather than the mac and cheese for better consistency. Surveyor requested a small portion of the puree items to be provided for a tasting.On 7/09/26 at 5:25 PM taste test of the puree dinner confirmed that it was spinach, mashed potatoes and turkey. Observation and taste test of a regular consistency meal revealed the winter blend vegetables consisted of broccoli and cauliflower rather than spinach. The regular consistency meal also included macaroni and cheese, rather than mashed potatoes.The concern regarding the pureed items not being what was on the menu was discussed with the Corporate Chef #47 at 5:30 PM and with the Nursing Home Administrator on 5:45 PM.On 7/13/26 at 12:35 PM Resident #41's family reported a concern that the resident requires pureed food and that the resident doesn't get the same food as everyone else. The family member went on to state that the food has been all white on the meal tray on occasion. Review of Resident #41's medical record revealed that the resident has a diet order, in place since 6/26/26, for pureed texture.On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing and the New NHA #10 the concern regarding failure to ensure menus were followed.

Based on observation and interview it was determined that the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety. This has the potential to affect all residents. The findings include: 1) On 7/6/26 at approximately 9:30 AM surveyor observed a cutting board located by the tray line in the kitchen with multiple cut marks. On 7/10/26 at 10:05 AM surveyor observed, with the Corporate Chef, the cutting located along the tray line in the kitchen. The cutting board was approximately 12 inches x 48 inches and 3/4 inch thick. It was noted to have multiple cut marks on the entire board, and orange stains on both the top and bottom of the board. Corporate Chef acknowledged the cut marks and the stains and stated: can order a new one.2) On 7/6/26 at approximately 9:46 AM surveyor observed in the dishwashing area two trays of cups resting open side down on a flat tray. Upon looking at the inside portion of the cups three out of three cups observed were noted to be wet. The Dietary Manager #15 then instructed staff to put these cups back on a drying rack.On 7/08/26 at 2:00 PM during a follow up visit to the kitchen with Dietary Manager (DM) #15 and the Corporate Chef #47, surveyor again observed cups sitting open side down on a flat tray in the dishwashing area. DM #15 and the Corporate Chef reported these cups are drying, once dried they bring them over to area near tray line. Surveyor then observed cups sitting open side down on flat trays near tray line. Two out of three randomly chosen cups were found to have water inside the cup. Corporate Chef validated this observation.3) On 7/06/26 surveyor observed an ice machine located in the main dining room. No issues or concerns were identified in regard to the cleanliness of this ice machine. The Dietary Manager #15 reported dietary staff are responsible for cleaning this machine weekly.On 7/08/26 at 1:07 PM observation of the nourishment room on the 300 unit revealed an ice machine. Upon opening the ice machine surveyor noted along inner aspect of the door of the ice machine an area of reddish build up with several black splotches.On 7/08/26 at 1:32 PM observation of nourishment room on the 300 unit with Corporate Nurse # 16 also observed the inside of the ice machine with the reddish discoloration. Surveyor then requested documentation regarding when this ice machine was most recently cleaned.On 7/08/26 at 1:36 PM while preparing to empty out the 300-unit nourishment room ice machine, the Maintenance Director #12 reported maintenance cleans the part of the machine that produces the ice, but the kitchen staff cleans the ice bin.On 7/8/26 at 1:39 PM the Dietary Manager #15 reported that dietary staff does not clean the ice machine on the unit. Unit Nurse #16 was present at this time, and she confirmed that the facility only has two ice machines.On 7/08/26 at 2:00 PM during a follow up visit to the kitchen the Dietary Manager (DM) #15 provided a copy of an Ice Machine Cleaning and Sanitation of the BIN log that revealed weekly cleaning of the ice machine for 2025 thru June 2026. DM #15 reported these logs are just for the ice machine in the dining room. Surveyor reviewed the concern with the DM and Corporate Chef regarding the failure to ensure the ice machine on the unit was being cleaned.4) On 7/08/26 at 1:32 PM observation of nourishment room on the 300 unit with corporate nurse # 16 revealed that the refrigerator contained several unlabeled, undated containers of food. Review of the facility policy Food Brought in from Outside Sources and Personal Food Storage revealed that Foods and beverages brought in from outside sources that require refrigeration or freezing will be labeled with the patient/resident's name and date and stored in the refrigerator/freezer apart from facility food. On 7/14/26 at 11:24 AM surveyor reviewed with the Director of Nursing and the New NHA #10 the concerns regarding failure to ensure: cutting board was in good repair; dishes dried completely before storing; the unit ice machine was kept clean and that food in the nourishment room refrigerator was labeled and dated.

Based on record review and interview it was determined that the facility failed to identify a cognitively impaired resident as an elopement risk and implement interventions to prevent elopement. This was evident for 1 (#6) of 1 resident reviewed for elopement. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 1/15/26 at 3:50 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 1/15/26 at 5:35 PM and it was not accepted. The facility submitted a second draft at 6:23 PM, and it was not accepted. The third draft was submitted at 6:38 PM and the facility's written plan to remove the immediacy was accepted on 1/15/26 at 7:00PM. After the immediacy was removed, the noncompliance was determined to continue with a scope and severity of D.The findings include:Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1. On 1/15/26 at 10:30 AM a review of the facility's policy titled, Elopements and Wandering Residents that was implemented on 3/14/24 and last reviewed on 4/4/25 was conducted. The policy read that the facility was equipped with door locks and alarms to avoid elopements, the alarms were not a replacement for necessary supervision, and the facility established a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering. The policy further noted that this included identification and assessment of risk and implementing interventions. According to the policy residents were to be assessed for risk of elopement and unsafe wandering on admission and throughout their stay by the interdisciplinary team, staff were to provide adequate supervision, residents assessed as a high risk would have an alarm bracelet placed on them, and a care plan with interventions was to be developed and implemented. According to the policy if a resident was a moderate risk then the Interdisciplinary team would review for interventions to possibly include an alarm bracelet and if deemed necessary the alarm bracelet would be placed on the resident. The alarm bracelet causes an alarm to sound if a resident was too close to an exit door that was armed. A medical record review for Resident #6 on 1/15/26 at 9:00 AM revealed a discharge summary from the acute care hospital documenting the resident was admitted to the hospital for a hemorrhagic stroke (a stroke caused by bleeding in the brain). Further review of the report revealed the resident was living at home, driving a car, and working a job prior to going to the hospital. The physical therapy (PT) notes from the hospital dated 11/12/25, revealed the resident was able to walk 2 feet with a rolling walker with maximum assistance of 2 people while at the hospital. A review of the facility's nursing admission assessment dated [DATE] revealed in the section for elopement, that Licensed Practical Nurse (LPN) #18 marked the resident was unable to ambulate (walk) and therefore the rest of the assessment was locked; deeming the resident no risk for elopement. A review of the progress notes revealed the resident had fallen on 11/15/25 at 3:15 AM and 3:40 AM. The nurse documented the resident tried to get out of bed and walk, but was unsteady on his/her feet. A review of the care plan revealed nursing staff initiated a care plan for the resident on 11/17/25 for noncompliance with using his/her walker. On 11/18/25 the resident had a Brief Interview for Mental Status conducted and it was determined the resident had severe cognitive impairment. A review of the miscellaneous section revealed the resident was deemed incapable of comprehending information and making decisions due to the stroke by the attending physician on 11/17/25 and by Nurse Practitioner (NP) #19 on 11/18/25. It was noted in the medical record under the census tab that the resident was moved from Longmeadow nursing unit to the Paramount nursing unit. A review of the physical therapy notes on 1/15/26 at 5:02 PM revealed that on 11/17/25 the resident had ambulated 70 feet with a rolling walker with minimum assistance. This was a change in the resident's condition. On 1/15/26 at 10:30 AM a review of the facility's investigation file for the facility reported incident #2675133 revealed that staff documented on the the initial report form that on 11/20/25 at 5:18 PM a nurse found Resident #6 in the parking lot of the facility. A statement written by the interim Director of Nursing Staff #3 revealed she interviewed the resident's spouse on 11/20/25 at 7:00 PM and when asked if the resident talked about leaving the facility, the spouse reported that s/he usually does, but not on that day. The spouse further reported that the resident was usually worked up when the family was getting ready to leave and asked repeatedly if they could go home. A review of the interview with LPN #25 on 11/20/25 conducted by the Nursing Home Administrator (NHA) revealed he was assigned to the resident on 11/20/25. He reported he was checking other resident's blood sugars and passing out dinner trays at the time the resident left the unit and had not seen Resident #6 leave the unit. A review of the interview with GNA #21 conducted by the NHA on 11/20/25 revealed she was assigned to the resident that day. She was passing out trays to other residents and had not observed Resident #6 leaving the unit. During the interviews, staff had not been asked if the resident had talked about going home or observed wandering. A review of the interview on 11/20/25 with the receptionist conducted by the NHA revealed that she saw the resident coming down the hallway carrying a basin with some items in it and a shoe box, but was not sure if it was a resident or not. She stated that after the resident went out the door, she walked over and saw a truck parked outside near the front door and thought the resident had gotten in the truck. On 11/20/25 the NHA interviewed the visitor who found Resident #6 lying in the parking lot. The visitor reported that when they drove into the visitor parking lot they noticed the resident lying on the ground. The visitor reported that the resident had a wash basin with some items in it and a shoe box with a pair of shoes in it. Another statement collected on 11/20/25 by the NHA was from LPN #2 who was leaving the facility and saw the resident lying on the ground in the parking lot behind a parked car. A review of the final report form revealed that based on the facility's investigation Resident #6 left the faciity on [DATE] at 5:09 PM in 41 degree weather and it was dark. The resident had not been wearing a coat and was found at 5:18 PM lying on the ground in the visitor parking lot. A review of the elopement assessment completed on 11/20/25 revealed the resident was deemed high risk for elopement and an alarm bracelet was placed on the resident. Further review of the investigation file revealed the facility staff had started educating all staff regarding the elopement policy and educating the nurses about the elopement assessments, but failed to ensure that all staff received the education. An interview with GNA #1 on 1/15/26 at 11:31 AM revealed she had been taking care of Resident #6 on a regular basis since 11/18/25 and the resident was constantly talking about going home. She reported it was worse on the days his/her family visited. She stated the resident would frequently get up out of bed with no assistance and ambulate, but the resident was not steady on their feet. When asked if she thought the resident could make it down the hallway to the front door, she stated it did not surprise her. Nurse Practitioner (NP) #19 was interviewed on 1/15/26 at 12:08 PM regarding Resident #6 and she reported she remembered the resident being confused, agitated, and impulsive. An interview with GNA #21 on 1/15/26 at 4:51 PM revealed she was assigned to Resident #6 on 11/20/25. She stated she remembered the resident would walk unassisted, but was unsteady. She stated the resident would get up and walk without any purpose and seemed confused. She stated that the resident talked about going home everyday. She stated that on the evening the resident had eloped, she gave him/her their dinner tray and then went on down the hall passing trays to the other residents on the unit. She stated when she finished and went back to check on the resident she was unable to find him/her. She stated that with the Thanksgiving event there were a lot of people in the building and it would have been easy for the resident to walk off the unit unnoticed. During an interview on 1/15/26 at 4:37 PM with Occupational Therapy Assistant Staff #22 it was reported that Resident #6 frequently talked about wanting to go home. An interview with the Occupation Therapist Staff #23 on 1/15/26 at 4:37 PM revealed the resident had poor safety awareness and was independent prior to coming to the facility. She stated that on 11/20/25 the resident was able to walk 50 feet with contact assistance. She stated the resident frequently stated s/he wanted to go home. She reported she was present on the day of the elopement and the resident stated s/he went outside to go home. On 1/15/26 at 11:41 AM an interview with LPN #2 revealed she was not assigned to Resident #6 on 11/20/25, but when she was leaving for the day, they drove through the visitor parking lot and saw the resident lying on the ground behind a parked car. She stated they first noticed the crowd of bystanders around him/her. She stated it was dark out and several visitors were coming to the facility for a Thanksgiving event. She stated at first she had not recognized the resident, but when she saw a brief (adult diaper) sticking out of his/her sweatpants she realized it was a resident and called for assistance. An interview with Corporate Clinical Resource Nurse Staff #3 on 1/15/26 at 1:29 PM she was the interim DON at the time of Resident #6's elopement. She reported that staff were expected to conduct elopement assessments on all new admissions/readmissions, quarterly, and with a change in condition/behavior. Review of the interviews conducted with staff and Staff #3 reported that the resident was displaying behaviors that should have triggered staff to reassess for elopement. When asked if she was aware of the behaviors, she stated that when the resident was first admitted she was told about the behaviors, but was then told during the morning meeting that the resident was talking about going home less and adjusting to the facility. On 1/15/26 at 1:47 PM an interview with the Nursing Home Administrator (NHA) revealed that she was present when the elopement occurred because it was the night of the facility's Thanksgiving event. She reported that a visitor found the Resident #6 in the parking lot lying on the ground. She stated that when she interview Resident #6, s/he said they were trying to go home. She reported that the resident was not someone they were watching for elopement because his/her elopement assessment on admission determined the resident was not an elopement risk. However, when asked the behaviors she considered to be high risk for elopement she reported the resident mentioning they wanted to go home, packing their things, and exit seeking behaviors. This deficient practice led to a cognitively impaired resident leaving the facility while it was dark, in 41 degrees (F) weather without appropriate outerwear and the resident fell on the ground in a visitor parking lot that was not well lit at the time visitors were arriving for a facility event. As a result of the fall the resident sustained an abrasion to the right side of his/her face and scrapes on both hands. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 1/15/26 at 3:50 PM. The facility submitted their plan to remove the immediacy. The provisions of the plan to remove the immediacy included the following: Resident #6 no longer resides in the facility.Updated elopement evaluations for all current residents will be completed by 1/15/26 to determine if any other residents are at risk for elopement. Updated elopement evaluations will be completed by the Unit Managers and DON. All residents determined to be at risk for elopement will have their [alarm bracelet] rechecked for proper placement and function. Any resident identified at increased risk for elopement will be placed on appropriate elopement precautions with a care plan updated.Education of all facility licensed staff working 3-11 shift on 1/15/26 was immediately performed by DON and Regional Resource Nurse on the elopement policy and procedure including the elopement risk evaluation process to ensure elopement risk is reassessed. All licensed nurses will be educated by 1/16/25. Any licensed staff member unable to be educated by 1/16/26 (i.e., call-out and vacation) will be educated upon arrival to the facility; DON will ensure that education has been provided to them prior to beginning their shift. The DON, Regional Resource Nurse, NHA, RDO (Regional Director of Operations), and Facility Department Heads will continue to educate all non-clinical staff on elopement policy and procedures including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.Any facility staff member unable to be educated by 1/16/26 (i.e., call-out and vacation) will be educated upon arrival at the facility; DON will ensure that education has been provided to them prior to beginning their shift.Education will be validated by quizzes performed randomly by DON, Unit Managers, Supervisors, or Regional Resource Nurse with 10% of staff weekly for a period of 3 months. The DON, Unit Managers, and Nursing Supervisors will conduct audits monthly x 3 months. Findings will be reported by the DON at the monthly QAPI (Quality Assurance Performance Improvement) meeting to monitor progress towards improvement and recommendations. On 1/27/26 at 10:00 AM, after validation of the implementation of the facility's plan of removal, which included staff interviews and record reviews, it was determined the facility completed the removal plan with a compliance date of 1/23/26.

Based on record review, staff interviews, and review of facility policy Pressure Injury Prevention and Management, the facility failed to provide wound care to one resident (R#1) of 5 residents reviewed for pressure ulcers. This resulted in R#1's stage 3 pressure ulcer to worsen resulting in hospitalization . Findings include: Review of facility policy titled Pressure Injury Prevention and Management last reviewed 5/26/2023 revealed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. R#1 was admitted to the facility on [DATE] with diagnoses including but not limited to pressure ulcer stage 3, Charcot's Joint Right Ankle/Foot, type 2 diabetes mellitus, venous thrombosis and embolism, hereditary motor and sensory neuropathy, and chronic kidney disease stage 3. Review of R#1's Wound Assessment Report, dated 8/17/2023, noted R#1 to have Stage 3 pressure ulcer on the sacrum and revealed an order from the Nurse Practitioner (NP) for Dressing Change Frequency: Daily, and PRN(as needed) Clean Wound With: Cleanse with soap and water, pat dry; Primary Treatment: Zinc Oxide Paste Other Dressings: Bordered gauze. At the time of the wound assessment, the wound measured 1.1 centimeters (cm) length (L) x .7 cm width (W) x .20 cm depth (D). Review of Minimum Data Set (MDS) dated [DATE] revealed R#1 had a stage 3 pressure ulcer on admission. Review of Treatment Assessment Record dated August 2023 revealed the treatment orders from 8/17/23 were not placed on the Medication Administration Record (MAR) until 8/28/2023, eleven days after admission and the initial wound assessment by the NP. Review of R#1's Wound Assessment Report for 8/21/2023 revealed the pressure ulcer increased in size. At the time of the wound assessment, the wound measured 1.4 cm L x .7 cm W x .20 cm D. Review of R#1's Wound Assessment Report for 8/28/2023 revealed the pressure ulcer increased in size again. At the time of the wound assessment, the wound measured 1.6 cm L x .8cm W x .20 cm D. Additionally, as well as two new pressure ulcers were found to be unstageable. One unstageable pressure ulcer was on the left buttocks and measured 7.80 cm L x 5.0 cm W x .10 cm D. The other unstageable pressure ulcer was on the right buttocks and measured 6.50 cm L x 7.0 cm W x .10 cm D. Continued review revealed, R#1 had a change in condition on 8/28/2023 related to the presence of the wounds and was sent to the hospital for evaluation. R#1 was admitted to the hospital with diagnoses of pressure ulcers with sepsis and cellulitis to the site. Since R#1 was admitted to the hospital on 8/28/2023, he never received the daily wound care treatment that was ordered by the NP, except when done on 8/17/2023, 8/21/2023, and 8/28/23 when completed by the wound care team. R#1 was at the facility for 12 days and missed nine wound care treatments and developed two additional pressure ulcers. During an interview on 12/30/2024 at 11:53 a.m., R#1's family member revealed R#1 was admitted to the hospital on 8/28/2023 with a diagnosis of sepsis related to his/her wound. R#1's family member further revealed R#1 was hospitalized from 8/28/2023 to 9/2/2023 and did not return to the facility afterward. R#1's family member stated the facility did not communicate with the family about the severity of the wounds. An interview on 1/3/2025 at 10:45 a.m. Licensed Practical Nurse (LPN) #5 revealed she was responsible to make wound rounds with the Nurse Practitioner in August 2023. LPN#5 stated she does not recall this resident. After reviewing the medical record, stated she did not make rounds on that particular day with the wound care NP because she did not work on Thursdays at that time. LPN #5 stated the Unit Manager or Director of Nursing (DON) would have made rounds with the NP that day. LPN #5 stated the Unit Manager would have been responsible to transcribe orders and ensure they were put into the MAR. LPN #5 further stated the Charge Nurse was responsible for doing daily treatments. LPN #5 confirmed R#1 did not have treatment orders transcribed from the NP in MAR until 8/28/23. During an interview on 1/3/2025 at 11:35 a.m., the DON stated LPN #5 was the full-time treatment nurse during the time frame of 8/17/2023 - 8/28/2023. The DON confirmed the wound care NP made note of the orders in the documentation. The DON stated the treatment nurse should have transcribed those orders in the Electronic Health Record (EHR) so that treatments could be completed daily by the charge nurses. The DON confirmed there were no orders in place for eleven days. The DON stated her expectation is when a wound is found, whether on admission or after, the MD is notified for orders to be received and implemented. The DON stated the family should be notified and updated of all changes in condition including wounds and the care plan should be updated.

Based on record review and staff interview it was determined that the facility failed to 1.) ensure that residents were free of accidents and 2) ensure that interventions were initiated after a fall to prevent recurrence. This was evident for 1 (#31) of 17 residents reviewed for abuse and 1 (#12) of 6 residents reviewed for falls. The deficient practice resulted in actual harm to resident # 31. The findings include: Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) A medical record review on 1/6/25, at 9:45 AM for Resident #31 revealed that on 12/7/20, facility staff initiated a care plan for self-care deficit related to the resident ' s impaired mobility and disease process. Interventions added on 4/29/21, read the resident required 2 staff for assistance while bathing and to turn and reposition in bed. A review of the Kardex (which was a tool that geriatric nursing assistants should use to determine the level of care and assistance a resident required) revealed that for bed mobility it noted the resident required 2 staff members to assist with turning and repositioning and while bathing. Further review revealed a change in condition evaluation dated 10/23/24 at 10:53 AM that documented the resident had a fall on that day. According to the report, after the fall the resident complained of musculoskeletal pain in the coccyx (tailbone) and right foot and x-rays were ordered. In the summary section it was noted that Resident #31 reported s/he was too close to the edge of the bed and rolled out. On 1/6/25 at 8:40 AM a review of a copy of the facility ' s investigation file revealed in the initial report that Resident #31 had accused GNA #8 of pushing him/her out of bed on 10/23/24. The report read that the resident reported this allegation on 10/30/24, to a visitor, who subsequently informed the facility. According to GNA #8 ' s statement dated 10/30/24, she was bathing the resident while the resident was rolled towards the opposite side of the bed. The GNA turned to rinse her rag and still had a hand on the resident ' s hip. The GNA wrote that the air mattress fluctuated and the resident rolled out of bed onto the floor. A statement written by the Director of Nursing (DON) regarding an interview with the Resident ' s roommate revealed that s/he heard GNA #8 state to Resident #31 to stop moving around because the resident was too close to the edge of the bed and she [the GNA] was not able to reposition him/her without assistance. According to the statement, the roommate reported the curtain was closed, so s/he had not witnessed the resident ' s fall, but right after that statement s/he heard a noise that sounded like the resident fell to the floor. A review of the facility ' s incident report revealed Resident #31 had a skin tear on the left elbow and complained of pain in the coccyx (tailbone) area and the right foot. In the section titled, Other Info it was documented the resident had been rolled on their side, too close to the edge of the bed and was noted to have an air mattress. The resident required 2 staff for assistance and the fall was avoidable. A review of the x-ray reports revealed that on 10/23/24, the resident had a series of x-rays to include; the left wrist, left humerus (upper arm bone), sacrum and coccyx, right foot, and left shoulder. The right foot impression read the resident had a suspected, non-displaced hairline fracture along the base of the 2 and 3 toes. The left shoulder impression read that they found no definite fracture, but if symptoms continued a follow up x-ray was clinically warranted. A review of the care plans revealed a care plan for a right foot fracture had been added on 10/23/24. The facility included, in the investigation file, an educational power point for using a coding system to identify a resident ' s level of care and assistance by looking at their name tag on the door. During an interview with GNA #8 on 1/7/25, at 10:56 AM, via a phone call, she reported that on 10/23/24, she was assigned Resident #31 for the first time. She admitted that she failed to review the resident ' s Kardex before providing care. She reported that while she was giving the resident a bed bath, she recognized the resident was too close to the edge of the bed but failed to intervene. Then stated while she had the resident rolled away from her the resident slipped out of bed. She reported the bed had been at her waist level at the time of the fall. An interview on 1/8/25 at 10:54 AM with Unit Manager #6 revealed it had not been the first time GNA #8 had worked with Resident #31. She stated that most bed bound residents in the facility were required to have the assistance of 2 staff for care to protect the resident and the staff. She reported she provided education to the GNA on 10/23/24, after the fall. The DON was interviewed on 1/8/25 at 3:18 PM regarding how staff were made aware of the needs and level of assistance each resident required. She stated that the GNAs were aware that they need to review the Kardex for each resident assigned to them, so they can provide safe care. 41274 2.) Review of the policy and procedure titled, Fall Prevention Program, last revised 9/5/2023, revealed it was the policy of the facility to assess each resident for the risk of falls and provide care and services in accordance with individual level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards were to be evaluated during development of resident ' s comprehensive plan of care. Interventions in the plan of care were to be monitored for effectiveness and revised as needed. When residents experienced a fall, the facility was to assess the resident prior to moving them, complete a post fall assessment and incident report, obtain witness statements in case of injury, document all assessments/ actions and review the resident ' s care plan and update as indicated. Resident #12 was admitted to the facility with diagnoses which included dementia without behavioral disturbance, lack of coordination, abnormalities of gait and mobility and adult failure to thrive. The Minimum Data Set (MDS, an assessment tool) dated 5/20/2022 documented the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3/15 which was indicative of severe cognitive impairment. The resident required extensive assistance to complete activities of daily living (ADLs) and was documented to have had two or more falls since their last assessment on 3/8/2022. An Unwitnessed Fall Event Note dated 6/24/2022 documented Resident #12 was observed lying on the floor in their bathroom with the right side of their head resting against the wall. The resident was assessed for injury and was observed with a red mark on the right side of their forehead with a bump measuring one centimeter. The resident was unable to recall what they were doing. The resident was documented to be confused and had impaired memory and balance. The facility did not document any actions taken or new interventions implemented to prevent recurrence. An Unwitnessed Fall Event Note dated 6/28/2022, documented the unit nurse heard a noise from the hallway and went to search where the noise had come from. Resident #12 was found lying supine on the floor with the back of their head resting on their roommate ' s bed frame. Resident #12 was assessed and noted to be bleeding from a laceration on the back of their head. The resident was documented to have been found with a change in vital signs. Both paramedics and family were called and arrived at the facility shortly after. On 12/31/2024, review of Resident #12 ' s Care Plan, initiated 3/9/2020, revealed fall interventions were last updated on 7/19/2021 and no new interventions were implemented in 2022 after the Resident #12 experienced falls. During an interview on 12/31/25 at 12:50 PM, Licensed Practical Nurse (LPN) #3 stated that if a resident had a fall, they would immediately alert the nurse supervisor, and the resident would be assessed for injuries. They stated the facility would investigate the fall to determine what factors may have contributed to the fall and determine appropriate new interventions to prevent recurrence. During an interview on 1/8/2025 at 2:48 PM, the DON stated when a resident had a fall, the interdisciplinary (IDT) team should evaluate what occurred during the fall to identify contributing factors and evaluate what interventions should be implemented to prevent recurrence; new interventions should then be included in the resident ' s care plan. They stated the facility should have looked at what occurred during Resident #12 ' s fall and implemented interventions. They stated fall interventions could be implemented by different departments including therapy, nursing and activities staff and may include more frequent checks on the resident or adding activities that assisted with gait and balance. They stated therapy staff should assess residents after they had a fall.

Based on observation of resident care areas, interviews, and review of documentation including resident records and facility policies, it was determined that, during the COVID-19 pandemic, the facility failed to: 1) ensure that newly admitted and readmitted residents received care and services in a manner that was safe and was consistent with guidance from the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), and the Maryland Department of Health (MDH). This was evidenced by the facility demonstrating, both in policy and in staff practice, that Personal Protective Equipment (PPE) was not being utilized safely and according to the above guidance. Additionally, the facility failed to, 2) ensure that nursing staff who had assessed COVID-19 signs and symptoms in residents reported those findings to the resident's attending physician or nurse practitioner in a timely manner, resulting in related failures to update resident care plans, to move newly symptomatic resident rooms to protect from spread of [MEDICAL CONDITION], to initiate appropriate isolation precautions, and to timely obtain COVID-19 testing. Last, the nursing home failed to report known COVID-19 cases amongst both residents and staff as required. These noncompliant practices increased the risk for harm and possible death to all residents, staff, and visitors during a potentially fatal infectious outbreak in the building. As a result of these findings, an immediate jeopardy was declared on [DATE] at 1:20 PM. The facility submitted a plan of removal at 4:10 PM and it was accepted by the State Agency at 4:39 PM. The Immediate Jeopardy was removed on [DATE] at 2:30 PM after on-site confirmation of the completion of the facility's plan of removal. After removal of the immediacy, the deficiency remained with a potential for more than minimal harm and at a scope and severity of E. The findings include: 1) It was determined that the facility failed to ensure that caregivers of newly admitted or readmitted residents utilized all recommended PPE while the residents were kept on a 14-day quarantine post-admission. This was evident for 4 out of 4 residents ( # 1, #2, #10, #15) reviewed for infection control during a complaint/ focused infection control survey. According to [DATE] guidance from the CDC reviewed by surveyors on [DATE] entitled Coronavirus Disease 2019 (COVID-19): Nursing Homes & Long-Term Care Facilities and located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, the CDC advised facilities to 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. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. 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. According to additional guidance from the CDC reviewed by surveyors on [DATE] entitled Considerations for the Public Health Response to COVID-19 in Nursing Homes and located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, the CDC also advises, All recommended COVID-19 PPE should be worn during care of (newly admitted or readmitted ) residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. According to a directive from the MDH dated [DATE] and pursuant to Executive Order No. [DATE]-01, the MDH ordered that, Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: . Designate a room, series of rooms, unit, or floor of the nursing home as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. According to the CDC, contact precautions include, wearing a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. (Droplet precautions include) wearing a mask when entering the resident room and utilizing single rooms when able. According to a directive from the MDH, dated [DATE], and pursuant to Executive Order No. [DATE]-01, the MDH ordered that all facilities shall report the following information to the Chesapeake Regional Information System for Our Patients (CRISP). On a daily basis, each facility report should include at least the following: I. The census of occupied beds; II. Number of residents with positive COVID-19 test results; III. Number of residents with suspected COVID-19; IV. Number of residents with negative COVID-19 test results; V. Number of deaths, by COVID-19 status; VI. Number of staff with positive COVID-19 test results; VII. Number of residents with severe respiratory infection or COVID-19 resulting in hospitalization ; VIII. Number of staff with severe respiratory infection or COVID-19 resulting in hospitalization ; 3 IX. Number of residents or staff with new-onset respiratory symptoms that occur within 72 hours of another resident or staff developing respiratory symptoms; and X. Any other information required. During an interview on [DATE] at 12:45 PM, Registered Nurse (RN) #8 stated that one resident (Resident #1) on her shift was under a 14-day quarantine after being newly admitted to the facility. RN #8 also stated that new admissions did not require her or other staff to use additional PPE when caring for that resident. Contrary to CDC guidance, RN #8 indicated that, when caring for Resident #1, she would follow standard precautions (gloves and performing hand hygiene) and wear a surgical face mask that she wore throughout her shift. Over the course of the survey, residents under observation were observed to be stationed on all units of the facility. During the [DATE] interview with RN #8, he/she indicated that the nursing home also did not dedicate staff members for residents under observation. Instead, those residents were on the assignment of nurses and caregivers who were also caring for COVID-19 negative residents that were not being quarantined. RN #8 further indicated that she did not utilize PPE differently when caring for the quarantined residents, than when caring for the non-quarantined residents. At 12:47 PM on [DATE], Geriatric Nursing Assistant (GNA) #7 was observed stepping outside Resident #1's room wearing only a surgical face mask. GNA #7 was not wearing a gown or gloves. GNA #7 obtained supply from a cart next to the resident's door and then returned inside Resident #1's room without performing any hand hygiene or donning any additional PPE. During an interview on [DATE] at 12:50 PM with the Chief Nursing Officer (CNO), the CNO stated that new admissions and readmissions were being placed under a 14-day quarantine at the time of admission to the facility. The CNO also stated there was no expectation for staff to change their use of PPE for new admissions or readmissions unless the residents showed symptoms of COVID-19. On [DATE] at 12:48 PM, Residents #2 and #10, who were both recent admissions and therefore under quarantine for 14 days, were observed with a sign outside their door stating, Leave Door Closed. No additional PPE was noted outside either room. At 12:50 PM on [DATE], GNA #9 was interviewed and stated that she would not utilize additional PPE for a resident unless there was a donning station placed at the entrance to the room. When asked about Residents #2 and #10, GNA #9 confirmed that she would only wear gloves and a surgical mask. On [DATE] at 9:33 AM during an interview with the Director of Nursing (DON), CNO, and Infection Preventionist, the CNO confirmed that new admissions and readmissions were to be kept on a 14-day quarantine. The CNO indicated that staff were to wear all recommended PPE while providing care to that resident only if the resident was symptomatic for COVID-19. Otherwise, asymptomatic residents were to be treated only with standard precautions and a surgical mask. The DON stated that they had reviewed this practice in regular weekly teleconferences with the local health department and that the health department was satisfied with these practices. However, the local health department was not satisfied with these practices. In interview on [DATE] at 11:10 AM, the Local Health Department Employees #1 and #2 were interviewed and stated that they provide facilities with guidance to treat new admissions and readmissions as if they had COVID-19 for the duration of their 14 day quarantine, including wearing all recommended PPE for a resident suspected of COVID-19. Local Health Department Employees #1 and #2 further stated that this very guidance was given to the facility on [DATE]. However, review of the facility's COVID-19 policies on [DATE] corroborated the noncompliant staff practice and confirmed that asymptomatic residents that were new admissions or readmissions, were by policy to be cared for using only standard precautions and a surgical face mask. As of [DATE], the facility was caring for 4 residents on observation for possible COVID-19 exposure. The 4 residents resided on different units in rooms 509, 704, 711 and 713. Observation of these 4 rooms on [DATE] at 11:30 AM revealed there was no additional PPE outside any/each of these 4 rooms. 2) It was determined that the facility failed to ensure that nursing staff who had assessed COVID-19 signs and symptoms in residents reported those findings to the resident's attending physician or nurse practitioner in a timely manner, resulting in related failures to update resident care plans, to move newly symptomatic resident rooms to protect from spread of [MEDICAL CONDITION], to initiate appropriate isolation precautions, and to timely obtain COVID-19 testing. This was evident for 3 out of 3 (#4, #5, #6) residents reviewed for Covid-19 symptom assessments during a complaint/focused infection control survey. According to guidance from the CDC reviewed on [DATE] and entitled, Evaluate and Manage Residents with Symptoms of COVID-19, (located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), the CDC recommended that facilities Actively monitor all residents upon admission and at least daily for fever and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry . Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures > 99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Further CDC guidance also reviewed on [DATE] and located at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html stated, People with these symptoms may have COVID-19: fever or chills; cough; shortness of breath or difficulty breathing; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; and diarrhea. The facility's policy entitled 'COVID-19' was reviewed on [DATE]. This policy had an effective date of [DATE], and was revised [DATE]. In a section labeled 'Who Should be Evaluated as a Suspected Case, the policy stated, Cadia Healthcare will consider testing for COVID-19 in residents with a fever (99 or greater), severe lower respiratory infections (cough, shortness of breath), body aches, and or gastrointestinal symptoms (nausea, vomiting, diarrhea) without an alternative diagnosis. Cadia Healthcare will follow CDC guidance and will test residents who are symptomatic after consultation from the provider. Residents #4 and #5 become roommates on [DATE], prior to the below COVID-19 assessments in which symptoms known to be associated with COVID-19 were both observed and documented. During [DATE] review of resident medical records, the Surveyor noted that COVID-19 assessments for Resident #4 dated [DATE] and [DATE], both indicated Resident #4 was experiencing symptoms of COVID-19 including fever of 99.1, dry cough, and body aches. At the time of the COVID-19 assessments on [DATE] and [DATE], there was no evidence of physician notification, no change in the resident plan of care, no new orders for isolation precautions, no orders to obtain COVID-19 testing, and no relocation of the resident from the room shared with Resident #5. During a [DATE] interview with the Certified Registered Nurse Practitioner (CRNP) #1 at 2:30 PM, CRNP #1 indicated that she was not notified of Resident #4's symptoms until [DATE], which was two days after the symptoms were first documented by nursing staff on [DATE]. The resident was seen by CRNP #1 on [DATE]. The provider reviewed the resident's symptoms but did not place the resident on isolation precautions, did not order COVID-19 testing, and did not initiate any room change to protect Resident #5 from possible ongoing exposure. Despite the known community spread of COVID-19, when Resident #4 became symptomatic the CRNP attributed the symptoms to prior GI symptoms and a sore throat from the spring related to allergies [REDACTED]. Under State mandate, all residents in the facility were tested on or by [DATE]. On [DATE], positive COVID-19 test results were obtained for Resident #4. Resident #5's medical record was reviewed on [DATE]. The review revealed a nursing COVID-19 assessment for Resident #5 dated [DATE], the day after mandated testing was conducted and more than a week after his/her roommate (Resident #4) first showed signs and symptoms of COVID-19. This assessment indicated that Resident #5 by then had body aches. However, no notification to a provider could be found regarding these identified body aches on [DATE]. At the time of the assessment on [DATE], there was no evidence of physician notification, no change in the resident plan of care, no new orders for isolation, and no relocation of the resident. During the CRNP [DATE] interview at 2:30 PM, CRNP #1 stated that she was not notified of Resident #5's symptoms until [DATE]. Review of Resident #5's medical record revealed this was one day after the symptom associated with COVID-19 was documented by nursing staff on [DATE]. With two known positive staff cases the level of suspicion for COVID in the building should have been even higher than when Resident #4 was assessed by the CRNP on [DATE]. However, as was evident with Resident #4, when Resident #5 was seen by CRNP #1 on [DATE], with insufficient rationale he/she elected again not to initiate any room change or isolation precautions. Once tested under State mandate, on [DATE] positive COVID-19 test results were obtained for Resident #5. After the failure to protect Resident #5 when his/her roommate was first symptomatic, Resident #5 then became symptomatic in the same room. Once symptomatic the plan of care was not revised and appropriate precautions were still not initiated, and the facility then reported in an MDS record (an electronic assessment record) that on [DATE] Resident #5 died . Resident #6's medical record was reviewed on [DATE]. During the review, a nursing COVID-19 assessment on Resident #6 dated [DATE] documented a temperature of 99.3. Another on [DATE] identified the resident had gastrointestinal symptoms and a fever of 100.2. On [DATE], another identified a temperature of 99.5. On [DATE], another identified a temperature of 99.0. Over the course of these 4 days, there was no evidence of physician notification, no change in the resident plan of care, no new orders for isolation, no orders for COVID-19 testing, and no relocation of the resident. The resident was seen by the Medical Director on [DATE]. Resident #6 was symptom-free and afebrile on the date of this visit, but the Medical Director's progress note did not document any awareness of any of the symptoms staff had documented for Resident #6 over the immediate prior four days, and no actions were ordered to treat resident #6 or to protect other residents from possible exposure given the days long history of symptoms known to be associated with COVID-19. Once tested under the State mandate, on [DATE] positive COVID-19 test results were obtained for Resident #6. With three residents with known COVID symptoms, under State mandate all residents in the facility were tested on or by [DATE]. On [DATE], the facility inaccurately published on their web site that for the week of [DATE] through [DATE], no residents were under investigation for possible COVID-19. Nursing home documentation revealed that positive COVID-19 results were obtained for three different nursing home staff. Documentation indicated that Staff #2 tested positive on [DATE]. Staff #3 notified the Administrator of positive testing on [DATE] and this staff positive test was then confirmed to the nursing home by the local health department on [DATE]. A third staff with an illegible name documented in infection prevention and control documentation was tested on [DATE] with a positive result obtained [DATE]. In a mandatory reporting program, the nursing home inaccurately reported to the State daily (every day from ,[DATE] through [DATE]) that no staff had tested positive. One staff case was reported on [DATE] during the survey. No other staff cases were ever reported to the State reporting program before or during the survey. Additionally, in reporting posted to the nursing home web site on [DATE] for the week of [DATE] - [DATE] the nursing home inaccurately published that there were no positive staff and no staff under investigation during that seven day window. During [DATE] interview with the Administrator and the Director of Nursing (DON) at 9:00 AM, the Administrator indicated that the facility had three residents (Residents #4, #5, and #6) who were COVID-19 positive. The Administrator also confirmed that the facility had received positive COVID-19 test results for those residents on [DATE] after universally testing all residents and staff in the facility. During the same interview, the DON indicated that nursing staff were expected to assess for COVID-19 symptoms every shift, including taking resident temperatures and measuring oxygen saturation via pulse oximetry. These assessments were to be documented in an assessment form entitled the 'COVID-19 assessment' that had been specifically developed in the facility's electronic medical record system. During an interview with the DON on [DATE] at 1:28 PM, the DON confirmed, based on her review of Resident #4, #5 and #6's medical records and her own interview with the Medical Director on [DATE], that there was no evidence any facility medical staff had been notified of the above symptoms for Residents #4, #5, and #6 at the time those symptoms were first identified. During the same interview, the DON then stated that facility staff are expected to notify the residents' physician when the facility staff identify any symptoms of COVID-19 at the time of the assessment. Further corroborating the above findings, on [DATE] at 3:00 PM the Medical Director stated he did not recall being notified by nursing staff of the COVID-19 assessments for positive symptoms in Residents #4 on [DATE] or [DATE], for Resident #5 on [DATE] and for Resident #6 on [DATE], [DATE], [DATE] or [DATE]. As a result of these findings, an immediate jeopardy was declared on [DATE] at 1:20 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 3:50 PM and it was not accepted. The facility submitted a second plan at 4:10 PM and it was accepted by the state agency at 4:39 PM. The provisions of the plan to remove the immediacy included the following: For Part 1) 1. Residents #1, #2, and #10 were placed on quarantine isolation on [DATE]. Precautions included wearing gowns, gloves, eye protection, and N95 mask or higher-level respirator for 14 days post admission to the facility. All other residents under 14-day quarantine isolation will follow the same guidelines. The signs labeled leave door closed on the doors of residents #2 and #10 were removed. 2. All new admissions /readmissions will be placed on a 14-day quarantine isolation. All nursing staff, therapy staff, housekeeping staff, and facility department heads will be re-educated on caring for residents who are in isolation and the procedures for required personal protective equipment (PPE). Dietary will be educated not to enter the facility nursing units. In-servicing for staff began on [DATE]. 3. The facility revised its policy on [DATE] for admissions/readmissions to include instituting full PPE for 14 days after the admissions/readmitted to the facility. 4. The DON will coordinate daily audits until substantial compliance is met of all new admissions / readmissions to ensure that proper isolation precautions are in place and that all staff are donning full PPE upon entering/exiting isolation rooms. In-servicing for staff began on [DATE] by the Staff Educator. All results for the audits will be reviewed in the facility weekly Quality Assurance Committee Meeting until 100% compliance is achieved over 2 weeks. The Committee will review and decide if further action is needed. For Part 2) 1. Resident #4 remains in the facility with no signs or symptoms of COVID-19. The provider was made aware of Resident #4's symptoms on [DATE]. Resident #5 no longer resides in the facility. Resident #6 remains in the facility and has no further signs or symptoms of COVID-19. The provider was made aware of the resident's symptoms on [DATE]. 2. A facility wide audit was conducted on [DATE] on all residents from [DATE] to [DATE] to assure the provider was notified for identified symptoms related to COVID-19 and changes in condition. All findings were corrected upon discovery. 3. The DON will coordinate in-servicing on notifying the provider for changes in condition that could be related to COVID-19. The NHA/DON/Staff Educator will conduct daily audits on all residents on all changes in condition/COVID screening to assure that the provider has been made aware of any changes and interventions that are needed. All results for the audits will be reviewed in the facility weekly Quality Assurance Committee Meeting until 100% compliance is achieved over 2 weeks. The Committee will review and decide if further action is needed. The Immediate Jeopardy was removed on [DATE] at 2:30 PM after on-site confirmation of the completion of the facility's plan of removal. Cross Referene Federal Tags F885 and COMR 1410 and 1440