Every finding on record at Complete Care at Heritage LLC

Based on reviews of facility investigative records, resident medical records, and staff interviews, the facility failed to ensure that a resident remained free from verbal abuse. This was evidenced by one of six residents reviewed for abuse allegations (Resident #25) during this annual survey.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facility's plan and implementation were verified during this survey; therefore, this deficiency was determined to be Past Non-Compliance with a facility compliance date of 07/24/2026.The findings include:Review of facility-reported incident #3094560 on 08/04/2026 at 8:00 AM revealed that the facility substantiated an allegation that Geriatric Nursing Assistant (GNA) #26 used verbally abusive and inappropriate language toward Resident #25 while providing care.According to the facility investigation, on 07/14/2026 at approximately 8:00 PM, Resident #25 reported to Unit Manager #27 that after activating the call light following a bowel movement, the resident had to wait 20 minutes for assistance. GNA #26 stated she would return with supplies, but returned 30 minutes later. Resident #25 reported that GNA #26 repeatedly told the resident to shut the F*** up and called the resident a derogatory name.A review of the facility investigation packet on 08/04/2026 at 9:10 AM showed that Resident #134 (Resident #25's roommate, who is cognitively intact) was interviewed regarding the incident on 07/17/2026. Resident #134 stated that Resident #25 requested assistance after having a bowel movement and waited to be changed. When the assigned GNA returned after approximately 20 minutes, GNA #26 used profanity toward Resident #25, including stating F*** you.Additionally, a review of a phone interview record with Staff #9 on 07/17/2026 at 10:00 PM documented that upon returning from lunch break, Staff #9 heard GNA #26 loudly yell F*** you as GNA #26 walked out of a room adjacent to Resident #25's room.During an interview on 08/04/2026 at 12:20 PM, the Nursing Home Administrator (NHA) stated that GNA #26 was terminated on 07/24/2026 as a result of the incident involving Resident #25. The NHA further stated that following the incident, the facility immediately implemented corrective action by providing abuse prevention education with scenario-based post-tests to all staff and establishing a Quality Assurance and Performance Improvement (QAPI) monitoring plan.On 08/04/2026 at 2:00 PM, the surveyor reviewed the facility's training records, tracking logs, and QAPI plan. Records verified that the facility initiated mandatory re-education on abuse prevention for all facility staff beginning 07/21/2026, incorporated post-training competency evaluations, and completed training tracking for all personnel.Surveyor verification confirmed that the facility identified the non-compliance, took immediate corrective actions to protect the resident, implemented systemic corrective measures, and sustained these actions prior to the start of the current survey. Consequently, the deficient practice was determined to be Past Non-Compliance with a compliance date of 07/24/2026.

Based on observation, interview, and record review, the facility failed to ensure that appropriate colostomy care was provided in accordance with professional standards of practice, physician orders, and individual care needs. This was evidence of 1 (Resident #86) of 1 resident reviewed for colostomy care during this annual survey.The findings include:On 08/03/2026 at 11:25 AM, during an initial resident interview, Resident #86 expressed concern regarding his/her colostomy care. Resident #86 stated that nursing staff frequently utilized incorrect ostomy supplies, causing the pouching system to lose adhesion and pop off due to waste overload. Resident #86 further reported that skin irritation was present around the stoma site but prescribed topical skin treatments were not being applied by facility staff.On 08/03/2026 at 11:32 AM, an observation of Resident #86's peristomal area revealed medical tape applied directly around the perimeter of the stoma site to secure the barrier to the skin.On 08/07/2026 at 11:30 AM, an interview was conducted with Central Supply Staff #23. Staff #23 stated that Resident #86's colostomy supplies had been changed from a one-piece system to a two-piece system in January 2026 per the resident's request.During a follow-up interview on 08/07/2026 at 1:41 PM, with Resident #86, the resident displayed an ostomy supply barrier (Ref #11703, a soft convex barrier with thick adhesive). Resident #86 stated that this specific barrier did not adhere well to his/her skin, causing the pouching system to detach frequently. During this interview, Geriatric Nursing Assistant (GNA) #24 entered the room holding an alternate barrier (Ref #11203, a flat barrier with thinner adhesive). Resident #86 stated, See, they have it. But they did not use it for me. That's why I need to change myself urgently.On 08/07/2026 at 2:40 PM, an interview was conducted with the Director of Nursing (DON) and Central Supply Staff #23. They acknowledged that colostomy supplies were not stocked on an individualized basis per resident, allowing nursing staff to pull arbitrary supplies from general supply storage. When asked regarding Resident #86's concerns, the DON stated that the resident had a large amount of stoma output, which was why staff utilized the thicker material (Ref #11703).The surveyor requested clinical documentation demonstrating that the facility evaluated Resident #86's ostomy barrier failures, provided interventions to resolve pouch dislodgement/leakage, ensured the correct resident-preferred pouching system was supplied, or reviewed stoma/peristomal skin status with the primary care provider. The DON confirmed there was no documentation available.On 08/10/2026 at 7:28 AM, the surveyor inspected the medication cart and treatment cart assigned to Resident #86 alongside Registered Nurse (RN) #22. Prescribed stoma powder (an absorbent topical powder used to treat weeping peristomal skin and promote barrier adhesion) was absent from both carts. Unit Manager #15 was interviewed at the time of inspection and stated the supply might be all used and indicated she would check the facility's main supply storage.A review of Resident #86's Treatment Administration Record (TAR) covering the period from November 2025 through August 2026 revealed that nursing staff had consistently signed off as having administered colostomy care with stoma powder every shift. However, Unit Manager #15 confirmed that stoma powder was not present on the treatment cart or readily available on the unit for staff administration.On 08/10/2026 at 1:02 PM, during a follow-up interview with the DON, she stated that the stoma powder was located inside Resident #86's bedside table drawer. The surveyor reviewed Resident #86's TAR entries with the DON, highlighting that nursing staff documented providing colostomy care with stoma powder every shift, while the resident reported no skin treatments were applied by staff, and the product was kept stored in the bedside table rather than administered per standard treatment protocols. The DON validated these findings.

Based on medical record review and staff interview, it was determined that facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#5, #4, #2, #1, #14) of 14 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 2/20/26 at 8:46 AM a review of Resident #5's medical record was conducted. Review of Resident #5's December 2025 Medication Administration Record (MAR) revealed the administration of Gabapentin every 8 hours for neuropathy. Gabapentin is classified as an anticonvulsant drug and is commonly used to treat nerve pain as well as partial seizures.Review of Resident #5's significant change MDS assessment with an assessment reference date (ARD) of 12/30/25, Section N0415 (High-Risk Drug Classes), failed to capture the anticonvulsant (Gabapentin). Review of Resident #5's MDS assessment with an ARD of 12/24/25, Section N0415 (High-Risk Drug Classes), also failed to capture the anticonvulsant (Gabapentin). On 2/24/26 at 11:21 AM an interview was conducted with the MDS Coordinator, Staff #28 who confirmed the error. Staff #28 stated that the primary MDS Coordinator had been out on leave and other people had been filling in doing the MDS assessments. 2) On 2/20/26 at 9:40 AM a review of Resident #4's medical record was conducted and revealed an 9/29/25 at 4:39 AM note that stated, resident found on the floor next to the resident's door in a sitting position. Review of Resident #4's MDS with an ARD of 9/25/25, Section J1800, any falls since admission/entry or reentry or prior assessment, documented 0 falls. The facility staff failed to capture the fall. On 2/24/26 at 11:21 AM the MDS Coordinator, Staff #28 confirmed that the fall was not captured. 3) On 2/20/26 at 10:48 AM a review of Resident #2's medical record was conducted. Review of Resident #2's MDS assessment with an ARD of 11/14/25, Section N0415 (High-Risk Drug Classes, captured the use of a hypoglycemic medication. Hypoglycemic medications are used to lower high blood sugar in people with type 2 diabetes. Review of Resident #2's November 2025 MAR did not document any hypoglycemic medications. Resident #2 did not receive hypoglycemic medications during that time. On 2/25/26 at 11:18 AM an interview was conducted with the MDS Coordinator who confirmed that Resident #2 was not on hypoglycemic medications and that was an error.4a) On 2/20/26 at 12:48 PM a review of Resident #1's medical record was conducted. Review of Resident #1's January 2026 MAR documented that Resident #1 received Lorazepam on 1/30/26 at 1:06 AM. Lorazepam is an antianxiety medication.Review of Resident #1's Discharge Return Not Anticipated MDS Assessment with an ARD of 1/31/26, Section N0415 (High-Risk Drug Classes), failed to capture the use of the antianxiety medication.4b) Review of Resident #1's vital sign section of the medical record documented the use of oxygen via nasal cannula.Review of Section O, Special Treatments, Procedures, and Programs, C1 Oxygen therapy was not coded. The facility failed to capture the use of oxygen.Continued review of Section O, Hospice Services, was checked off as received.Review of Section J1400 Prognosis, does the resident have a condition that may result in a life expectancy of less than 6 months? was coded, yes.On 2/25/26 at 11:21 AM an interview was conducted with Staff #28. Staff #28 stated that the resident did not receive Hospice services while at the facility, therefore that should not have been coded. Staff #28 also confirmed that there was no documentation from the physician that the resident had a life expectancy of less than 6 months. Staff #28 also confirmed the error regarding the Lorazepam. 5a) On 2/24/26 at 9:15 AM a review of Resident #14's medical record was conducted and revealed a 2/11/26 at 18:38 (6:38 PM) change in condition note that documented, aggressive/combative behavior.Review of a 2/11/26 at 20:21 (8:21 PM) change in condition form documented, behavioral symptoms - agitation, psychosis. Aggressive behavior, throwing stuff at staff, destroy facility property. The form stated, describe verbal aggression: 1. Aggression - throwing plates, stating [he/she] wants to hurt [her/himself].Review of the MDS assessment with an ARD of 2/11/26, Section E0200, Behavioral Symptom - Presence and Frequency, was coded 0 for physical behavioral symptoms directed toward others and 0 for verbal behavioral symptoms directed towards others. 5b) Continued review of Resident #14's medical record revealed Resident #14's February 2026 MAR documented Resident #14 received Gabapentin 3 times per day. Review of Resident #14's MDS assessment with an ARD of 2/11/26, Section N0415 (High-Risk Drug Classes), failed to capture the anticonvulsant (Gabapentin). On 2/25/26 at 11:21 AM an interview was conducted with the MDS Coordinator, Staff #28. Staff #28 confirmed that she did not see the behaviors on the form and that the Gabapentin was missed. Staff #28 stated that she made the Nursing Home Administrator and the Director of Nursing aware of the errors.

Based on review of facility documentation and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #8). This was evident for 1 of 11 residents reviewed for abuse during a complaint survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 12/5/25. The findings include: Review on 2/24/26 of a facility reported incident that occurred on 11/29/25 revealed Staff #19 (geriatric nursing assistant) witnessed Staff #25 (licensed practical nurse) tell Resident #8 hit me you (expletive language), you not gonna do (expletive language), I will beat the (expletive language) out of you. Staff #19 notified Staff #20 (nursing supervisor) who responded to the situation and also witnessed Staff #25 tell Resident #8 he will beat (expletive language) out of you. Review of Resident #8's medical record on 2/24/26 revealed the Resident was admitted to the facility in 2025 and is alert and oriented. During interview with Staff #20 on 2/24/26 at 9:05 AM, Staff #20 stated he was the nursing supervisor on 11/29/25. Staff #20 stated he was notified by Staff #19 that she had heard Staff #25 call Resident #8 (expletive language) and that Staff #25 told the Resident he will beat (expletive language) out of him/her. Staff #20 stated he immediately approached Staff #25 and also heard what Staff #19 reported. Staff #20 stated Staff #25 was being abusive to Resident #8 and was afraid it was going to get physical. Staff #20 told Staff #25 he had to leave the facility, which Staff #25 initially refused to do but eventually did leave the facility when Staff #20 was calling the police. During interview with Staff #19 on 2/24/26 at 10:02 AM, Staff #19 stated Resident #8 approached the nursing station where Staff #19 was documenting and asked if Staff #19 would tell Staff #25 to stop coming into his/her room. Resident #8 stated, I ask him to leave the door closed but he keeps going back and forth with me. Staff #19 stated that she walked back with Resident #8 to his/her room and told Staff #25 what the Resident requested. Staff #19 stated Staff #25 said I don't care I am going back in and went in anyway, further stating I have to give his/her roommate their medications. Resident #8 kept telling Staff #25 to leave his/her room but Staff #25 refused so Resident #8 began yelling. Staff #19 kept telling Staff #25 to leave the room but he said you can't allow patients to talk to you like that. It became heated and Staff #25 and Resident #8 were talking to each other like they were on the streets. Staff #25 told Resident #8 he was going to beat (expletive language) out of him/her and they were both calling each other (expletive language). Once Staff #25 left the Resident's room and Staff #19 felt the Resident was safe I notified Staff #20. Staff #20 then told Staff #25 they had to leave the facility and Staff #19 saw Staff #25 leave. During interview with the Administrator on 2/24/26 at 9:45 AM, the Administrator stated the facility confirmed verbal abuse of Resident #8 by Staff #25 on 11/29/25. The Administrator stated we put a plan into place and completed the plan on 12/5/25. The Surveyor attempted to interview Resident #8 on 2/24/26 at 10:18 AM but the Resident stated he/she didn't want to talk about the incident anymore. The Surveyor reviewed the facility's plan on 2/24/26. The plan included: 1) Removal of Staff #25 pending investigation 2) Staff #25 reported to nursing agency with results of investigation 3) Staff #25 not allowed to return to facility 4) Staff #25 reported to Maryland Board of Nursing 5) Resident assessed by providers and social services 6) All staff were reeducated on abuse prohibition and mandatory reporting. 7) All interviewable residents in facility were interviewed for abuse. No residents reporting abuse. 8) All non-interviewable residents had skin assessments completed and no signs of abuse were identified. 9) An Ad-hoc QAPI (Quality Assurance Performance Improvement) meeting was held on 12/1/25. The Surveyor verified completion of the plan on 2/24/26.

Based on staff and resident interviews, and record review the facility failed to give Resident #12 a shower on Tuesday and Friday as ordered for the month of January 2026 and February of 2026. This was evident for one (Resident #12) of 1 resident reviewed for ADLs during the complaint survey. The Findings Include: An interview was conducted with the responsible party (RP) of Resident #12 on 2/20/26 at approximately 2PM. The RP of Resident # 12 complained that the Resident has had no shower in the last 2 months. An interview was held with Resident #12 on 2/20/26 at 12:30PM who is alert and oriented and can make his/her needs known. Resident #12 also stated he/she has had no shower in the last 2 months and stated he/she wanted a shower. There was one time in [DATE] that the resident refused a shower/bed bath because he/she had diarrhea. The Surveyor reviewed the treatment and GNA (Geriatric Nursing Assistant) record and the documentation showed Resident # 12 has only received a bed bath, but not a shower. The resident is not opposed to a bed bath once in a while, however she/he should be offered a shower on his/her shower days and not a bed bath. The administrator was made aware of this on Friday 2/20/26 and said ok.

Based on medical record review and interview, it was determined the facility staff failed to administer medications as ordered by the physician (Resident #13). This was evident for 1 of 14 residents reviewed during a complaint survey.The findings include:Review of Resident #13's medical record on 2/24/26 revealed the Resident was admitted to the facility in December 2025 with a diagnosis to include acute prostatitis. Acute prostatitis is a sudden, severe bacterial infection of the prostate gland, often causing intense pain, fever, and urgent urinary symptoms. Review of Resident #13's hospital Discharge summary dated [DATE] revealed the Resident was ordered Ertapenem 1 gm intravenous antibiotic every day to end on 1/30/26. Review of Resident #13's January 2026 Medication Administration Record revealed the Resident did not receive Ertapenem on 1/30/26.Further review of Resident #13's physician ordered revealed the Resident's antibiotic was changed from Ertapenem to Meropenem 2 gm intravenous antibiotic every 8 hours on 2/4/26. Review of Resident #13's February 2026 Medication Administration Record revealed there is no evidence the Resident received Meropenem on 2/15/26 at 10:00 PM. Interview with the Director of Nursing on 2/25/26 at 8:30 AM confirmed the facility staff failed to administer antibiotic medication to Resident #13 on 1/30/26 and 2/15/26.

Based on medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice (Resident #1 and #13). This was evident for 2 of 3 residents reviewed for respiratory services during a complaint survey. The findings include: 1) Review of Resident #13's medical record on 2/24/26 revealed the Resident was admitted to the facility in December 2025 with a diagnosis to include Obstructive sleep apnea. Obstructive sleep apnea (OSA) is a sleep disorder characterized by repeated episodes of complete (apnea) or partial (hypopnea) collapse of the upper airway, causing oxygen desaturation or sleep arousal. Review of Resident #13's hospital Discharge summary dated [DATE] revealed the Resident was to continue on BiPAP for sleep. BiPAP (Bilevel Positive Airway Pressure) is a noninvasive ventilation device used to treat breathing difficulties, such as sleep apnea, by delivering pressurized air through a mask. Review of Resident #13's December 2025 Treatment Administration Record revealed the BiPAP was not ordered and documented it was administered until 12/29/25, 3 days after admission. Interview with the Administrator on 2/24/26 at 2:00 PM confirmed the facility staff failed to administer the Resident's BiPAP for 3 nights after admission. 2) On 2/20/26 at 12:48 PM a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in December 2025 with diagnoses that included but were not limited to COPD, asthma, and chronic myeloid leukemia. Review of a 12/13/25 system note documented that Resident #1 was receiving oxygen at 3 LPM (liters per minute) via nasal cannula. Review of a 12/16/25 history and physical documented the chief complaint for the visit included acute on chronic hypoxic hypercapnic respiratory failure. The note documented the resident had COPD and asthma and was on home oxygen of 2 to 3 liters. It was documented that while the resident was in the hospital prior to admission, Resident #1 had community-acquired pneumonia and acute hypoxic respiratory failure. Review of the vital sign section of Resident #1's electronic medical record documented intermittent use of oxygen. Review of Resident #1's December 2025 and January 2026 physician's orders failed to produce an order for oxygen therapy and orders for tubing changes, humidification, oxygen saturation goals, and basic care of the resident receiving oxygen therapy. Review of the oxygen therapy policy that was given to the surveyor by the Director of Nursing (DON) on 2/24/26 at 1:30 PM documented the procedure, 2. Verify medical doctor order (should include liter flow, type of O2 delivery device). On 2/24/26 at 1:30 PM an interview was conducted with the DON. The DON reviewed the vital sign section of the medical record where it was documented that Resident #1 received oxygen therapy. The Medication Administration Record (MAR) and the Treatment Administration Record (TAR) were reviewed with the DON who confirmed that there was no documentation of oxygen usage, the changing of oxygen tubing, and if humidification was used.

Based on observation and staff interviews, it was determined that the facility failed to maintain a clean, sanitary and homelike environment for their residents. This was evident for 1) 1 of 2 nursing units in the facility and 2) observation of the laundry room during the recertification/complaint survey.The findings include:1) On 9/8/25 at 3:31PM during the initial rounding in the facility, the surveyor observed that the bathroom ceiling in room [ROOM NUMBER] was busted inwards where the water sprinkler was located about 10x4 inches long. Further observation of the ceiling on the second-floor hallway by the medication room and janitor's closet were three vents. All three were covered in dust and had multiple rusty brown colored stains plastered all over.On 9/10/25 at 8:55 AM, Staff #10, a maintenance director, in an interview, was asked if they round on the floors in the building and he said they do so daily. He was asked what they look out for during the rounds, and he said everything, mainly safety issues such as trip hazards, wheelchairs, doors not working properly, automatic closure on doors etc. He was asked if they checked the vents in the hallways and he said he had a painter paint one recently and placed an order for a new one for the kitchen. He was asked if their vents got cleaned at all. He said they don't have a scheduled cleaning of the vents.On 9/10/25 at 9:26AM the surveyor took Staff #10 up to the second floor and showed him the 3 rusty and dust covered vents including the bathroom ceiling in room [ROOM NUMBER]. He said that the vent has been painted many times and needed to be vacuumed, cleaned or replaced, and that the black spot was due to condensation from the cold air. He stated that staff put in a ticket for room [ROOM NUMBER]'s bathroom to have it replaced but was not sure when it was put in. Regarding room [ROOM NUMBER]'s bathroom, he said they are upgrading the bathrooms and will fix the ceiling too. He was made aware that it was a concern, he said he was the only maintenance in the building, and the facility is currently hiring.09/10/2025 10:01 AM the administrator was made aware of the concern2) On 9/12/25 at 9:30AM- Observation of the laundry room revealed that on the dirty side where dirty laundry is received and sorted, a large sink reserved for eye wash was very dirty and covered with brown stains, it was also leaking and had towels underneath to catch the leaks. Staff # 27, the housekeeping supervisor/Account manager, said she made Staff #10 the maintenance director aware of it about 2 weeks ago. She stated that one side was leaking and staff #10 came and fixed it and it worked for a while. She said it stopped working. At 11:05 AM the DON was made aware of the findings/concern, she said she will bring it to the attention of the maintenance director.

Based on observation, record reviews and staff interviews, it was determined that the facility failed to label oxygen (02) tubing with change dates. This was evident for 7 (#44, #127, #153, #149, #116, #76, #91) of 7 residents reviewed for respiratory care during the recertification/complaint survey.The findings include: A nasal cannula is a device that delivers oxygen directly to a person's nose through a flexible plastic tube that is attached to a piece of equipment that provides oxygen. The plastic tube can harbor bacteria and mold. It is important to change the tubing to prevent the spread of germs and to maintain health and safety during oxygen therapy. Staff should label the tube with a date to indicate when it had been changed. 1) On 9/8/25 at 8:30 AM during the initial rounding on the units, the following residents were noted to be on oxygen (O2) therapy: Resident #44, #127, #153 and #149. All 4 residents had their O2 tubing used to deliver O2 through the nose connected to a humidifier at the bedside but none of the O2 tubes were labelled with a date to indicate when it was last changed. In an interview with Resident #44 observed on 02 at 4 liters on 09/08/2025 at 8:39 AM, S/he was asked when their O2 tubing was last changed and s/he stated, they only change it when asked. Further review did not reveal a physician order to change the O2 tubing. Resident #127 has orders that read: Oxygen at 2L/min via Nasal Cannula, continuously. every shift. There was no order for tubing change. Resident #153 orders read: Oxygen at 3 L/min via Nasal Cannula continuous every shift. 10/27/23-Oxygen tubing, change weekly Label each component with date and initials, every day shift every Wed. Label each component with date and initials AND as needed. It was not labelled. Resident #149 orders read: Oxygen at 2 L/min via NC continuous every shift for COPD. 5/24/25: Oxygen humidifier bottle tubing, change weekly- Label each component with date and initials every day shift every Mon. Label each component with date and initials. It was not labelled. On 9/8/35 at 11:25 AM, Staff #33 a Registered Nurse, was asked in an interview who does the O2 tubing changes and she said it's done by day shift. She was asked how often, and she said she was not sure, but the frequency will be on the Medication/treatment administration records. She was asked when the O2 tubing was last changed and she said she did not know. She was asked if the tubing should be labeled with a change date and she said she did not know but will find out. On 9/8/25 at 11.31AM- Staff #33 came back to say that she asked her unit manager and was told that O2 tubes should be labelled with change dates. On 9/8/25 at 11:34AM Staff #28, the Unit Manager, in an interview was asked how often the O2 tubing should be changed, and she said it should be labelled and changed every 7 days. She was made aware that all residents on the 2nd floor on O2 did not have a label on their O2 tubes. She indicated that it had been brought to her attention, and she was addressing the issue with her staff. On 9/11/25 at 8:15 AM the Director of Nursing was made aware of the concerns, and she said she will follow up. 2) During the screening process of the survey on 09/08/2025 at 8:39 AM, surveyor observed the oxygen tubing did not have a label dated for Residents #116, #76, and #91. On 09/08/2025 at 12:02 PM during the investigative phase of the survey, surveyor observed Resident #116's oxygen concentrator and nasal tubing without a label, therefore, surveyor did not know when tubing was changed, and the resident was unsure of the last time tubing was changed. In an interview on 9/8/2025 at 12:25 AM, Staff # 33 stated that the oxygen tubing was to be changed on day shift but were not sure about how often. When asked if the tubing should be labeled, staff # 33 stated that she/he did not know but will find out. Staff # 33 returned and informed surveyor at 12:31AM that nasal cannula tubing should be labelled. An interview was conducted 9/8/2025 at 12:34AM with the Unit Manager (Staff # 28) who stated that the oxygen tubing should be changed every 7 days and was also supposed to be labelled. A review of Resident #116's medical record on 9/8/2025 at 11:40 AM revealed an order written on 2/17/2025 for Oxygen 2L/min via Nasal Cannula continuous every shift. There were no order for changing or labelling tubing. On 09/09/2025 at 2:17 PM, an interview was conducted with the Nurse Educator (Staff #3) who stated that the staff are now getting an Inservice on oxygen delivery and labeling of the tubing and oxygen equipment. When surveyor asked about the documentation for changing the oxygen delivery supplies, staff #3 stated that orders, care plan, and treatment records will be updated to capture the proper documentation. 09/11/2025 at 8:23 AM Surveyor informed DON that the oxygen tubing was not labeled and there were no orders or documentation for changing the oxygen tubing in Resident # 116's medical record. the DON acknowledged that this was a concern and stated that it will be corrected.

Based on a review of employee files and staff interviews, it was determined that the facility failed to implement a system to ensure newly hired Geriatric Nursing Assistants (GNAs) were competent in their skill sets. This deficiency was evident in four (GNA #15, # 17, 36, and #37) out of five GNA employee files reviewed during the recertification/complaint survey.Findings include:According to the American Nurses Association, nursing competence is an expected level of performance that combines knowledge, skills, abilities, and judgment.On 9/11/25 at 9:40 AM, a surveyor reviewed five randomly selected GNA employee files. The reviewed revealed four employees did not have records showing their competencies were verified upon hire: GNA #15 (hired March 2023), GNA #17 (hired December 2022), GNA #36 (hired September 2023), and GNA #37 (hired July 2024).During an interview on 9/11/25 at 2:05 PM, Staff #3 (an educator) confirmed that GNA skills are required to be verified before they can begin working on a unit. When the surveyor reviewed the files for GNAs #15, #17, #36, and #37 with Staff #3, she acknowledged that their competencies and skills had not been verified upon hire.The Director of Nursing (DON) was informed of these findings during an interview on 9/15/25 around 1:00 PM.

Based on observation and staff interviews, it was determined that the facility failed to process linen in such a manner as to prevent infection, evidence by staff not wearing a protective gown to sort dirty linens and having drinks and personal items on the clean folding table next to clean laundry. This was observed during the recertification/complaint survey.The findings include:On 9/12/25 at 9:30 AM an observation of the laundry room revealed 2 folding tables located to the left and right side of the room. On the clean folding table to the right was observed a large (20 oz) cup of ice coffee about 1/4 full lying on the table, a cell phone plugged in to an electric outlet charging on the table, 3 lunch bags, and a table fan with the blade cover removed and the blades covered in dust.On the clean folding table to the left was observed an open can of cold breeze berry energy drink about 3/4 full, a Remedy essential cleanse shampoo and body wash, an open packet of Twizzlers pull and peel candy (orange cream top), a lunch bag and a cell phone.In an interview with Staff #31 a laundry assistant on 9/12/25 at 9:35AM, she was asked if those items were supposed to be left on the clean laundry folding table and she said no, that she was sorry and proceeded to take them away. The surveyor then entered the dirty side of the laundry room where laundry is sorted and found Staff #32 (laundry aide) sorting dirty linens. The laundry aide had a glove and mask on; the mask was pulled down underneath her nose exposing it. She was not wearing a protective gown. Hanging on a peg were 3 yellow gowns and a pack of gloves was in a corner.In an interview on 9/12/25 at 9:38 AM, Staff #31 was asked what sort of PPE she was required to wear to sort dirty linens, and she said, gowns and gloves. She was asked if she got trained in the use of Personal protective equipment (PPE) for sorting and she said yes. She was asked if she was taught that protective gowns should be worn for sorting and she said she was taught to wear gloves and mask but not gowns. The surveyor requested to speak to a supervisor.On 9/12/25 at 9:43 AM Staff #27, the laundry supervisor / Accounts manager came in and was asked what sort of PPE's the staff should be wearing for sorting dirty linens, and she said gowns, gloves and masks. She was made aware that her staff were sorting without appropriate PPE's. She said they were trained to use PPEs. She was also made aware of the personal items found on the clean laundry folding tables and she said they belong to a new staff member who just started that has no locker. She was made aware that it was a concern and she said she would do more training.On 9/12/25 at 10:02 AM, the Director of Nursing was made aware of the concerns, she said she will address them.

Based on surveyor observations and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was observed during the recertification/complaint survey.The findings include:During the survey several observations were made of gnats in the building. On the first day of the survey on 9/8/25 at 7:35 AM, surveyors were placed in the facility's conference room with multiple flying gnats observed in the room. On 9/8/25 at 9:10 AM during initial rounds, the surveyor observed a brown insect and gnat flying around the resident in Room125. The resident tried to swat them and missed. S/he stated flies are a problem.Throughout the survey conducted from 9/8/25 through 9/16/25, there were observations made each day of gnats in the conference room. An interview was conducted with the Maintenance Director on 9/10/25 at 8:57 AM. During the interview he stated the facility had an insect/pest maintenance program by a company called Allstate who comes weekly. When asked if there had been an issue, he stated we had some mice more so last winter and came up with a plan of correction. We took all the ptac covers off the external units of the building and put hardware cloth on top to try to keep the mice out. He also stated, we have some gnats that are seasonal in the summertime. The surveyor shared the sightings of gnats in room [ROOM NUMBER] and the conference room. The Maintenance Director stated, The vendor, Allstate, does not deal with gnats because they say it is a water and cleanliness issue. If you throw a banana peel in the trash and if it's not taken out right away, there will be gnats. We deployed the plastic apples that get filled with apple cider vinegar to address the gnats.

Based on a review of medical records and interviews, it was determined that facility staff failed to ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act. This was evident for one resident (Resident #1) out of the four residents reviewed for advance directives during the recertification/complaint survey.The findings included:On 9/08/25 at 1:29 PM, the surveyor reviewed Resident #1's medical records. The review revealed that the resident was admitted to the facility in August 2025 with an altered mental status. The form named physician certification related to medical condition, substitute decision making and treatment limitation was completed on 8/14/25 by one physician, who noted that the resident was unable to make decisions due to a state of confusion. However, a second physician's signature was missing.During an interview with Staff #5 (Social Worker) on 9/09/25 at 9:14 AM, she explained the process for physicians' certification regarding residents' decision-making capacity. She confirmed that two signed certifications are required when residents are incapable and that the forms should be completed within a week. She also noted that the facility's staff should monitor the status of these certifications. The surveyor reviewed Resident #1's certification with Staff #6, who confirmed that only one form had been completed.On 9/09/25 at 10:58 AM, Staff #6 stated that the facility had scheduled the second certification, and she verified that this action was arranged after the surveyor's intervention.

Based on review of facility records and interview with staff, it was determined the facility staff failed to: 1) immediately report an allegation of suspected resident abuse and 2) timely report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #42) of 35 residents reviewed for intakes during the facility's recertification/complaint survey.The findings include:The OHCQ is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse, serious bodily injury, and misappropriation of resident property are to be reported to the OHCQ in a timely manner (within 2 hours for the initial report and within 5 working days for the final report).A facility reported incident involving Resident #42 was reviewed on 9/15/25 at 6:00 AM. The facility report indicated that facility staff, Guest Services Director (GSD) became aware of the allegation of verbal abuse on 12/11/24 at 8:59 AM. Further review of the facility's initial report revealed the Nursing Home Administrator (NHA) was not notified by the GSD about the allegation until 12/13/24 at 10:00 AM. The facility reported the allegation to the OHCQ on 12/13/24 at 11:50 AM and began an investigation, however this was 2 days after the GSD was made aware of the concerns. The GSD failed to immediately report the allegations to the NHA.On 9/16/25 at 8:28 AM in an interview with the NHA when asked what the expectation would be for any staff member who was made aware of an allegation of abuse, he stated it would be for the staff to report the allegation to their supervisor immediately. Additionally, he stated that the supervisor would then immediately report it to the Director of Nursing or NHA who would start an investigation. During a dual observation with the NHA, the surveyor shared the concern that the initial self-report from the facility documented that the GSD became aware of the allegation on 12/11/24 at 8:59 AM and did not notify the NHA until 12/13/24 10:00 AM. Furthermore, the facility did not submit their initial report until 12/13/24 at 10:00 AM, 2 days after the GSD was made aware of the concerns. The NHA acknowledged and confirmed understanding.

Based on the matrix, medical record review, and staff interview, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments diagnoses were updated. This was evident for 3 (Residents #82, #113, and #13) residents identified with a diagnosis of COVID on the matrix out of 74 resident records reviewed during the recertification/complaint survey process. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Active diagnoses documented on the MDS assessment should correlate with an accurate picture of the resident's current health status.The Facility Matrix is a tool used for assessing the care needs of residents and contains the active diagnoses pulled from the MDS. It also identifies care categories used to determine the appropriate level of care and resources required for each resident. The matrix is completed by the facility and must reflect all residents on the day of the survey. During the infection control facility task investigation, it was noted that 3 Residents, #82, #113, and #13 had a diagnosis of COVID on the Matrix. On 9/11/2025 at 10:35 AM the Infection Preventionist (Staff #3) stated that there were no resident with COVID in the facility.Upon further review of the MDS assessments for all 3 residents on 9/11/25 at 11:12 AM, the Active Diagnoses tab (section I), additional diagnosis indicated UO7.1 COVID 19.In an interview on 9/12/25 at 12:01 PM, the MDS coordinator (Staff #8) stated that he/she was not aware of the diagnosis of COVID for the 3 residents and she will have to look into it.On 9/12/2025 at 12:54, the MDS Coordinator provided an outline related to the 3 residents with the diagnosis of COVID on the Matrix:Resident #82 was admitted on [DATE] with COVID and diagnosis remained in the Diagnosis tab in the MDS when Matrix was pulled on 9/8/25.Resident #113 tested positive for COVID on 4/3/25, the quarterly MDS was done on 6/1/25 and still had a diagnosis of COVID. The following quarterly MDS initiated on 9/1/25 was to be completed on 9/11/25, but the Matrix for the survey entry on 9/8/25 was pulled prior to completion of the 9/1/25 MDS, which had the COVID diagnosis.Resident #13 tested positive for COVID on 4/10/25 and diagnosis remained in the diagnosis tab in the MDS. The Medicare 5 day assessment was done 4/17/25 with the diagnosis of COVID. The quarterly MDS done on 4/18/25 had a diagnosis of COVID which was resolved on 4/23/25. A significant change MDS that was done on 6/16/25 had a diagnosis of COVID and the Matrix pulled on 9/8/25 indicated that resident had a diagnosis of COVID because it was not removed from MDS diagnosis tab.On 9/12/25 at 1:30 PM, the Nursing Home Administrator and DON were made aware that the matrix was wrong and the MDS assessments for the 3 residents were not accurate. They both agreed that this was a concern, and it will be corrected.

Based on interview with family, a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 2 (Resident #13, # 2) out of 4 residents reviewed for care plans during the facility's recertification/complaint survey.The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) On 9/8/25 at 12:44 PM, Resident #13's responsible party (RP) was interviewed. During the interview, the RP indicated that s/he had recently received an invitation to a care plan meeting on 9/17/25. However, s/he stated prior to this invitation, s/he had not been invited to or attended a care plan meeting. On 9/9/25 at 2:18 PM review of Resident #13's medical record revealed the resident was admitted on [DATE]. The review failed to reveal evidence that a care plan meeting was held. On 9/9/25 at 2:24 PM in an interview with the Social Worker (SW #5) when asked about care plan meetings she stated, they were held quarterly, every 3 months. During the interview she stated residents' RPs were notified through email or snail mail or if the resident was here in the building, the notification would get hand delivered to them. Additionally, she stated that she created an attendance sheet for the meetings and that they along with the invitations were kept in the social work office. Furthermore, she stated that she documented her interactions with residents and family members. The surveyor requested any and all documentation related to any care plan meetings for Resident #13 such as attendance sheets, invitations, social services notes, et cetera. On 9/10/25 at 9:29AM in a follow up interview with SW #5, she provided the survey team with two documents: an attendance sheet from a 3/28/25 care plan meeting and an invitation for an upcoming care plan meeting scheduled for 9/17/25. When asked if there was documentation/evidence of additional care plan meetings for Resident #13 she stated, No, the only thing I can think is it might have been missed or overlooked. 2) On 09/08/2025 at 1:01 PM during the initial rounding on the units, Resident #2 was asked if s/he was invited to attend a care plan meeting or have attended one. The resident stated that s/he has been in the facility for 7 months but has not had one and was never invited. On 09/09/2025 at 12:40 PM review of the social works (SW) progress notes revealed that the resident had a care plan meeting on 6/26/25. Care Plan meetings are held quarterly, and this resident was admitted on [DATE] so he/she should have had a care plan meeting in May of 2025. Further review did not show that the resident was given advance notice for the care plan meeting. In an interview with the social worker (SW)Staff #5 on 9/9/25 at 1:07 PM, she was asked about the care planning meeting and made aware that Resident #2 was admitted in February 2025 but did not have a care plan meeting until June 2025 which was 4 months later. She confirmed that the residents' care planning meeting was held late because she was the only social worker at the time. She was asked how often the care plan meetings are held and she said that for long term care (LTC) residents, care plan meetings are held quarterly, and families are notified vis email. For residents who are oriented, care plan meeting notifications are hand delivered to them via a letter. She was asked to provide proof that Resident #2 was notified. She stated that she will check On 9/9/25 at 1:40 PM the SW came back to report that she did not have documentation to show that a care plan invite to the June care plan meeting was provided to the resident. She was made aware that it was a concern. On 9/11/25 at 9:42 AM the Director of nursing was made aware of the concerns

Based on interviews with residents, review of medical records, and interviews with facility staff, it was determined that facility nursing staff failed to follow professional standards of nursing practice when documenting medications given to residents. This was evident for 1 (Resident #102) out of 2 residents reviewed for timely medication administration during the recertification/complaint survey.The findings include:It is the standard of nursing practice to document administered medications immediately after administration. Failure to do so can result in an inaccurate medical record where it cannot be determined when a medication was given and therefore has the potential to result in medication errors (such as a resident receiving a dose twice or two doses of a medication being given too close in time).On 9/8/2025 at 9:42 AM in an interview with Resident #102 s/he stated that the facility staff waited until his/her pain medications ran out or almost ran out before reordering them and so s/he received the medication late because they had to wait for it to come. On 9/14/2025 at 5:35 PM review of the MAAR [Medication Administration Audit Report] for August and September (up to September 13th) 2025 revealed an order for OxyContin Oral Tablet 20 mg [milligram]. Give 1 tablet by mouth two times a day for back and shoulder pain. On the MAAR, the ordered/scheduled time for administration of the medication was 9:00 AM; however, the following dates/times were when the medication was documented as being administered:08/01/2025 2:06 PM08/02/2025 10:49 AM08/12/2025 11:21 AM08/14/2025 10:11 AM08/26/2025 10:11 AM8/28/2025 10:32 AM09/05/2025 1:12 PM09/08/2025 10:17 AM09/09/2025 11:38 [NAME] the MAAR, the ordered/scheduled time for administration of the medication was 9:00 PM; however, the following dates/times were when the medication was documented as being administered:08/03/2025 10:59 PM08/09/2025 10:15 PM08/13/2025 10:08 PM08/17/2025 10:10 PM08/27/2025 10:38 PM08/31/2025 10:47 PM09/05/2025 10:37 PM09/06/2025 10:12 PM09/07/2025 10:25 PM09/09/2025 10:09 PM09/10/2025 10:28 PM09/13/2025 10:24 PMReview of these MAARs demonstrated a pattern of multiple staff documenting the pain medication late. This practice occurred on 18 out of 44 days (40% of the days) under review and involved a significant pain medication.On 9/14/2025 at 6:08 PM Resident #102's care plan was reviewed and revealed the resident had a care plan for chronic back/shoulder pain. The following interventions were documented to address the chronic pain: Administer my pain medication(s) per order and notify MD if goal is not met with regime. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.On 9/15/25 at 8:09 AM in an interview with the Director of Nursing (DON) when asked about staff reordering medications, she stated the normal process was to reorder the medication when it gets to the last column [on the blister pack]. During the interview she stated, Do they [facility staff] consistently do that, no. Sometimes pharmacy sends a backup card [of the medication], but if not, they are supposed to reorder when it is in the last column. When asked what the standard of practice was for documenting medications, the DON stated immediately after administering. The surveyor shared a few examples of medications being documented hours after the scheduled time and shared this as a concern. The DON verbalized and acknowledged understanding. The surveyor interviewed Registered Nurse (RN #22) on 9/15/25 at 10:43 AM, who was identified as one of the staff documenting medications late. When asked what the standard of practice was for administering medications he stated 1 hour before and 1 hour after the medication was scheduled. During the interview, he stated, So if it is ordered at 9:00 AM, we can start giving it at 9:00 AM and up to 11:00 AM. When asked what the standard of practice was for documenting medications he stated, As I pull each medication, I click sign and then after administering all the resident's medications, I click save which documents that I administered the medications. During a dual observation, the surveyor showed RN #22 several of the above times where the medication was documented as being administered late. RN #22 stated, So I gave it on time, but didn't document on time. The surveyor shared this was a concern and RN #22 acknowledged understanding of the concern.

Based on interviews with residents, review of medical records, and interviews with facility staff, it was determined the facility staff failed to provide care and services to maintain or improve a resident's ability to carry out Activities of Daily Living (ADLs). This was evident for 1 (Resident #6) of 2 residents reviewed for rehabilitative or restorative services during the facility's recertification/complaint survey.The findings include:ADLs are the basic, essential self-care tasks individuals perform to maintain their daily lives such as hygiene, eating, mobility, and toileting.On 9/8/25 at 8:32 AM in an interview with Resident #6 s/he stated s/he had requested an exercise band several times and was not provided with one. When asked who s/he made the request to s/he stated some aides and nurses, both of whom said Rehab [rehabilitation department: physical therapy (PT), occupational therapy (OT), and speech therapy] would have to make that determination. S/he stated a nursing staff member coordinated a phone call to the Rehab department and Resident #6 requested an exercise band from a female staff member who stated s/he was not able to have one. Resident #6 stated another instance s/he specifically requested an exercise band from Rehab was when a male Rehab staff member came to provide services to his/her roommate and s/he requested one from him. He told Resident #6 he would ask. He left, came back later, and said he was unable to provide one. Resident #6 stated s/he was requesting an exercise band because s/he wanted to exercise and strengthen his/her arms to be able to, as an example, move him/herself in bed because s/he cannot move his/her legs. Furthermore, s/he stated s/he had never been in his/her wheelchair since his/her admission and when s/he had asked, nursing said it was up to Rehab. Resident #6 stated they would call Rehab and Rehab would say s/he could not get up to his/her wheelchair because of his/her pressure ulcers.On 9/9/25 at 11:17 AM in an interview with the Director of Rehab (DOR #7) when asked if Resident #6 was on caseload she stated s/he was initially evaluated on admission and then screened quarterly. When asked if the resident got up to his/her wheelchair or received services, the DOR #7 stated, The Wound Team communicated to Rehab that the resident was not able to get into his/her wheelchair due to his/her sacral wounds being down to the bone and could not come down for Rehab. When asked if she had documentation to support this, she stated she would have to look into it. On 9/9/25 at 11:30 AM in an interview with the DOR #7, the surveyor requested a copy of Resident #6's initial evaluation and all screenings. In addition, a second request was made of documentation of when the Wound Team had communicated to Rehab that the resident could not get into his/her wheelchair. On 9/9/25 at 11:31 AM review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including but not limited to paraplegia and acquired absence of right leg above the knee. Further review of the medical record failed to reveal documentation from the Wound Team that noted the resident was unable to get out of bed and into his/her wheelchair for any period of time. Additionally, the review revealed a nursing assessment/progress note dated 9/12/24: Bed Rail evaluation completed. Bed Rail(s) in use. - Results: Independently able to turn side to side, not independent in moving up and down in the bed, not able to independently to pull self from laying to sitting position, not able to balance self while transferring to and from bed, not able to independently support self, unable to independently enter/exit bed safely, unable to independently transfer safely to and from bed. - Outcomes: rail served as an enabler with turning side to side/holding self to one side (for comfort, ADL/continence, pressure redistribution, etc.), with assistance rail served as an enabler with moving up and down in bed, with assistance rail served as an enabler with pulling self from laying to sitting position, with assistance rail served as an enabler with improving balance. - Final determination was that rails will be implemented. - Type of rail, bar or pole: Rail: left upper and right upper. Finally, the review of Resident #6's medical records revealed a care plan for:Focus: The resident has limited physical mobility related to disease process and weakness.Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date.Interventions: - Invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility. - Provide supportive care, assistance with mobility as needed. - Document assistance as needed. - PT [physical therapy], OT [occupational therapy] referrals as ordered, PRN.On 9/9/25 at 12:03 PM in an interview with the DOR #7, she provided the surveyor with two documents: a Therapy Screen Form dated 9/12/24 and a SLP (speech language pathology) Evaluation and Plan of Treatment dated 10/10/24 -11/5/24. The surveyor stated Resident #6 was originally admitted [DATE] and that according to this document provided, s/he was screened and not evaluated on his/her initial admission. When asked what was more comprehensive a screening or an evaluation, DOR #7 stated, An evaluation would be more comprehensive, but it would be case to case and as needed. Initially if there is a concern, we get a nursing referral and I did not receive one, so we just did a screen. When asked if a new admission who was paraplegic but still had upper extremity movement, would benefit from a Rehab evaluation and/or any rehab services, the DOR #7 stated, I think that would have to be case by case. When asked if a resident requested equipment or services, how Rehab would respond, the DOR #7 stated, When I get a nursing referral, we screen and evaluate as appropriate. When asked how referrals were made, the DOR #7 stated, Nursing or any other department can make a referral. During the interview when asked, if a resident requested equipment or services would that trigger a referral, the DOR #7 stated, I did not have a referral for this resident [#6] and s/he is someone who has been dependent since his/her admission. When asked if there was additional quarterly screening documentation for Resident #6 (since in the previous interview DOR #7 stated Resident #6 was screened quarterly), the DOR #7 stated, Those were dates he was due to be screened for, but I said I wanted to check my records to confirm and those two (the two documents she provided from 9/12/24 and 10/10/24) were the only ones I could find. The other dates I provided were times s/he could have been screened. When asked why s/he was not screened quarterly as she had originally stated, the DOR #7 stated, There was no referral provided. When I get a nursing referral, we screen and evaluate as appropriate. During the interview when asked for documentation that the Wound Team communicated to Rehab that Resident #6 could not get up to his/her wheelchair or come down for rehab, the DOR #7 stated, No, I do not have any documentation that the Wound provider [Wound Nurse Practitioner (WNP # 24)] communicated that to the Rehab department. On 9/10/25 at 12:38 PM review of the 9/12/24 Therapy Screen Form revealed the following:Reason for Screen: New/ReadmitScreening Indicator: - There was not one indicator documented as yes or no. - Some of the indicators included: risk for fall (gait/balance/positioning), wound (stage 3, 4, multiple 2), decreased ROM [range of motion]/contracture, decline in ambulation, decline in bed mobility and/or transfers, decline in ADLs (dressing, grooming, hygiene/WC [wheelchair] mobility/toileting), poor bed/WC positioning/restraints, decreased cognition, appropriate for exercise program, was resident on PT/OT before?, is resident appropriate referral to speech therapy? - In the comments section it stated, Pt [patient] admitted from hospital without significant change in status and therefore no services warranted at this time.Recommendation: No Therapy IndicatedOn 9/10/2025 at 12:44 PM in an interview with the Nursing Home Administrator (NHA), the surveyor shared concerns about Resident #6 requesting an exercise band to help keep his/her upper body strong and him/her not being referred to Rehab, screened or evaluated by Rehab, nor given an exercise band. The surveyor also shared concerns that the Resident #6 stated s/he had not been taken out of his/her bed and put in his/her wheelchair once since his/her admission and that when s/he asked staff they told him/her Rehab said s/he could not get out of bed due to the wounds on his/her bottom. The NHA stated we will get him/her a Rehab evaluation. On 9/10/2025 at 12:58 PM review of all documentation from Resident #6's most recent hospitalization (discharged to hospital on 8/28/25 and readmitted to facility on 9/1/25) revealed a Physical Therapy Adult Evaluation. Further review of the evaluation revealed in the Assessment Summary section, Pt would benefit from PT to maximize BUE [bilaterial upper extremity] strength and progress sitting tolerance as sacral wound healing allows. Recommend: home PT.On 9/10/25 at 2:35PM in an interview with the DOR #7, she provided documentation from WNP #24. Review of WNP #24's progress notes revealed the following:1/15/25- Continue to use Roho cushion when OOB [out of bed] in w/c [wheelchair]. - Avoid sitting up for extended periods of time. Patient education provided.4/8/25- Continue to use Roho cushion when OOB [out of bed] in w/c [wheelchair]. - Avoid sitting up for extended periods of time. Patient education provided.- Wounds are healing nicely without active local signs of wound infection at time of visit. 5/7/25- Continue to use Roho cushion when OOB [out of bed] in w/c [wheelchair]. - Avoid sitting up for extended periods of time. Patient education provided.- Preventative measures: pressure sitting upright in bed exceeding greater than 1-2 hours at a time.The review of WNP #24's progress notes failed to reveal documentation recommending Resident #6 to not get out of bed at all and/or documentation recommending the resident to not get up to his/her wheelchair. On 9/11/25 at 8:23 AM in an interview with the Director of Nursing (DON) when asked which residents are evaluated by Rehab she stated, when a resident was admitted or readmitted , we discuss them the next morning in our clinical meeting and there is a batch order put in for PT to evaluate and treat. During the interview she stated, We just write the initial order for PT and then PT evaluates and makes the decision if they would benefit from therapy. When asked the process if a resident requested equipment such as an exercise band, the DON stated, If a resident requested adaptive equipment, we would let therapy know and therapy takes over. Anything the resident asked us for, we would let therapy and the attending know, but we usually just let [DOR #7's name] know that they are requesting more therapy or equipment and she would follow up on it. We discuss everything in our clinical meeting and go through everything in their [hospital] discharge paperwork. The surveyor requested any policies and procedures related to rehab services, adaptive equipment, et cetera and all 9/1/25 hospital discharge paperwork. On 9/11/25 at 10:17 AM in an interview with the DON she stated we do not have a policy or procedure related to the referral process, but when any resident is admitted or readmitted , a PT order is placed, it is a batch order, for PT to evaluate and treat. During the interview she stated, We also have this form that we fill out when a resident shares a concern or nursing has a concern. The DON stated this was the best copy (the title was cut off) and provided a copy to the surveyor. She verified and confirmed that this was the Referral Form that the facility uses. When asked if one of these forms was completed for Resident #6, she stated no, but she did see the PT note from Resident #6's last readmission recommending PT and that she just spoke with DOR #7 and Resident #6 would be evaluated now. The surveyor requested documentation of a PT order and/or Rehab notes from when Resident #6 returned from the hospital [on 9/1/25]. On 9/8/2025 at 9:00 AM in an interview with Registered Nurse (RN #2) when asked how long he had worked at the facility he stated a little over a year. During the interview when asked if he personally had ever assisted Resident #6 to his/her wheelchair he stated no. Additionally, when asked if he had ever seen Resident #6 in his/her wheelchair in the time he had worked at the facility, RN #2 stated, No, I cannot remember him/her ever in his wheelchair. On 9/11/25 at 11:35 AM in an interview with RN #12 when asked how long she had worked at the facility, she stated, Over a year I have been coming here. During the interview when asked if she personally had ever assisted Resident #6 to his/her wheelchair she stated no. Additionally, when asked if she had ever seen Resident #6 in his/her wheelchair in the time she had worked at the facility, RN #12 stated, No, I have not ever seen him/her sitting in his/her wheelchair. On 9/11/25 at 11:40 AM in an interview with Resident #6 s/he stated, No, I have not got up to the wheelchair since we last spoke on Monday [9/8/25]. On 9/11/25 at 11:43 AM review of the facility's policy for Assistive Devices revealed, Purpose- To ensure resident/patients in need of an assistive device is provided with proper equipment to enhance functional skills and abilities, improve communication and resident/patient participation in social and recreational and community activities. Further review revealed, Policy- Assistive devices will be provided to resident/patients to increase activities of daily living and quality of life. Additionally, the policy stated, Procedure- 1. Staff should be knowledgeable regarding type and availability of assistive devices and evaluate resident/patient, noting specific assistive devices needed for resident/patient's abilities and disabilities. On 9/11/25 at 11:54 AM in an interview with the DON she stated she asked the Unit Manager (UM #1) if there was a PT order to evaluate and treat Resident #6 and this was what she provided (and handed 2 orders to the surveyor). Both orders were for PT eval (evaluate) and tx (treat) with one dated 9/1/25 and the other dated 9/11/25. During a dual observation, the DON observed the surveyor pull up Resident #6's medical record on the computer and that the PT order dated 9/1/25 was ordered was today, 9/11/25, after surveyor intervention. When asked prior to surveyor intervention was there an order when Resident #6 came back from the hospital on 9/1/25 for PT to evaluate and treat, she stated no. The surveyor shared this was a concern and the DON acknowledged understanding.On 9/11/25 at 12:10 PM in an interview with the DON and Nursing Home Administrator (NHA) he stated there are different things that will trigger a PT eval. During the interview the NHA stated, Yes, a resident requesting should be enough to trigger a PT eval. He also stated, There was no order placed when the resident returned from the hospital for PT. The surveyor shared the concern that the DON had stated that all admissions/readmissions were ordered a PT order and that all hospital discharge paperwork is reviewed the morning after admission in the clinical meeting. Moreover, Resident #6's hospital discharge paperwork recommended PT. The NHA acknowledged understanding. The surveyor also shared the concern that Resident #6 stated he/she asks to get up to his/her wheelchair and stated s/he had never been able to. The NHA stated, We looked and there was no order saying the resident could not get up to his/her wheelchair. The DON stated that the resident often refused to get out of bed. The surveyor requested documentation to support this. On 9/11/25 at 1:20 PM in an interview with the DON she stated, I did not find a progress note or care plan that the resident [#6] refused to get out of bed.On 9/15/25 at 1:28 PM in an interview with the Wound Nurse (WN #25) when asked if she ever communicated to Rehab that Resident #6 could not get up to his/her wheelchair because of his/her pressure ulcers she stated, No, and I do not know of anyone on the Wound Team that said s/he could not get out of bed at all.

Based on observations, interviews, and a medical record review, it was determined that facility staff failed to provide personal hygiene services to totally dependent residents. This was evident in 2 (Residents #96 and #42) of the 5 residents reviewed for activities of daily living (ADL) care during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a standardized screening and assessment tool for the health status of all residents in long-term care facilities that are certified to participate in Medicare or Medicaid. Activities of Daily Living (ADLs) are the basic, essential self-care tasks people need to perform to maintain their health, safety, and well-being, such as bathing, dressing, eating, and toileting. 1) During a phone interview on 9/08/25 at 9:53 AM. with Resident #96's responsible party, they reported that the resident had long toenails, and one had fallen off. On 9/10/25 at 11:23 AM, a surveyor observed Resident #96's toenail with Staff #21 (Registered Nurse). The toenail appeared yellowed, thickened, and misshapen. A review of Resident #96's MDS, dated [DATE], revealed that the resident was totally dependent on personal hygiene. During an interview on 9/10/25 at 10:51 AM, Staff #11 (Geriatric Nursing Aide) stated that they assess residents' ADL needs. While they provide and document nail trims when needed, they noted that toenail care is managed by nurses or doctors. Staff #3 (Educator) confirmed in a 9/10/25 interview at 12:06 PM that residents' toenails are managed by Podiatry. When the surveyor shared concerns about Resident #96, Staff #3 stated that the resident might have refused care. On 9/10/25 at 2:10 PM, Staff #3 confirmed that Resident #96 had not yet been seen by Podiatry. She noted that a consultation was placed on 9/09/25, only after the surveyor's intervention. 2) Complaint 333464 was reviewed on 9/10/25 at 8:39 AM. The review revealed the complainant stated Resident #42 had not received a shower in years and s/he loves showers. On 9/10/25 at 11:44 AM in an interview with the complainant s/he stated they do not give him/her a shower, that s/he had a layer of filth on his/her head, and [family member's name] had to scrape his/her head with a comb to try to get the dirt off. On 9/15/25 at 12:01 PM review of Resident #42's medical record revealed s/he was originally admitted to the facility on [DATE] with diagnoses including, but not limited to, muscular dystrophy, Friedreich ataxia, and generalized muscle weakness. Further review of the medical record revealed the MDS [Minimum Data Set] dated 7/21/25 coded the resident as “dependent” for shower/bathe self and personal hygiene. Additionally, in section: GG0115. Functional Limitation in Range of Motion, Resident #42 was coded “2. Impairment on both sides” for his/her upper and lower extremities. The Documentation Survey Report from April 2025 through August 2025 was reviewed on 9/14/25 at 8:43 PM and revealed no documented showers or bed baths for Resident #42. Review of “Tasks: Shower/Bathing” on 9/15/25 at 11:26 AM and looking back 30 days (to 8/17/25) for “Question 1. Was shower given?” it was documented “No Data Found”. The answer choices to the question for facility staff to document were the following: “Yes”, “Resident Not Available”, “Resident Refused”, and “Not Applicable”; however, there were no dates listed, or responses documented for the dates of 8/17/25 through 9/15/25. On 9/9/25 at 7:55 AM in an interview with the Unit Manager (UM #1) when asked about showers, she stated that showers were offered 2 days a week for the residents. During the interview, she stated that Geriatric Nursing Assistants (GNAs) were responsible for providing the showers. When asked how the GNAs knew which residents were supposed to be showered, she stated a list was put on the assignment board and the GNAs have been trained and educated to look at the board to see which residents need to be showered. When asked if this was documented, she stated yes, on the shower papers and the POC's [In Point Click Care, the facility's electronic health record, POC stands for Point of Care. It refers to a feature or solution that enables healthcare staff to document resident care and other information in real-time, directly at or near the patient's location, using mobile devices, kiosks, or other digital tools. This system improves the accuracy and efficiency of documentation for things like activities of daily living (ADLs), vitals, and behaviors.] On 9/10/25 at 9:57 AM in an interview with UM #1, the surveyor asked to see the shower sheets for the year (2025) for Room [Resident #42's room number]. During a dual observation, the surveyor noted many shower lists with no date on the paper. When asked about the dates, UM #1 stated, yes, there should be a date written on the paper. When asked how it was identified who provided the shower, she stated by looking at the assignment sheet for the day. After looking through all the shower sheets in the folder, she provided the surveyor with two sheets for Room [Resident #42's room number] dated 6/25 and 7/16, which she confirmed were from 2025. On both dates, it was documented that the resident refused. When asked if there were any other places additional shower sheets might be, UM #1 stated, “No”. The surveyor shared this was a concern and UM #1 verbalized and acknowledged understanding of the concern. Resident #42's care plan was reviewed on 9/11/25 at 12:50 PM. The review revealed: Focus: [Resident #42's name] is dependent for ADL [activities of daily living] care in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Friedreich's ataxia, muscular dystrophy, limited mobility. Goal: Resident's ADL needs will be met: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. On 9/15/25 at 7:34 AM the surveyor requested documentation of showers for Resident #42 from January 2025 to present. On 9/15/25 at 11:28 AM in an interview with the Nursing Home Administrator (NHA), he provided the Documentation Survey Reports from January 2025 to present and had highlighted “GG-Shower/Bathe Self”. The surveyor shared the concern that this section just documented the resident's ability to shower/bathe and not whether the resident actually received a shower. The NHA verified and confirmed there was no evidence the facility could provide that Resident #42 had been given a shower in 2025. The surveyor shared this was a concern and the NHA verified and confirmed understanding.

Based on complaint intake, resident and staff interviews and record reviews, it was determined that the facility failed to provide quality of care services to their resident secondary to a delay in medication administration and wound treatments. This was evident for 2 (Residents #2, #174) of 37 residents reviewed for medication administration and wound treatment during the recertification/complaint survey.The findings include: 1) On 09/11/2025 at 2:39 PM review of a complaint incident #2580727 alleged that Resident #2's medications are given late and that this happens a lot. In an Interviews with Resident #2 on 9/9/25 at 9:30AM regarding late medication administration. The resident blamed it on the agency staff that the facility frequently uses and stated that his/her medications are given late most of the time. On 9/9/25 at 9:45 AM a review of the August 2025 Medication administration records (MAR) did confirm that numerous medications (Meds) were given 2-4 hours late on different days. For instance, on: 8/1/25: the 8:00 AM meds. Renvela and Ferrous sulphate was given at 11:22 AM 9/2/25: The 10:00 AM meds. Lidocaine patch and Jardiance were given at 16:33 PM 8/3/25: the 10:00 AM meds. Pregabalin and lidocaine patch were given at 12:58 PM 8/6/25: the 8:00 AM meds. Iron sulphate and Renvela were given at 12:50 PM 8/6/25: the 10:00 Am meds Keppra and senna were given at 13:02 PM 8/11/25: the 10:00 AM Metoprolol was given at 15:15 PM including some other medications. This late medication administration continued throughout the month of August. On 9/11/25 at 1:24 PM Staff #2 a Registered Nurse who was also contracted from the agency was asked in an interview to explain the policy for med administration. He said that medications should be given one hour before or one hour after the medication administration scheduled time. He was asked to explain some of the reasons why meds are given late. He stated that sometimes they are short staffed and have only 2 nurses available in their unit. Sometimes a medicine aide was not available to help, or an emergency could occur that could delay medication administration. He was asked what the major contributor was, and he said it's mostly from being short staffed. On 9/11/25 at 8:15 AM the Director of Nursing was made aware that meds are given late to the residents and that this was a concern. She explained that the facility was aware of the late medication pass and has recently changed the times meds are given on different units to help decrease the lateness issue. She was made aware that the lateness is still a concern. 2) Complaint 333453 was reviewed on 9/10/25 at 8:01 AM. The review revealed that the complainant stated that it took two days for the facility staff to clean or change the bandages for Resident #174's left foot wound. Additionally, the review revealed that the complainant said that it took two days for the resident to receive his/her IV [intravenous] antibiotic. On 9/15/25 at 10:01 AM review of Resident #174's medical record revealed s/he was admitted on [DATE]. Further review of the medical record revealed the following order: Wound: (L) plantar foot - cleanse wound with ns [normal saline], pack with silver alginate, cover with abd [abdominal gauze pad, used to absorb discharges from draining wounds] pad then wrap with kling [a stretchy gauze bandage that sticks to itself]. Every day shift for wound care AND as needed for wound care. This was ordered on 10/31/23. On 9/15/25 at 11:39 AM in an interview with the Director of Nursing (DON) the concern was shared that the resident's wound treatment was not cleaned or dressed until two days after his/her admission. During the interview, a dual observation of the resident's October TAR [Treatment Administration Record] the wound treatment order Resident #174's left foot wound was observed with an order date of 10/31/23. The surveyor shared the concern that this treatment was not ordered until two days after the resident was admitted to the facility. The DON acknowledged the concern and stated she would see if there was any additional documentation/evidence of earlier wound treatment. On 9/15/25 at 12:57 PM in an interview with the DON she stated she looked and there was no additional wound treatment order aside from the 10/31/23 order. The surveyor shared this was a concern and the DON confirmed understanding. On 9/15/25 at 12:59 PM review of Resident #174's physician orders and his/her October 2023 MAR revealed the following orders for IV antibiotics: - Vancomycin Intravenous Solution, order date: 10/29/23 12:00 PM. There were no doses documented as administered by nursing staff in the MAR [Medication Administration Record]. - Vancomycin Intravenous Solution, order date: 10/29/23 10:48 PM The first dose documented as administered by nursing staff in the October MAR was on 10/30/23. On 9/15/25 at 12:29 PM review of the Medication Administration Audit Report [MAAR] for Resident #174 revealed the IV vancomycin (antibiotic) was first scheduled for 10/30/2023 at 9:00 AM and first administered 10/30/2023 at 11:57 AM; however, the resident was admitted to the facility on [DATE] at 11:02 AM. On 9/15/25 at 2:27 PM in an interview with the NHA he stated there were no additional orders for the IV vancomycin aside from the one ordered a day after Resident #174's admission. The surveyor shared this a concern and the NHA acknowledged understanding.

Based on review of a facility reported incident, review of administrative and medical records, and staff interviews, it was determined that the facility failed to ensure a resident was free of a significant medication error when a nurse incorrectly administered the medication Methadone to a resident instead of the prescribed medication Methylphenidate. This was evident for 1 of 1 resident (Resident #1) reviewed for unnecessary medications during a complaint survey. The failure of the facility to ensure that Resident #1 was free of a significant medication error resulted in the determination of an immediate jeopardy situation being identified on February 25, 2025, at 6 PM. The findings include: Resident #1 was admitted to the facility after a brief hospital stay on 01/26/25 with diagnoses that included but were not limited to Narcolepsy, muscle weakness and recurrent falls. On 01/28/25, the plan for Resident #1 was to be discharged home. Review of facility reported incident #MD00214721 revealed Resident #1 received 100 milligrams of Methadone on 02/15/25 between 12 noon and 1 PM. Resident #1 should have received 20 milligrams of Methylphenidate which was prescribed for Narcolepsy. A review of the facility investigation on 02/24/25 at 3 PM revealed that RN#1 was performing treatments and then stopped and began administering medications. When RN#1 saw the letters M-E-T-H on Resident #1's MAR (medication administration record) RN#1 assumed the medication name was Methadone and administered a dose to Resident #1. It was not until about an hour later that RN#1 realized that he had given the wrong medication to Resident #1. RN#1 reported that he immediately assessed Resident #1 and stated that Resident #1 was sleepy, and his/her vital signs were stable. RN#1 then informed the nursing supervisor, RN#2, of the medication error. RN#2 instructed RN#1 how to complete the Change in Condition documentation, contact the on-call physician provider, and notify Resident #1's family. The third party physician service was notified of the error at this time. Further review of the facility's investigation revealed that RN#1 indicated that he did not compare the medication pulled from the cart (Methadone) to Resident #1's medication administration record and did not confirm the medication. RN#1 stated in the investigation that I was moving too fast and that he made an honest mistake. RN#1 indicated he saw the METH and assumed it was Methadone and administered the medication to Resident #1. RN#1 also indicated that he did not look at the bottle to see if was for Resident #1. RN#1 indicated that he did not check to see if the medication was in the correct form. Methylphenidate is prepared in a tablet (pill) and the Methadone that was administered to Resident #1 was in a liquid form. RN#1 indicated that he assumed the medication to be administered to Resident #1 was to be Methadone. In an interview with the third party physician service provider, CRNP#1, on 02/25/25 at 10 AM, CRNP#1 stated that she was on-call from 1 PM to 3 PM on 02/15/25. CRNP#1 stated that she received a telephone call on 02/15/25 at 2:14 PM regarding a medication error regarding Resident #1. CRNP#1 stated that during the a video telephone call she asked for the name of Resident #1 the date of birth which RN#1 could not provide. CRNP#1 stated she was informed that Resident #1 received a dose of another resident's Methadone in error. RN#1 was unable to provide CRNP#1 the exact dose of Methadone administered. CRNP#1 stated she was also informed the Methadone was located in the medication cart for a resident who had not been admitted to the facility. CRNP#1 stated she continued to ask RN#1 for the dose that was administered to Resident #1 but RN#1 was unable to inform her. CRNP#1 stated that she educated RN#1 on Methadone overdose and withdrawal signs and symptoms. CRNP#1 stated she confirmed that the facility had a supply of Narcan in the facility with RN#1. CRNP#1 stated that RN#1 informed her that Resident #1 was stable, in no distress, and that RN#1 would not administer Narcan to Resident #1 because Resident #1 had no symptoms of overdose. CRNP#1 asked for RN#1 to take the phone to Resident #1's bedside and was told by RN#1 that Resident #1 did not want to be bothered. CRNP#1 asked RN#1 to hold up the bottle of Methadone that was administered to Resident #1. CRNP#1 stated that RN#1 could not find the discarded bottle of Methadone administered to Resident #1 and held up a sealed unused container of Methadone to the camera. The sealed unused dose of Methadone was listed as having 100 milligrams in the bottle. CRNP#1 again asked RN#1 what was the dose of Methadone administered to Resident #1 and RN#1 stated that he did not know because he did not measure the dose of Methadone. RN#1 indicated that he could not find the empty bottle of Methadone administered to Resident #1. CRNP#1 was asked if she had access and if she reviewed Resident #1's electronic clinical record. CRNP#1 stated that she did not have access to Resident #1's clinical record due to the software not being the same. CRNP#1 stated that she relied on RN#1's information at the time of the call. CRNP#1 stated that RN#1 again informed her that Resident #1 was not symptomatic and stable. CRNP#1 stated that she did not think Resident #1 needed to be sent to the hospital at that time based on the report from RN#1. When asked, CRNP#1 stated that she did not call the facility back to check on Resident #1, did not speak with Resident #1's attending physician, and did not inform the oncoming CRNP of Resident #1's medication error after the phone call from the facility. In an interview with RN #1 on 02/25/2025 at 2:22 PM, RN#1 stated that he was an agency nurse and that 02/15/25 day shift was the very first shift working in the facility. RN#1 stated that he became aware of administering Methadone to Resident #1 in error during the shift. RN#1 stated that he called the nursing supervisor and reported the medication error. The nursing supervisor instructed him to notify the medical provider and the family. RN#1 stated that he was not familiar with the facility procedure on how to notify the medical provider and had to go to the nursing office to receive assistance from the nursing supervisor to notify the medical provider. RN#1 stated that he received instructions to monitor Resident #1 frequently and notify the medical provider if there were any changes. When asked, RN#1 stated that he did not follow the 5 rights for administering medications to Resident #1 on 02/15/25. RN#1 stated that he was also heavily distracted during the medication pass on 02/15/25 when he incorrectly administered a dose of Methadone to Resident #1. Resident #1 was incorrectly administered a dose of Methadone at approximately 12 noon on 02/15/25. Resident #1 was found pulseless and without respirations by the nursing staff at approximately 9:50 PM on 02/15/25. Resident #1's death was reported to the Medical Examiners office. These failures resulted in an Immediate Jeopardy situation being identified on February 25, 2025 at 6 PM. The Maryland Office of Health Care Quality (OHCQ) determined that F 760 concerns, affecting Resident #1, met the Federal definition of Immediate Jeopardy and the facility was given the template and notified of this determination 02/25/25 at 6:00 PM. On 02/25/25 at 9:56 PM, the facility provided a plan to remove the immediacy while the surveyor was onsite. The removal plan was accepted by OHCQ at 9:56 PM on 02/25/25 and verified by the surveyor at that time. The abatement plan included: 1) Education of all nurses was initiated overnight on 02/15-02/16 on medication administration with focus on the six-rights medication administration, opioid management, and signs of opioid overdose, and in-house escalation protocol. All outstanding education will be completed prior to the next scheduled shift. 2) Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee ' s personnel file. All medication evaluations will be completed prior to the next scheduled shift. 3) Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification. All quizzes will be completed prior to the next scheduled shift. 4) Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support. All quizzes will be completed prior to the next scheduled shift. 5) Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee for the next 6 months. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee ' s personnel file. 6) The results will be reported by the DON to the Quality Assurance Performance Improvement Committee for at least six months or until 100% compliance is achieved. The alleged date of compliance is 02/25/2025. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents.

Based on observation, medical record reviews, staff, and family interviews, it was determined the facility failed to: 1.) correctly assess a resident for smoking independently to include an accurate account of incidents of past unsafe smoking behaviors; 2) provide increased supervision and safety interventions after multiple unsafe smoking incidents; 3) keep a resident who had multiple smoking-related incidents from igniting flammable materials and safe from self-harm. This was evident for 1 of 4 (#92) residents reviewed for smoking. As a result of the deficient practice, residents were placed at risk for harm/injury causing an immediate jeopardy. The facility also failed to protect a resident who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury (Resident #144). The failure resulted in harm to the resident who sustained a right arm fracture. The facility also failed to utilize the correct transfer tool to transfer a resident back to bed (R#157). This was evident for 2 of 13 residents reviewed for accidents. The immediate jeopardy(IJ) template was provided to the facility and an IJ was called on August 10, 2023, at 9:25 AM. The initial plan of action was submitted on August 10, 2023, at 12:20 PM, and was rejected and returned. The final plan of action was received at 2:24 PM and accepted at 3:00 PM. The IJ was abated on 8/17/2023 at 11:30 AM. After removal of the immediacy, the deficient practice remained with a scope and severity of G. The findings include: 1.) Record review of Resident #92's medical record on 07/14/23 at 10:15 AM revealed the resident was admitted to the facility on [DATE]. A smoking care plan was initiated on 2/23/21 with the goal for the resident to smoke safely for 90 days with a target date of 3/10/21 with the resident being reminded of the location of smoking areas and times. Additionally, on 2/23/21 a behavioral contract was signed with the resident with smoking goals for the resident not to smoke in his/her room or other areas of the facility not designated for smoking and the resident would not pick up or handle used cigarette butts from the floor, ash tray and/or trash can. Further review on Resident #92's medical record on 07/14/23 at 2:03 PM revealed that on 04/07/22 Resident #92 was found smoking in the dining room by a security guard who also found 7 cigarette butts in a cup in the sink. No new interventions were added to the smoking care plan after this incident. A goal for the resident to only smoke in designated areas was added to the care plan on 04/07/22. The target date was updated to 5/23/22. On 07/25/23 10:04 AM a review of the smoking assessment dated [DATE], it was documented the resident was no longer a smoker and recently quit within a month which was incorrect information. During an interview with Resident #92, on 08/07/23 at 5:09 pm he/she stated that he/she enjoyed smoking, had always smoked, and had no desire to stop. DON #2 was present during the interview. Review of Resident #92's electronic medical record (EMR) on 08/03/23 at 10:15 AM revealed that on 6/12/22 Resident #92 sustained a partial thickness burn to the tip of the nose from lighting a cigarette. The burn was discovered on 6/13/22 by Licensed Practice Nurse (LPN) #66. A note written by Nurse Practitioner (NP) #47 on 6/13/22 indicated Resident #92's smoking privileges were revoked, however the record failed to reveal details regarding the length of the revoked smoking privileges. During an interview with LPN #66 on 08/07/23 at 4:23 pm he/she was unable to remember the incident when Resident #92 burned his/her nose. During an interview with the DON#2 on 08/03/23 at 12:44 PM, she revealed that after the incident when Resident #92 burned his/her nose, staff education and education with the resident was done, and staff made sure the resident did not have a lighter. She also revealed an updated smoking assessment should have been done as the resident was care planned prior to the smoking incident and that the resident had been a smoker since he had been in the facility. Review of the EMR on 08/03/23 at 12:25 PM revealed a smoking assessment dated [DATE] that documented that the resident did not have a history of smoking-related incidents which was incorrect. The assessment also noted the staff reviewed the policy related to smoking times and storage materials with the resident. The section for care plan initiated/updated was documented as N/A for not applicable. Further review of the EMR revealed that on 10/12/22 Resident #92 was found smoking in the bathroom and refused to give the cigarettes and lighter to staff. Staff reminded the resident of the smoking times and areas and educated about safety and the resident stated, I don't care. Six days later 10/18/22 a smoking assessment was completed on Resident #92 and indicated the resident did not have a history of smoking-related incidents which was incorrect. Again, the section for care plan initiated/updated was documented as N/A. On 1/19/23 a smoking assessment was completed for Resident #92 and categorized the resident as an independent smoker and that the resident did not have a history of smoking-related incidents which was incorrect. The section for listing previous assessments was documented as N/A. The section for care plan initiated/updated was documented as yes, however, none of the interventions on the form were checked off. On 07/14/23 while reviewing Resident #92's EMR it was documented that on 4/8/2023 Resident #92 was found with a lit cigarette butt along with 7-8 cigarette butts wrapped around a towel on his/her wheelchair cushion. The towel and part of the wheelchair cushion had burned, and staff put the fire out. The smoking assessment completed on 04/08/23 indicated the resident was an assisted smoker with a history of smoking-related incidents that included: burning clothing, burning furniture, disposing of lighted products in trash, smoking in bed, dropping ashes on self, and smoking in a non-smoking area. It was also documented the resident did not have the ability to extinguish a cigarette safely. Continued review of Resident #92's EMR revealed that on 07/05/23 a smoking assessment was completed on Resident #92 and categorized the resident as an independent smoker and that the resident did not have a history of smoking-related incidents which was incorrect. Under the smoking care plan focus section, the following was documented: the resident had been found smoking in the bathroom and leaving lit cigarette butts on a wheelchair or other places. The goal was documented as resident will smoke in designated smoking areas during smoking times with interventions listed as; instruct resident about smoking risks/hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, and safety concerns. Provide cigarettes and lighters to the resident only at facility smoking times at facility-designated smoking areas. The resident requires supervision while smoking. On 7/13/23 a smoking assessment was completed on Resident #92 and categorized the resident as an Assisted Smoker and failed to document the resident's history of smoking-related incidents as that section on the assessment had nothing checked off. The section for care plan initiated/updated was documented as yes but the only intervention checked off was the resident requires supervision while smoking. On 7/13/23 Resident #92 had two goals initiated to a care plan dated 04/08/23 and revised on 07/17/23. The care plan did not have any goals or interventions documented prior to 07/13/23. The focus was the resident was a smoker and had been found smoking in the bathroom and left lit cigarette butts on the wheelchair or other places. The goals added on 07/13/23 were: the resident will not smoke without supervision through the review date, and the resident will not suffer injury from unsafe smoking practices through the review date which was documented as 08/13/23. The intervention dated 07/13/23 read: notify the charge nurse immediately if it is suspected the resident has violated the facility smoking policy. The interventions added on 07/17/23 were listed as: instruct resident about the facility policy on smoking: times, safety, and concerns; the resident requires a smoking apron while smoking, and the resident requires assistance when smoking. During a follow-up interview with the DON#2 on 08/07/23 at 05:12 PM she revealed a smoking assessment is completed on admission and when changes occur and every time Resident # 92 had an incident. She indicated she was not sure if the smoking assessment triggered a care plan and stated the care plan is updated any time an incident happens and if there is a change in the assessment. She also indicated an independent smoker doesn't need supervision and independent smokers are allowed to have their cigarettes, but no one is allowed to have a lighter. She continued that a designated staff assists an assisted smoker depending on their need and that one staff member lights everybody's cigarettes. The facility plan of correction to remove the IJ immediacy was as follows: a) An updated smoking assessment was completed on Resident #92 on 7/13/23 which categorized the resident as an assisted smoker with a history of smoking-related incidents. Resident's care plan was updated on 7/17/23 to include the use of a smoking apron for safety. Resident #92 was discharged to another facility on 8/8/23. b) On 8/10/23, smoking assessments for all current residents were audited by the nursing management team to ensure no further inaccuracies. Nursing Managers, DON, and Regional Clinical Consultant reviewed the medical records of all current residents in the facility who smoke to ensure that all current smokers have an updated, accurate smoking assessment and an updated, accurate care plan which includes appropriate interventions to prevent smoking-related injury. On 8/10/23, recreation staff verified via direct observation that smoking supervision was provided, and care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Residents who fail to comply with the rules of the facility's smoking contract, which is signed on admission by the resident, or with safety interventions as outlined in their care plan, will be issued a behavioral contract. Continued noncompliance after issuance of behavioral contract may result in involuntary discharge notice. This was reviewed with current smokers by NHA during an ad hoc meeting on 8/10/23 and was added to the facility's smoking contract. c) Unit Managers and Nurse Practice Educator were educated via speakerphone while in the NHA office by Director of Nursing on 8/10/23 on smoking assessment accuracy, timeliness of smoking assessment, care plan intervention updates and accuracy related to smoking. Education of all licensed nurses working 7-3 shift on 8/10/23 was immediately performed by Nurse Practice Educator (NPE) and NPE will continue to educate all other licensed nurses on smoking assessment accuracy, timelines of smoking assessment, and care plan intervention updates and accuracy related to smoking. Education of all licensed nurses will be completed by 8/14/23. NHA educated Department Heads on 8/10/23 regarding safe smoking practices while supervising smoking. Department Heads began educating their staff on safe smoking practices on 8/10/23 and will continue to educate all staff within their department. Education of all facility staff will be completed by 8/14/23. NHA educated recreation staff on 8/10/23 to verify via direct observation that smoking supervision was provided, and that care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Any facility staff member or agency staff member unable to be reached by 8/14/23 (i.e., call-out, vacation) will be educated upon arrival at the facility; NHA will ensure that education has been provided to them prior to beginning their shift. Education will be validated by quizzes performed randomly by Nurse Practice Educator with 10% of staff weekly for a period of 3 months. d) DON, Unit Managers, and Nursing Supervisors will conduct audits on smoking assessments and care plan updates (related to smoking) weekly x 3 months to determine compliance with smoking assessment accuracy, timeliness of smoking assessments, and care plan updates related to smoking. Recreation staff will conduct daily audits to verify that smoking supervision was provided, and care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Findings will be reported by the DON at the monthly Quality Assurance Performance Improvement (QAPI) meeting for a period of 3 months to monitor progress towards improvement and recommendation 42863 2.) A review of Resident #144 's medical record on 07/11/23 revealed the resident was totally dependent for care. The review of the medical records on 08/18/23 at 12:30 PM revealed that on 12/15/18, the resident was admitted with a side rail order (no indication for the purpose of side rails). On 12/17/18 the side rails order was discontinued. On 12/17/18 at 11:49 AM, the half-side rails were reordered for turning and positioning. On 01/06/19, the side rails order was discontinued and no further physician orders for side rails were found in the medical record. Resident #144 was readmitted to the facility on [DATE] and the resident was re-evaluated for side rails. However, no written physician orders for the installation of side rails could be found in the medical record. A review of the Minimum Data Set (MDS), Section P for the time period of 12/15/21, revealed the resident did have side rails, not used as a restraint, had a left-hand contracture, and the resident was coded as a two-person assistance for activities of daily living. On 07/17/23 the review of attending medical doctor (MD) #23 ' s orders revealed Resident #144 was transferred to the hospital at 16:21(4:21 PM) on 12/9/2022 via ambulance due to injury to the right arm when it became stuck in the bed rail. The resident was treated for a fracture to the right ulna and humerus and discharged back to the facility on [DATE]. Review of the medical record on 07/11/23 revealed a change in condition progress note written by Staff # 61 on 12/09/22 at 12:30 PM regarding what occurred between the hours of 2:00 AM and 5:00 AM. The progress note stated that while the resident was receiving care on 12/09/22, the resident's right hand was found caught in between the right-side rail and the mattress per GNA # 56. GNA #56 removed the resident's arm and Resident #144 complained that his/her whole arm was painful, and refused to be moved, touched, or receive care. Staff #61 documented that passive range of motion was unable to be performed. No swelling or bruising was noted by Staff #61 and the resident was found with his/her arm resting on his/her chest when Staff #61 entered the room. Staff # 61 documented that the physician was notified and ordered an X-ray of the right arm to rule out a fracture. A progress note written by Staff # 58 on 12/09/22 at 12:43 PM titled change in condition documented Resident #144's right arm pain with swelling and bruising to the inner forearm present at 07:30 AM during the change of shift rounds. The Resident complained of pain with motion of the right arm. The resident was described as currently resting with arm on chest. Tylenol was given with effective results and Mobilex called for an estimated time of arrival for X-ray at 10:00 AM. A review of the medical record revealed that on 12/09/22 a bed evaluation was performed for installation of 1/4 side rails on the left upper and right upper sides after Resident #144's injury was reported. On the bed evaluation document, the following check marks were selected under the section titled: with the final actions for bedrail use: 2. Obtain consent, 2a. Physician Order. The document was signed by LPN # 58. However, upon further review of the medical records the surveyor did not find a consent form signed by the resident ' s representative for 12/09/22 or any date thereafter. On 08/18/23 at 10:30 AM the review of the progress note dated 12/10/22 at 12:30 PM written by Staff #61 revealed that Resident #144 returned to the facility from the hospital at 12:20 PM on 12/10/22 via ambulance. Per the hospital discharge report, Resident #144 had a fracture of the right ulna and humerus bones and was treated with a Splint applied with a sling. On 08/18/22 at 2:20 PM, the surveyor interviewed Staff #1 and Staff # 49 regarding Resident # 144's right arm fracture injury on 12/9/22 that was a result of the right arm being caught in between the mattress and the side rail. Both admitted the incident occurred as described in the medical record. In an interview with the resident's family member/resident representative on 08/18/23 at 2:40 PM he/she stated that the resident's right arm was broken in two places. This family was present while the resident was treated in the emergency room . Additionally, the family member described the resident as unable to move around in the bed independently, so the resident did not do this on his/her own. The family member stated that, after talking with staff members, the facility Administrator and the Director of Nursing, the details are still unknown as to how it happened. During an interview on 08/21/23 at approximately 3:20 PM, the surveyor asked the Administrator to explain the bedrail evaluation and assessment process, and the specific events that occurred on the night of the injury to the resident's right arm. The administrative staff stated that the facility believed the injury was a result of the resident throwing his/her arm against the bedrail. The surveyor asked the administrative staff to provide evidence of the resident meeting the criteria for bed rails as an enabler. On 08/22/23 at approximately 3:20 PM the administrator provided a copy of the 12/18/18 consent form for bed rails signed by the resident representative. The administrator stated that there had been discussions with the resident's representative regarding the need for the side rails during the past three years. However, the administrative staff could not provide an explanation of why the consent form had not been updated each time the resident was discharged and readmitted to the facility or why the resident continued to have side rails without an active physician order. A discussion was held with the surveyor regarding the side rail policy compliance of the facility based on the lack of consistent and frequent reassessments during a three-year period. The administrator and Staff #49 acknowledged that no additional consent forms were signed by the resident's representative and/or power of attorney after 12/18/18. A review on 08/21/23 of the facility's Side Rail Use policy with the creation date of 11/2019, and a last reviewed date of 01/2021, stated the interdisciplinary care plan team would: On admission, readmission, with a significant change in condition or change of bed surface assess the resident for the need for side rails to assist in bed mobility. On 08/22/23 at 09:22 AM, the maintenance director, Staff # 29 presented a hard copy of the bed system measurement device test results worksheet dated 12/09/22, related to Resident #144's bed. This assessment was performed after the Resident's injury was discovered on 12/9/22. Staff #29 stated that on 12/09/22, Resident #144's bed did not pass the bed assessment secondary to the five-inch gap between the headboard and the side rail on the right side. Staff #29 stated that he replaced the entire bed on 12/09/22. Staff #29 stated and provided a written statement that on 12/09/22 he performed a whole house audit for all beds in the facility Also, Staff # 29 stated that he/she was unable to locate a bed rail assessment for all beds for the year 2021. Additionally, Staff #29 observed Resident #144 in the bed with the side rails up prior to completing the assessment on 12/09/22. The concerns related to the deficient practice of not providing an accident-free environment for Resident #144 were reviewed again with the DON, NHA, and the VP of Clinical Operations during the exit conference on 08/22/23 31985 3) On 08/03/23 10:08 AM, facility incident MD00190558 was reviewed and revealed that Resident #157 was transferred to bed without using the mechanical lift causing a bruise on the resident's shoulder blade. Review of the medical record on 8/3/23 at 10:15 AM revealed the resident was admitted to the facility for rehabilitation and with diagnoses that include generalized muscle weakness, and difficulty walking. Further review of the lift transfer repositions assessment revealed the following: the resident is not able to transfer independently, full body sling the resident is not able to bear weight, a total lift is required ( indicating a hoyer lift to be used.) Further review of the assessment revealed that the resident was documented as needing a 1 person assist for bed mobility. A hoyer lift requires a 2 person assist with the correct sling for lifting. Further review of the facility investigation revealed that on 3/23/23 the resident had asked the Geriatric Nursing Assistant (GNA) # 96 to put him back in bed. When GNA#96 came to the resident's room he picked the resident up by himself placing Resident #157 in bed bruising his/her back. During an interview with the DON on 8/3/21 at 10:30 AM, the surveyor asked about the incident with Resident #157 and she reported that GNA #96 was employed through a nursing staffing agency who was notified the GNA should not return to the facility for failing to follow the resident treatment plan on transfer causing a bruise. The concern regarding the failure to ensure the resident was transferred via Hoyer lift with the assist of two persons was reviewed with the DON and the Administrator on 8/22/23 during the survey exit.

Based on medical records review, facility investigation review and interviews with staff it was determined that the facility failed to protect cognitively impaired residents from physical, sexual, emotional, and verbal abuse which resulted in harm to Resident #144 and Resident #76. This was evident for 3 of 28 residents (Resident #144, #76, #103) reviewed for abuse during the survey. The Findings Include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 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 resident care. 1. Review of complaint MD00164757 on 8/18/23 at 12:54 PM revealed that on March 5, 2021, Resident #144 had her/his hair shaven to the scalp causing him/her emotional distress. On 8/18/23 review of Resident #144's medical records revealed the resident was admitted to the facility with a diagnosis that included dementia, dysphagia, legal blindness and was hard of hearing. Review of the Minimum Data Set (MDS) for Resident #144 revealed that in February 2021, the BIMS (Brief Interview for Mental Status) score was a 9 indicating that the resident's cognition was moderately impaired. BIMS is a mandatory tool used to screen and identify the cognitive condition of residents. Review of the MD00164757 and the facility grievance form revealed that when the complainant went to see the resident in March 2021, she noticed that the resident's hair had been shaved and the resident told the complainant that she/he begged them not to cut it. The complainant also revealed that the resident started to cry. Continued review of a facility grievance/concern form dated 3/5/2021 revealed that during an interview with the resident regarding his/her hair, it was revealed that the resident was unable to remember it happened or who may have cut it. During an interview with the Director of Nursing (DON) on 8/18/23 at 2:30 PM the surveyor asked about the hair cutting incident for Resident #144. The DON stated, I remember it very well. I was notified by the niece that the resident's hair was cut. She further revealed that she has a good rapport with the family and when she was told by the niece what happened she immediately went to observe the resident. The surveyor asked what she saw, she replied it appeared that the resident's hair had been shaved. The surveyor also asked what the length of her hair was prior to the incident and the DON replied that Resident #144's hair was 1/2 way down her/his back and it did not appear that the hair was cut with scissors but with a razor. The DON further revealed that the resident did not cut her/his hair due to religious reasons. The surveyor asked the DON if everyone was aware that the resident's hair should not be cut, she replied our staff knew not to cut it. During an interview with geriatric nursing assistant (GNA) #46 on 8/18/23 at 2:50 PM, she acknowledged that when she returned from vacation on 1/29/21 she noticed that the resident's hair had been cut. She further revealed that she told the resident's nurse, who was an agency nurse, that the resident's hair had been cut. The surveyor asked what the agency nurse's name was, and she stated I'm not sure. The surveyor asked if she knew what the nurse did with the information she replied, nothing. The DON and GNA # 46 were unable to provide the agency nurse's name. GNA #46 also revealed that when the resident's nurse, Staff # 58, returned from vacation she was informed that the resident's hair had been shaved. On 8/18/23 at 3:15 PM, Staff # 58 was interviewed about the resident's haircut. The surveyor asked when she was notified of the resident's haircut and she replied it was when she returned from vacation. When asked whom she informed that the resident's hair had been shaved and she replied, no one. During a follow-up interview with the DON on 8/22/23 at 11 AM the surveyor asked if the facility investigation determined who shaved the resident's hair and she replied, no we didn't. During the survey exit on 8/22/23 the NHA and the DON again was notified of the harm to the resident and all questions regarding the harm were answered. 2. Review of the medical records on 8/7/23 at 9 AM revealed Resident # 76 was admitted to the facility in October 2021 for long-term care and with diagnoses that include Alzheimer's. Review of the care plan meeting dated 3/15/23 revealed that the resident was always confused and liked to walk around with a walker. Review of the facility-reported incident MD00194493 on 08/07/23 at 8 AM revealed an allegation that on 7/17/23 GNA #88 was physically abusive towards Resident # 76. Further review of the facility investigation documentation revealed the following: On 7/17/23 the Director of Nursing was notified by the night shift supervisor of the report that was given to her. Around 4 AM, a resident was heard yelling stop you're hurting me. It was further reported that Staff # 55 heard the resident yelling and recognized the voice as being her assigned resident and when she looked outside the door, she observed (GNA) #88 pushing and shaking the resident. Staff# 55 shouted No to GNA #88 who then went up the hallway away from the resident. Afterward the resident walked to the nurse's station and told staff #8 she hurt me. During an interview with the DON on 08/07/23 at 11:29 AM in reference to the allegation of abuse the surveyor asked the DON about the investigation. The DON reported that she received notification of an allegation of abuse, she further reported that she reviewed the facility cameras and saw that GNA #88 had acted aggressively with the resident #76. The DON revealed that the video showed GNA # 88 as she ran past the resident and came back to the resident and started shaking the resident and walker. The DON acknowledged it was abusive. GNA #88 was terminated and reported to the Maryland Board of Nursing. On 8/7/23 the NHA reviewed the video coverage with the survey team. This video showed Resident #76 ambulating in the the hallway with her/his walker and you could see GNA # 88 as she ran past the resident and turned back and grabbed the walker and the resident and started shaking the resident. In addition, the video showed Staff # 55 peek out of a resident's room. During an interview with Staff #55, she informed the surveyor that she was in another resident's room giving care, and she heard a commotion in the hallway. She then revealed she heard a resident yell stop it you're hurting me, so she went to the door and observed a GNA #88 with the resident shoving him/her and shoving his/her walker and Staff #55 yelled stop and she then revealed that the GNA #88 went up the hall and the resident went towards the nursing station. The GNA revealed that she was scared at first, but she reported it immediately. The surveyor asked why she was scared she stated because residents should not be abused by anyone. During an interview with staff # 93 on 8/7/23 at 5:30 PM she verbalized that she did not see Resident #76 being shaken just that the resident appeared at the nursing station and said she hurt me. 3. Facility reported incident MD00189348 was reviewed on 8/7/23 at 2:30 PM for allegations of abuse. Review of the facility's investigation, on 2/24/23 at approximately 3:30 pm, revealed a Licensed Practical Nurse (LPN) #54 heard a (GNA) # 91 cursing at Resident # 76. Further review of the facility's investigation and a statement by LPN # 54, revealed the following: while she was in the hallway, she heard someone say, what did you say and she looked up and saw Resident # 76 walking towards room [ROOM NUMBER] and GNA # 91 started walking towards the resident saying what did you say multiple times. The resident stopped walking and turned towards GNA # 91 and said [expletive] you. GNA # 91 said to the resident [expletive] you and walked away, LPN # 54 called out to GNA # 91 multiple times but was ignored, LPN # 54 revealed she reported it immediately. Further review of the investigative interview revealed GNA # 91 allegedly stated [expletive] you in a joking way, she further reported that she did not think it was that serious. During an interview with LPN # 54 on 8/7 at 3:15 PM, she acknowledged that she heard the resident say expletive word GNA # 91, she also reported that how GNA #91 said it back to the resident was not in a joking manner and when she tried to question GNA #91, she kept walking and it was reported. LPN #54 informed the surveyor that GNA #91 was removed from the floor and sent home. On 8/7/23 at 3 PM, a review of the social work note (undated) stated Resident #76 has dementia and cognitive impairments in relation to the diagnosis. Social work followed up with the resident for a supportive visit and no further distress was noted. Resident as stated above has short and long-term memory deficits and did not recall the incident. An interview was conducted with the DON on 8/7/23 at 4:30 PM about the incident and the DON stated that GNA # 91 admitted to using an expletive word to the resident and that there were witnesses that overheard the GNA use the curse word. As a result, GNA # 91 was placed on the do not return list and was reported to the Board of Nursing. 30440 4. MD00174320 was reviewed on 7/25/23 for allegations of abuse. According to the facility's investigation, on 11/13/21 GNA # 31 reported that upon entering the facility's dining room, she observed Resident # 103 sitting on the lap of Resident # 240 who was in a wheelchair. Resident # 240 was observed with his/her pants lowered and Resident # 103 was wearing a gown. The staff immediately separated the residents and notified the supervisor. The staff stated that she did not see any genitalia exposed from either resident. Skin checks were done, and no concerns were noted. Review of the medical record for Resident # 103 on 7/25/23 at 10:00AM revealed the resident was admitted to the facility with the following but not limited diagnoses: Dementia, Cognitive Communication Deficit. Continued review of Resident #103's Quarterly MDS assessment dated [DATE] Section C for cognitive patterns revealed a BIMS score of 4/15. BIMs is a brief screen that aids in detecting cognitive impairment. A score of 0-7 indicates severe impairment. Further review on 7/25/23 of resident # 240's 5 Day Admission MDS assessment dated [DATE] Section C for cognitive status revealed a BIMS score of 13/15. A score of 13-15 indicates cognitive intact. Review of resident #103's care plan on 7/25/23 at 10:00AM revealed the resident had impaired cognitive function and impaired thought processes. Continued review on 7/25/23 of resident # 240's care plan revealed a care plan that was initiated on 10/9/21 for behavior problems including saying sexually inappropriate things, verbal/physical touching to female resident/staff members. The interventions listed on the care plan were as follows: Administer medications as ordered; Monitor/document for side effects and effectiveness; Anticipate and meet the resident's needs; If reasonable, discuss the resident's behavior; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others; Approach/speak in a calm manner; Divert attention; Remove from situation and take to alternate location as needed; Praise any indication of the resident's progress/improvement in behavior. The care plan did not address the specific behaviors of touching female staff and or residents inappropriately. On 11/15/21 the care plan was updated to include a one-one sitter. This intervention was put in place after Resident # 240 made sexual contact with Resident # 103. An interview was conducted with the DON on 7/25/23 at 2:00 PM and she stated the following: On approximately 11/13/21 in the late afternoon, close to evening, Resident # 103 was in the dining room with Resident # 240 after dinner time. There was no staff present while the residents were in the dining room. Resident # 103 was observed sitting in resident # 24's lap as the resident sat in the wheelchair. Resident # 103's walker was nearby. The DON stated that Resident # 103 stated that Resident # 240 was his/her spouse. The DON stated that both residents were fully clothed and that Resident # 240 had on jeans that were lowered exposing the resident's incontinence brief. The residents were witnessed together by the front office GNA #31. The DON stated that Resident # 103 was resistant to leaving because the resident made statements that Resident # 240 was his/her spouse. The DON went on to say that both residents were immediately separated and taken to their prospective places where they reside. The DON stated that Resident # 103 lacked adequate decision making and Resident # 240 was alert and oriented. She further stated that this was the first and only encounter with these residents. The police were notified and Resident # 103 was sent to the emergency room for evaluation. Resident # 240 was placed on 1:1 monitoring due to the resident's sexually inappropriate behavior. The DON was asked if Resident # 240 had any previous sexually inappropriate behaviors, and she stated the resident had a history of being flirtatious and that a care plan was initiated on 10/9/21 due to an incident that occurred with Resident # 240 and a rehabilitation staff member where the resident displayed sexually inappropriate behaviors. A phone interview was conducted with GNA#31, on 7/25/23 at 3:40 PM and she was asked about the incident that occurred on 11/13/21 and she stated the following: she worked at the facility for approximately [AGE] years as of this November. On 11/13/21 at approximately 8:00PM in the evening she was going through the dining room to get to her locker, and she heard water running. She then looked over and saw Resident # 103 sitting on top of Resident # 240's lap. She went onto say that she heard Resident # 240 say it feels good and Resident # 103 responded, yes. Resident # 240's hands was on the waist of Resident # 103 and moving Resident # 103 up and down on his/her lap. GNA # 31 stated that Resident # 103 had a gown on that was covering Resident # 240 but she was able to see Resident # 240's right leg. GNA# 31 told Resident # 103 to get off the lap of Resident # 240 and called for the supervisor to come to the dining room. GNA # 31 stated that Resident # 103's gown was up in the back, but it was covering Resident # 240 so genitalia was not exposed. GNA # 31 further stated that a staff member that usually eats in the dining room at 8pm was not in the dining room at the time of the incident because the staff was out in the lobby. She confirmed that there was no staff present in the dining room at the time of the incident. GNA # 31 went on to say that the police were notified and resident # 103 was taken to the emergency room for evaluation. GNA# 31 also stated that on the day before the incident Resident # 240 was sitting in the front of the building near the dining room and said to another Resident # 109 who was going to their room, I will take you to your room. GNA # 31 interjected and told Resident # 240 to go to their room and directed Resident # 109 to their room. GNA # 31 stated that she did not report the incident with Resident #240 and Resident #109. An interview was conducted on 7/26/23 at 8:45 AM with Unit Manager (UM)# 8, Unit manager, # 9, and they were asked to describe any behaviors that Resident # 240 exhibited and they both stated the following: Resident # 240 was flirtatious towards female staff and would make cat calls, such as calling staff sugar pie and sweetie pie however, the resident was redirectable and apologetic. An interview was conducted on 7/26/23 at 9:15 AM with Occupation Therapist Staff #34 and she stated the following: Resident # 240 was on caseload and the resident was sexually inappropriate. Staff # 34 stated that the resident was difficult to engage because of his/her behaviors. Staff # 34 went on to say that the resident was sexually inappropriate to the degree that it would hinder the therapy sessions, and the sessions would have to stop. Staff # 34 stated that she reported the resident behaviors to her rehabilitation director, staff # 32. A phone interview was conducted with Rehabilitation Director Staff # 32, on 7/26/23 at 9:42 AM and she was asked if she recalled working with Resident # 240 and she stated that she was very familiar with the resident. She stated that she has worked at the facility for thirteen years, however, she stopped working at the facility in March 2023. She went on to say that Resident # 240 was sexually inappropriate, verbally and that the resident would grab parts of her body where s/he was not supposed to. She further stated that the resident's inappropriate behavior was so significant because it would occur during the entire session and Resident #240 had to be assigned to a male Physical Therapist Staff # 32 and that Resident # 240 was at the facility for a short stay and was on caseload during the stay. She went on to say that during Interdisciplinary Team (IDT) meetings that occurred every week with the administration, the resident's behaviors were discussed and Resident # 240's sexually inappropriate behaviors were added to the resident care plan. Another interview was conducted with the DON and the Administrator on 7/26/23 at 1:00PM and she was asked what the facility put in place to protect vulnerable residents from a resident with known sexually inappropriate behaviors and she stated that the IDT team spoke about this resident and the administration met with the staff and told them that if they see Resident # 240 making any advances towards residents, they are to redirect the resident. The administrative team stated that they did not provide additional monitoring of the resident. They stated that they would not have known that Resident # 240 would be with Resident # 103 even though they were aware of Resident # 240's sexually inappropriate behaviors. The DON stated that Resident # 240 was placed on one-to-one monitoring immediately after the incident with Resident #103. The survey team requested documentation of the one-to-one monitoring and they were unable to provide documentation of the monitoring. Resident # 240 was discharged against medical advice on 11/16/21.

Based on review of medical records, facility policy and interview with facility staff it was determined that the facility failed to have a system in place to readily and accurately determine a resident's CPR (Cardio [MEDICAL CONDITION] Resuscitation) status and honor a resident's wishes to not have intervention in the event of a [MEDICAL CONDITION]. This was evident for 1of 13 records (Resident #12) reviewed for CPR status. As a result of these findings, an Immediate Jeopardy situation was identified on [DATE] at 1:45 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on [DATE] around 3:30 PM and the State Agency was unable to accept this plan. The facility submitted an additional plan around 3:30PM. The facility's removal plan was accepted by the State Agency at 3:45 PM. The immediate jeopardy was removed on [DATE] at 2:50 PM after confirmation of all staff training, chart audits and policy revisions. After removal of the immediacy, the deficiency remained with potential for minimal harm at a scope and severity of D. The findings include: On [DATE] Resident # 12's medical records were reviewed. This review revealed that the resident was admitted to the facility on [DATE] for rehabilitation and with a complex medical history that included [MEDICATION NAME] hemorrhage (stroke) secondary [MEDICAL CONDITION](high blood pressure), [MEDICAL CONDITION] (irregular heartbeat), heart failure, kidney disease and obstructive sleep apnea. Review of the medical records revealed a physician certification related to medical condition, decision making and treatment dated [DATE] which revealed the following: the resident is in an end stage condition and that the physician certifies that to a reasonable degree of medical certainty, the following treatments CPR, mechanical ventilation or respiration and hospitalization which under generally accepted medical practice are life sustaining in nature, would not prevent or reduce the deterioration of the individual's health or prevent his or her impending death. It further revealed that the resident lacked adequate decision-making capacity. Further review of the medical records revealed a MOLST (Maryland Medical Orders for Life-Sustaining Treatment) which is dated [DATE] which revealed the resident had an order for [REDACTED]. Review of the facility reported incident revealed that on [DATE] a GNA (geriatric nursing assistant) found the resident with labored breathing and not responding. The GNA made the resident's nurse LPN (licensed practical nurse) staff #9 aware and the nurse went in to see the resident. Further review of the facility investigation revealed that staff #9 checked on Resident #12's source of oxygen, repositioned him/her than proceeded to the nurse's station to check on the resident's code status which is documented on the residents MOLST in the resident's chart. Upon exiting the resident' room nurse # 9 saw the Nurse Practitioner (NP) staff #15 and called for assistance with the resident. Once the NP came into the resident's room staff # 9 left the room to go to the nurse's station to check the MOLST for the resident. Staff # 9 further revealed that she was unable to locate the MOLST in the section where it is supposed to be, so she called 911 and grabbed the code cart for the resident. During an interview with staff #15 on [DATE] at 4:15 PM, she revealed that the resident became pulseless while in her presence and she began cardiopulmonary resuscitation. Review of the facility investigation further revealed staff # 10 was the acting supervisor, and he was paged for an emergency. The investigation also revealed that when staff # 10 responded to the resident's room he observed the NP staff # 15 doing chest compression. Further review of the investigation revealed other staff members arriving to assist with the code, as the NP was doing chest compressions another staff began using the ambu bag (A self-refilling bag-valve-mask unit used for artificial respiration). The investigation also revealed that paramedics arrived at the same time the facility was able to locate the MOLST in the resident's chart indicating that the resident was a NO CPR. After they found out that the resident was a NO CPR, they stopped compression and artificial respiration to the resident. The surveyor asked staff#10 how long it takes for 911 to arrive, and he replied about ,[DATE] minutes. Surveyor asked if the staff was doing CPR for 10 minutes and he replied yes. The surveyor asked staff #10 what took so long to find the MOLST? And he replied, 'maybe it was misplaced in the chart, it wasn't where it was supposed to be.' During interviews with the DON and Administrator, it was revealed that the only intervention put in place after the [DATE] event was to audit all medical records to ensure that a MOLST was present in the physician order [REDACTED]. Failure to have system in place to readily identify a resident's CPR status and end of life wishes in the event of a [MEDICAL CONDITION] resulted in Resident #12 having CPR performed for several minutes when his/her and/ or family's documented wishes were to not have CPR performed. The facility's continued failure to have a system in place to readily identify a resident's CPR status and end of life wishes in the event of a code places all residents at risk of not having their wishes followed. As a result of these findings, an Immediate Jeopardy situation was identified on [DATE] at 1:45 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on [DATE] around 3:30 PM and the State Agency was unable to accept this plan. The facility submitted an additional plan around 3:40 PM. The facility's removal plan was accepted by the State Agency at 3:45 PM. The immediate jeopardy was removed on [DATE] at 2:50 PM after confirmation of all staff training, chart audits and policy revisions. After removal of the immediacy, the deficiency remained with potential for minimal harm at a scope and severity of D. The facility removal plan included the following: Identified Issue: The facility failed to have a system in place to efficiently identify a resident's CPR status and end of life wishes in the event of a code. Immediately upon discovery of the Maryland Medical Orders for Life Sustaining Treatment (MOLST) form, cardiopulmonary resuscitation was discontinued for resident# 12. 1 Immediately upon identification of the Immediate Jeopardy, an emergency Ad-hoc QAPI meeting was held to develop a QAPI plan regarding MOLST (see attached). 2. Every patient's chart will be audited by the Assistant Director of Nursing (ADON) and/or designee on [DATE] for MOLST location as the 1st page behind the physician's orders [REDACTED]. Any discrepancies were corrected. The MOLST order for every patients' code status will be entered PCC as an electronic order by the Center Nurse Executive (CNE) and/or designee on [DATE]. 3. All nursing staff (including GNA's), social workers, unit secretaries, rehab therapy staff, nurse practitioners, and physicians will be educated on Draft Operations Policy - Code Status Orders by the Nurse Practice Educator (NPE) and/or designee. Education was initiated on [DATE] and will be ongoing for staff prior to the start of their next scheduled shift. This will include a post test that is graded and signed by the grader and employee taking the test to validate competence. A. Center will implement Draft Operations Policy Code Status Orders. Patient identification mechanisms and information about each patient's code status (Full Code vs. Do Not Resuscitate) will be easily accessible to the Clinical staff for all patients. All patients require a code status order as soon as possible upon admission /readmission or a change in patient preference or condition as part of the patient's electronic admission order set in Point Click Care. MOLST form and orders will be reviewed at every scheduled care plan meeting. 4.Ongoing Monitoring of Resident Clinical Paper Charts and Electronic Records (100%) weekly by the Center Nurse Executive or Designee weekly for four weeks and then A. Monthly for three months to review for Location of the MOLST, Accuracy, Provider signature and date as well as entry of the Code Status Order in Point Click Care as part of the electronic admission order set. B. The Center Nurse Executive will report findings of the reviews to the monthly Quality Assurance Performance Improvement Committee monthly for review and recommendations to maintain sustained compliance. The Center will direct the ongoing monitoring and compliance with this plan. On [DATE] at 8:51 AM the facility presented an addendum to their plan of correction to the surveyors regarding staff that have not and are not scheduled to work. The following was reviewed and confirmed by the survey team. 1. The facility held an emergency Ad-hoc meeting to develop a QAPI plan regarding the MOLST [DATE]. 2. Every Resident's chart was checked for the MOLST and placement. 100% [DATE]. 3. All nursing staff, social workers, unit secretaries, rehab therapy, NP, and physician will be educated on Draft Operational Policy-Code Status Orders. 4. Education was initiated on [DATE] and will be completed prior to employees returning to duty. 5. Nurse practice educator or designee will call each individual identified from the staff roster who did not receive training that they are required to complete MOLST training before returning to work. 6.The facility has a list of employees that have not worked or are not scheduled by [DATE], those employees are either coming in today or will not be allowed to return to work until education and testing is complete. 7 Daily monitoring of the schedule and comparison with the master roster will continue to occur until everyone has completed their education. 8. Supervisors on the off shift were given additional training to be able to educate and test off shifts. 9. Ongoing monitoring of Resident's clinical paper charts and electronic records 100% weekly by the Center Nurse Executive or designee weekly for four weeks and then monthly for 3 months.

Based on review of the medical record, the facility investigation, written employee statements, the mechanical lift owner's operation manual as well as interviews with the resident and staff it was determined that the facility staff failed to provide a safe lift/transfer for a resident (#1). This resulted in a fractured left arm/shoulder, trauma to the right ankle and pain and swelling in both areas. This was evident for 1 of 2 residents selected for review. The findings included the following: On 12/2/15 the office of health care and quality received a complaint (MD 904). The complainant alleged that resident #1 received injuries to his/her left shoulder and right ankle/leg after being dropped from a transfer/lift due to the carelessness of a geriatric nursing assistant (GNA). On 1/12/16 the surveyor began an investigation and continued to gather information on 1/13/16, 1/15/16, 1/19/16, 1/20/16 and 1/21/16. By way of history, according to the medical record, resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] and 8/4/12. [DIAGNOSES REDACTED]. On 7/8/15, according to the physician certification of decision making capacity Resident #1 had adequate decision making capacity. On 7/31/15, according to the physical therapy assessment, Resident #1 required maximum assistance for transfers. The onset date of her stroke resulting in flaccidity and [DIAGNOSES REDACTED] on the left side was 5/16/07. On 8/1/15, according to the quarterly minimum data set, section G, the resident was totally dependent on the staff and required 2 persons for physical assistance during transfers. On 8/18/15, according to the fall risk nursing care plan the resident's risks included the stroke with left sided weakness and [DIAGNOSES REDACTED] and a lack of safety awareness. As a result 2 persons were required for complete assistance during the mechanical lifts/transfers. From October 1-8, 2015, according to the medication administration record, Resident #1 ' s medications had included: xanax at bedtime for anxiety, since 9/2/15; baclofen three times per day for spastic left sided [DIAGNOSES REDACTED], since 9/15/14; neurontin three times per day for generalized pain, since 2/4/15; ibuprofen every 6 hours as needed for pain, since 9/3/15 and tramadol every 6 hours for pain, since 9/22/15. Review of: the employee written statements from GNA #1 dated 10/7/15, the Unit Manager (UM) dated 10/9/15 and the charge nurse dated 10/20/15; the medical record progress notes/change in condition assessment dated [DATE]-10/8/15; the UM ' s written time line summary dated 10/8/15; the individual performance improvement plan and the event summary report dated 10/27/15; and the surveyor's interviews with the assistant director of nursing (ADON), GNA #1 and resident #1 on 1/12/16; revealed the following: On 10/7/15 sometime before 2:30pm, GNA #1 took resident #1 to the shower room to provide incontinence care. The resident was transferred to the shower room by wheel chair. A sling was placed around the resident ' s lower back and hooked to the sit to stand mechanical lift. The resident was lifted out of the wheel chair while GNA #1 provided incontinent care (removed the brief and washed the resident). While GNA #1 was cleaning the resident with a cloth, the loop attached to the sling detached from the lift, the resident swung around hitting the wall with her/his left shoulder, the lift fell over, his/her right ankle was wedged beneath the lift and the resident slid to the floor. GNA #1 was the only staff member with the resident at the time of the transfer/lift/fall. GNA #1 left the room and reported the fall/requested assistance from other staff members. The UM and charge nurse responded. The nurses responding and GNA #1 described the resident complaining of pain in the right ankle and left shoulder. The resident was transferred from the floor using a total lift, placed in a Geri chair, taken to her/his room, and transferred with the total lift to her bed. At 3:05 the certified registered nurse practitioner (CRNP) ordered X-rays of both the right foot and left shoulder. At 6:50pm the X-rays were completed. At 7:14pm the results were faxed to the facility, noting an acute impacted humeral neck fracture and soft tissue swelling to the ankle but no fracture. The Humerus is the bone at the top of the arm which fits into the shoulder to form the joint. The neck of the humerus is at the top of the bone. A fractured neck of the humerus is often caused by falling /direct impact to the shoulder. On 10/8/15 at 6:45 am the MD and CRNP were notified of the X-ray results. There was a delay in review of and physician notification of the results of the X-rays (see F 508 and F 511). An orthopedic consultation, bedrest and immobilization were ordered. At 10:30 am the orthopedic surgeon reviewed the X-ray results and ordered that the resident should be transferred to the hospital emergency department for evaluation. At 11:35 am the resident was transferred to the hospital. On 1/12/16, the surveyor interviewed the ADON, GNA #1 and Resident #1. At 10 am the surveyor interviewed the ADON. She described the events surrounding Resident #1 ' s fall/injuries. Resident #1 was described to be alert, oriented, and interview-able. She said the lift fell over due to operator (GNA #1) error: GNA #1 had been the only person with the resident at the time of the transfer/fall, there should have been two persons; the brakes had been locked during the lift/transfer and should not have been; and the sling loop attachment had not been double checked during the transfer/lift. The resident had a broken right shoulder and trauma to the right foot as a result. At 12:20 pm the surveyor interviewed GNA #1, she reenacted the events of the transfer/lift/fall with the Reliant 440 and the standing sling in the shower room. The GNA pointed out the marks that remained on the wall from the fall. She confirmed that she was the only one in the shower room with Resident #1 at the time of the transfer/ lift/fall. She demonstrated how the sling was applied by wrapping it around her lower back then hooking the loops to the rubber tipped knobs on the arms of the lift, stating that this had been her normal routine with Resident #1. The GNA leaned back in the sling and put the lift in the highest positron - the lift was battery operated and she pushed it up until it stopped at the top. At that point she described herself bent over changing the resident. She said that one of the loops hooked to the lift detached adding that the resident told her but stated that she couldn ' t see because she was bent over with a cloth in her hand. During the demonstration, while she was raised up in the sling in the lift she attempted to demonstrate how the hook on the sling could detach. The peg that the hook goes around is a round metal piece- about the width of a small mallet head - the top has a sloped (toward the peg) rubber stopper - which made it difficult to pull off. Next she described getting out of the way of the lift, she said it fell over. The resident hit the wall with her left shoulder and slid down the wall. She described the resident ' s right foot under the lift and described hearing a crack when the resident hit the wall and the floor - she went down fast and hard . She confirmed that she had locked the brake/casters on the lift, been the only staff member in the room during the transfer and that the hook had detached. At 1 pm the surveyor observed and interviewed resident #1. The events were described by the resident. The girl (GNA #1) was taking me to the bathroom/shower room, the hook came off of the machine - that ' s what holds you up there -and I fell . She didn ' t have it hooked right, I hit my shoulder and my ankle. It hurt and hurts now. She stated that she did get relief from pain medication. On 1/15/16 the surveyor reviewed the owner ' s manual for the Reliant 440 Power sit to stand lift. The lift was described for use with weight-bearing residents and for those needing rehabilitation supports. The sling used had large opening around the seat to facilitate dressing, undressing and for transfers to and from the toilet. In section 4: Two persons were recommended during transfers/lifts; the rear casters/wheels of the lift were NOT to be locked and doing so could cause the lift to tip and endanger the resident and assistant; the attachment points (loops that hooked the sling to the lift) were to be re-checked when the lift was slightly lifted to ensure safety. The facility failed to have 2 persons in attendance, assure that the brakes/casters were unlocked and assure that the sling was secure during a lift/transfer. This resulted in the resident and the lift falling and ultimately fracturing the resident ' s left arm/shoulder and causing trauma to the right ankle.

Based on medical record review and interviews with the facility staff and resident #1's family,it was determined that the facility failed to consistently manage 2 residents pain, resulting in pain for both. This was evident for 2 of 5 residents selected for review. The findings included the following: 1). The facility failed to consistently manage resident #1's pain. The surveyor reviewed the resident's medical record and interviewed the facility staff as well as the resident's granddaughter between 2/7/13 and 2/22/13. On 1/29/13 at 7:30 AM, Resident #1 was discovered lying on the floor screaming. She was described to be in pain. She was transferred back to bed and described to continue to scream during the transfer and after. The physician was notified, the resident was given Tylenol and an X-ray was ordered. At 8:11 am order for pain medication, [MEDICATION NAME] HCL every 8 hours was added for pain as needed. At 10:58, the resident received the first dose of [MEDICATION NAME], it was noted to be effective. At 11:21, the X-ray results described a fractured right hip. An intertrochanteric [MEDICAL CONDITION] was diagnosed . Mild cephalad displacement of the distal fracture fragment was noted. At 3:10 pm, the [MEDICATION NAME] was changed to every 8 hours for pain and the effectiveness was to be monitored and an orthopedic consultation was ordered. At 3:39 pm the resident received her next dose of [MEDICATION NAME] the medication was noted to be ineffective. At 9:05pm [MEDICATION NAME] was added, 5 mg every 8 hours standing and every 4 hours as needed. At 9:45pm the resident received the first dose of [MEDICATION NAME], it was noted to be effective. The [MEDICATION NAME] administered at 3:39 pm was noted to be ineffective. Over 6 hours later at 9:45 pm. the resident received the [MEDICATION NAME]. The resident's granddaughter contacted the Office of Health Care Quality with concerns about her grandmother's pain. She felt her grandmother's pain had not been controlled. During the surveyor's interview she said she could hear her grandmother moaning in pain all the way down the hall the afternoon/ evening of 1/29/13 - the day of the fall. The surveyor contacted the facility through 2/22/13 for additional information regarding the resident's pain management the day of the fall from the time the [MEDICATION NAME] was ineffective until the [MEDICATION NAME] was administered. They were unable to provide any additional information. The facility failed to consistently manage resident #1's pain, this resulted in pain. 2). The facility failed to consistently manage resident #5's pain. From 2/7/13 through 2/22/13, the surveyor reviewed the resident's medical record and interviewed the facility staff. On 12/24/12, at 4 pm the resident had a witnessed [MEDICAL CONDITION] while in her recliner. Following the [MEDICAL CONDITION] the resident was described to be "limp". Geriatric Nursing Assistant (GNA) #4 and #5 transferred the resident to the bed from the recliner. They described placing their hands beneath her arm pits. The transfer took place by placing her feet on the floor, pivoting her body to the right, placing her body on the bed, and finally lifting her feet into the bed. When the resident "woke up" she was described to have significant pain. The pain increased with movement like turning and during incontinent care. At 5:31 pm, the resident received one tablet of Tylenol 325 milligrams. This was noted to be effective. The facility failed to administer any other pain medication that day. Sometime before 6:55 pm, the resident was transferred out of the bed to the recliner and then back again using the same method. The resident continued to be described in pain when she was moved. On 12/25/12, the resident was again described to have pain when she was moved, during bathing, incontinent care and transfers. She was transferred from the bed to the recliner and back again. The facility failed to administer pain medication that day. On 12/26/12 at 8:46, the resident had an x-ray of her left hip ordered which revealed a fracture. At 12 noon, the resident received her first dose of pain medication, Tylenol 650 milligrams, ordered for left hip pain/ discomfort. On 12/28/12, she was seen by an orthopedic surgeon and diagnosed with [REDACTED]. A Garden 4 fracture is a complete fully displaced [MEDICAL CONDITION] neck. A fully displaced fracture is when the bone pieces become separated with no alignment between the proximal and distal fragments. The surgeon further noted that as the resident had not had a fall he felt the fracture may have occurred during the [MEDICAL CONDITION] on 12/24/12. Review of the medical record and interviews with the assistant director of nursing (ADON) failed to reveal any other interventions indicating pain management between the dose of Tylenol on 12/24/12 at 5:30pm and the dose administered on 12/26/12 at 12 pm. The facility failed to consistently manage resident #5's pain, resulting in pain. In conclusion, the facility failed to manage pain for both resident's #1 and #5. The facility failed to manage pain for resident #1 for over 6 hours and resident #5 for a day and a half.