Every finding on record at Complete Care at Hyattsville

Based on facility investigative record review, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a cognitively impaired resident from leaving the facility without supervision. This was evident for 1 (Resident #9) of 5 residents reviewed for elopement during the complaint survey. This deficient practice resulted in Immediate Jeopardy. However, the facility developed, implemented, and completed corrective actions prior to the start of this survey. The facility's plan and actions were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 8/7/2026. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment completed by facility staff that evaluates a resident's cognition, behaviors, functional abilities, and care needs.The Brief Interview for Mental Status (BIMS) is an assessment used to determine a resident's cognitive status. A score of 13-15 indicates cognitively intact, 8-12 indicates moderate cognitive impairment, and 0-7 indicates severe cognitive impairment.A review of Facility Reported Incident (FRI) #3132615 on 8/18/2026 revealed an incident related to Resident #9's unauthorized exit from the facility on 8/1/2026. A review of the facility's investigative documentation on 8/18/2026 revealed that on 8/1/2026, Resident #9 left the facility without authorization at approximately 8:00 PM by means of a manual wheelchair. The facility's investigation revealed that per surveillance recordings, Resident #9 entered the main lobby, paused momentarily, and exited from the main lobby doors at approximately 8:02 PM. Exterior surveillance footage displays Resident #9 self-propelling their wheelchair on the sidewalk proceeding towards the gazebo on the front lawn and there was no available surveillance coverage indicating Resident #9's whereabouts after they were seen near the gazebo on the front lawn. Continued review revealed the incident was reported to facility administration, law enforcement was notified, a silver alert was initiated, and a missingresident protocol was initiated. The facility's investigation verified the resident's unauthorized exit through review of video surveillance recordings and staff interviews obtained during the investigation. On 8/19/2026 at 9:27 AM, review of Resident #9's clinical record revealed diagnoses including but not limited to, dementia, cognitive communication deficit, generalized muscle weakness, and lack of coordination. Review of Resident #9's admission MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Continued review of Resident #9's clinical record revealed a temporary healthcare guardian court order dated 7/7/2026. The petition identified Resident #9 as continuing to lack capacity to make medical decisions due to altered mental status. The court order documented that Resident #9 remained incapacitated.Continued review of Resident #9's elopement risk assessment dated [DATE] revealed a score of 6, indicating moderate risk. The assessment identified dementia and shadowing staff as Resident #9's risk factors. Review of Resident #9's nursing quarterly assessment dated [DATE] documented the resident's elopement risk score of 3, indicating moderate risk.A review of Resident #9's care plan did not reveal a focus, goals or interventions related to elopement risk prior to the elopement incident on 8/1/2026.On 8/19/2026 at 11:30 AM, in an interview, the Director of Nursing (DON) stated he was notified of the incident on 8/2/2026 at approximately 12:00 AM and came to the facility to assist with the search after Resident #9 could not be located. The DON stated review of surveillance footage revealed Receptionist #7, who was assigned to the front desk at the time of the incident, was looking down at his cell phone when he activated the electronic facility doors using the door-control button, allowing Resident #9 to exit the facility without supervision. The DON stated cognitively impaired residents are not allowed to leave the facility unsupervised. The DON further stated that if a resident exhibits exit-seeking behaviors, the front desk receptionist should contact the unit manager or supervisor for assistance with keeping the resident safe. The DON stated the facility entrance doors do not open automatically, and the receptionist must activate the door-control button to allow a resident to exit the facility.On 8/19/2026 at 3:54 PM, in an interview, LPN #9 confirmed she was Resident #9's assigned nurse at the time of the incident. LPN #9 stated she last observed Resident #9 at approximately 7:00 PM to 8:00 PM self-propelling their wheelchair toward the nursing station and elevator. During shift change, at approximately 11:55 PM, LPN #9 informed the incoming nurse that Resident #9 was not in their room.On 8/19/2026 at 4:29 PM, in an interview, GNA #11 confirmed she was assigned to Resident #9 at the time of the incident. GNA #11 stated she last observed Resident #9 between 7:30 PM and 8:00 PM leaving his/her room and going toward the nursing station.Review of the facility's elopement investigation timeline revealed that on 8/1/2026 at 11:55 PM, the charge nurse became aware Resident #9 was not in their room and could not be located in the immediate area. At approximately 12:15 AM on 8/2/2026, the facility initiated its missing resident response, and staff searched the facility, facility grounds, and surrounding area. Continued review revealed facility staff reviewed surveillance footage at approximately 4:00 AM and determined that Resident #9 had exited the facility at approximately 8:00 PM on 8/1/2026.Review of the Regional Director of Operations' (RDO) investigative written statement dated 8/3/2026 revealed that after Resident #9 was located on 8/3/2026, the RDO interviewed the resident at the hospital. Resident #9 reported he/she left the facility because he/she believed they had been there long enough and wanted to return home. Resident #9 reported boarding a bus with the intention of returning to a shelter. The resident reported they reached the shelter but was denied admission because there were no vacancies. Resident #9 then traveled to Union Station because he/she believed he/she would be safe there and protected from the weather because it had been raining.On 8/21/2026 at 10:39 AM, review of an aerial map revealed that Union Station in [NAME], D.C., where Resident #9 was subsequently located, was approximately 5 miles from the facility. Travel from the facility to Union Station included multiple roadways, intersections and heavy traffic. The weather conditions on the evening of the 8/1/2026 incident were reported as approximately 81 degrees. Review of the facility's investigation timeline revealed that on 8/3/2026 at approximately 7:19 AM, the facility learned Resident #9 had been located and transported to the hospital. At approximately 8:00 AM, facility staff contacted the hospital and learned Resident #9 was in stable condition and would be admitted with sepsis. Sepsis is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death.Continued review of the RDO's investigative statement revealed the treating emergency department physician reported Resident #9 was brought to the hospital with sepsis suspected of having originated from a urinary tract infection. The physician reported the immediate treatment plan included intravenous antibiotics and diagnostic testing. Review of Resident #9's clinical record revealed the resident had an indwelling foley catheter for urinary retention (a foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag). A urology consultation dated 7/10/26 documented that a voiding trial of Foley catheter exchange was recommended to reduce the risk of catheter-associated urinary tract infection; however Resident #9 declined both. Review of Resident #9's nursing progress notes dated 7/14/26 and 7/19/26 further documented continued refusal of Foley catheter removal despite education regarding the risk of infection. On 8/21/2026 at 11:30 AM, during a follow up interview, the DON stated Resident #9's 7/10/2026 moderate elopement risk assessment was discussed during clinical rounds. The DON stated the nurse who completed the assessment identified shadowing because Resident #9 followed staff and asked for food. The DON stated the behavior was considered the resident's baseline and the facility determined no additional interventions or care plan revisions were needed.On 8/21/2026 at 12:38 PM, the Administrator and DON were notified that the facility failed to provide adequate supervision to prevent Resident #9, a cognitively impaired resident identified as being at moderate risk for elopement, from leaving the facility without supervision. Resident #9 exited the facility after Receptionist #7 activated the controlled exit doors and remained away from the facility without staff supervision until located on 8/3/2026. Resident #9 traveled by public transportation and was subsequently located at Union Station in [NAME], D.C., approximately 5 miles from the facility. The facility's failure to provide adequate supervision placed Resident #9 at risk for serious harm, injury, or death.The facility's corrective actions included:Initiating the facility's missing resident protocol and notifying law enforcement, Resident #9's guardian, physician, Ombudsman, and other applicable agencies. Placing Receptionist #3 on administrative leave pending investigation on 8/2/2026. Receptionist #3 did not return to work after that date. Initiating facility-wide education regarding the missing resident protocol, identification and reporting of exit-seeking behaviors, elopement assessment accuracy, and front entrance security procedures. Completing new elopement risk assessments for current residents. Inspecting WanderGuard door alarms and resident WanderGuard devices for proper functioning. A review of facility documentation and staff interviews revealed the facility completed corrective actions on 8/7/2026. This deficient practice was cited as past noncompliance with Federal and State requirements with a compliance date of 8/7/2026.

Based on medical record review and interview, the facility failed to notify a resident's responsible party when the resident had a change in condition (Resident #1). This was evident for 1 out of 14 residents reviewed during a complaint survey.The findings include: Review of Resident #1's medical record revealed the resident had a guardian since admission in 12/2025. Further review of medical records revealed the resident had change in condition statuses on 12/24/25, 1/24/26, 4/13/26, and 4/22/26 that required the facility to notify the resident's responsible party. Review of the change in condition documents on 12/24/25, 1/24/26, 4/13/26, and 4/22/26 revealed the facility contacted the resident's family instead of the resident's guardian. Surveyor interview with the DON (Director of Nursing) and the Administrator on 8/19/26 at 9:40 AM confirmed Resident #1 had a guardian since admission in 12/2025. The DON and the Administrator also confirmed that change in condition statuses required nursing staff to notify resident's responsible party. The DON and the Administrator admitted that nursing staff incorrectly informed the family instead of the resident's guardian on 12/24/25, 1/24,26, 4/13/26, and 4/22/26.

Based on medical record review and interviews, it was determined that the facility failed to ensure that allegations of abuse were reported to the State Agency no later than 2 hours after the allegation was made. This was evident in one (Complaint #3026441) of 2 Complaints investigated during the complaint survey. The findings include:A review of Complaint #3026441 related to Resident#1 noted an allegation that staff #4, a nursing assistant, had assaulted Resident #1 by slapping him/her while giving the resident a bed bath (washing the Resident in bed). A continued review showed that the allegation was reported to the facility staff members; however, the state agency had not received a report of the alleged abuse from the facility. A review of Resident #1's medical record showed that he/she had a tracheostomy (a surgically created opening in the neck that bypasses the nose, mouth, and throat to help with breathing). The Resident also had left-sided weakness due to a history of stroke, did not walk, was bedbound, and relied on staff for all self-care needs. The review also indicated that Resident #1 was alert but nonverbal due to aphonia (loss of voice); however, he/she communicated through signs and gestures and by mouthing words. In an interview with Resident #1 on 6/17/26 at 11:04 AM, the surveyor read the summary of the complaint reported by the resident's representative. Resident #1 nodded yes to indicate agreement with the allegation. The resident was asked how he/she was assaulted and gestured to indicate he/she was slapped in the right cheek. The surveyor asked Resident #1 a follow-up question to confirm whether he/she meant he/she had been slapped by a staff member, and Resident #1 nodded yes. During an interview on 6/17/26 at 2:32 PM, staff #3, the social service director, reported that Resident #1 had made the allegation to staff #7, a social worker, on 5/14/26 in the presence of the Resident's representative. Staff #7 reported it to the nursing home administrator (NHA) the same day. However, when the NHA spoke with Resident #1, he/she decided to retract the allegation, so the facility determined that no further action was necessary. An interview with the Regional Director of Operations on 6/17/26 at 2:59 PM found no evidence that the allegation of abuse involving Resident #1 had been reported to the state agency office.

Based on medical record review and interviews, it was determined that the facility failed to ensure that thorough investigations were completed for allegations of abuse. This was evident in one (Complaint #3026441) of 2 Complaints investigated during the complaint survey. The findings include:A review of Complaint #3026441 related to Resident #1 noted an allegation made on 5/14/26 that Resident #1 had been slapped by staff #4, a nursing assistant, during care on 5/13/26 while staff #4 was giving the resident a bed bath (washing the Resident in bed). Further review of the facility's investigation into the allegation revealed interviews with other residents on the same nursing unit where Resident #1 resided, as well as a statement signed by the assistant administrator and the assistant director of nursing. The review showed that some of the residents interviewed were unable. A continued review of the staffing schedule for the day of the allegation showed that the perpetrator had worked with two other staff members on that shift. However, the review failed to demonstrate that the facility had conducted a thorough investigation, including a head-to-toe assessment of Resident #1 and of the other residents who were unable to be interviewed. The facility's investigation also lacked written statements from staff #4, the perpetrator, and from staff members who had worked with staff #4 that day and may have been aware of the incident. A review of the facility's policies and procedures on Abuse, Neglect, Exploitation found that the facility will protect residents from harm during an investigation by immediately removing the alleged perpetrator from the resident care areas. However, an interview on 6/17/26 at 3:30 PM with staff #4 showed that she continued working with residents from 5/14/26, when the allegation was made, and was not removed from the residents' care areas.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received care and services in accordance with physician orders and the resident's care plan to prevent pressure injuries. Specifically, the facility failed to reposition a resident every two hours as ordered and care planned. This failure occurred during multiple observations and placed one (1) of one (1) resident at risk for increased pressure injury development who were reviewed for turning and positioning. During an observation on 1/7/26 at 10:04 am, the surveyor observed Resident #8 lying in bed on the right side at an angle facing the wall.During another observation on 1/7/26 at 4:54 pm, the surveyor observed the resident lying supine (lying on back facing upward) with a wedge at their feet.During an observation on 1/8/26 at 9:38 am of Resident #8 the surveyor again observed the resident in the same position supine with no wedge, with no evidence the resident had been turned or repositioned. No staff were observed providing repositioning assistance during this time period.During an observation on 1/8/26 at 12:50 pm, the surveyor observed Resident #8 in bed positioned on their back with no wedge.During an observation at 3:16 pm, the surveyor again observed the resident in the same position, indicating the resident had not been repositioned in accordance with physician orders and the care plan.Record review of Resident #8 revealed an admission date of 8/16/25 with a list of diagnoses that included Pressure Ulcer of Sacral Region, Stage 4, Unspecified Dementia, Severe, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without Residual Deficits.Review of Resident #8's Care Plan with a date initiated of 9/8/2025 and a revision date of 10/2/2025, confirmed that Resident #8 had pressure injury preventative interventions that included being turned and repositioned every two (2) hours.Review of Resident #8's Physician's Orders with an order date of 8/16/2025, revealed an order to assist and/or encourage resident to turn and position every 2 hours for pressure relief every shift.During an interview on 1/8/26 at 11:46 am Licensed Practical Nurse (LPN 12) stated that for positioning staff went by the facility protocol, which was to reposition resident every two hours. During an interview on 1/8/26 at 12:04 pm LPN 13 reported that they round every two hours. LPN 13 also revealed that there was a time clock that they use to know what position and what time to reposition the resident and it was kept on every badge.During an interview on 1/8/26 at 12:16 pm LPN 14 stated that if the patient was stable, that they would reposition residents every 2 hours. LPN 14 acknowledged the clock that was on the back of every badge and that the nurses and the geriatric nursing assistants (GNA) work together.During an interview on 1/8/26 at 12:52 pm with the Assistant Director of Nursing (ADON) stated that the facility provided the staff a clock. Staff were not supposed to just walk through the hallway, and that training was on-going, and residents that are not able to move themselves, are supposed to be turned. The expectation was to turn the resident every two hours. The two GNAs on the floor knew that they were supposed to turn Resident #8. The only way to know if they had been turned, would be done by seeing the resident and making their rounds, it was an on-going education, and that the nurse's needed to over-see that the GNAs were doing it.During an interview on 1/9/26 at 8:54 am GNA 10 stated that they were supposed to round every 2 hours.During an interview on 1/9/26 at 9:08 am GNA 11 reported that they did rounds at the beginning of their shift. They stated that they tried to round every 2 hours or once an hour. GNA 11 also said that they knew it was required to do their rounds twice an hour.

Based on observation, staff interview, and review of infection prevention practices, the facility failed to implement proper infection control measures to prevent contamination of tracheostomy equipment. Specifically, the facility failed to ensure tracheostomy tubing remained off the floor for three (3) of four (4) residents observed for tracheostomy equipment. This failure occurred on two separate days and placed residents at risk for infection.1.) During an observation on 1/6/2026 at 10:15 am resident #14 who had a tracheostomy, with tracheostomy tubing extending from the tracheostomy site and resting on the floor. No staff were observed intervening to reposition or replace the tubing at that time.Record review of Resident #14 revealed, an admission date of 1/6/2026, an admission date of 5/10/2022, an original admission date of 7/10/2020.During an observation on 1/7/2026 at 9:54 am resident #14 was seen in their electric wheelchair in the resident's room with the tracheostomy tubing touching the floor.2.) During an observation on 1/6/2026 at 10:21 am resident # 6, who had a tracheostomy, with tracheostomy tubing touching the floor while connected to the resident's airway.Record review of Resident #6 revealed, an admission date of 10/7/2025, and a diagnoses list that included traumatic hemorrhage of left cerebrum with loss of consciousness status unknown, sequela, encounter for attention to tracheostomy, functional quadriplegia.3.) During an observation on 1/7/2026 at 8:40 am resident #10, who had a tracheostomy, with tracheostomy tubing in contact with the floor during routine care.Record review of Resident #10 revealed, an admission date of 12/23/2025, and a diagnoses list that included a traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, sequela, encounter for attention tracheostomy.During an interview on 1/8/2026 at 11:31 am Infection Preventionist (RN6), acknowledged that the tracheostomy tubing should not come into contact with the floor due to contamination risk. RN6 went on to report another reason the tubing should not be on the floor, was because the floor was considered dirty, and the residents were already immunocompromised.During an interview on 1/8/2026 at 11:46 am Licensed Practical Nurse (LPN 12), reported that they do rounds three times a shift and that they checked tracheostomy residents and if the tubing was on the floor.During an interview on 1/8/2026 at 12:04 pm LPN 12 disclosed that if something touched the floor then the expectation was to get something clean to replace it.During an interview on 1/8/2026 at 12:52 pm Assistant Director of Nursing (ADON) stated the staff are not supposed to have anything on the floor. The ADON was unable to explain how the tubing was consistently maintained off the floor.

Based on observations and interviews it was determined that the facility failed to ensure Residents were provided a dignified existence. This was found to be evident for 6 (Resident #126, #18, #162, #114, #229, & #183) out of 7 Residents observed for dignity during the recertification survey.The findings include: 1) During an interview conducted on 09/15/2025 at 8:17 AM, Resident #126 stated that when staff enter the room they do not introduce themselves and ask permission to enter. During an interview conducted on 09/15/2025 at 8:43 AM this Surveyor observed Geriatric Nursing Assistant (GNA)#8 knock on Resident #126's door once and then entered the room without introducing herself and asking for permission to enter. During an interview conducted on 09/15/2025 at 8:46 AM, GNA#8 stated that she should have said who she was and asked if she could enter. She further stated that it is the facility's policy to introduce yourself and ask permission to enter. 2) During an interview conducted on 09/16/2025 at 10:36 AM, Resident #18 stated that the staff do not ask for permission to enter his/her room. The Resident stated that sometimes the staff do even knock they just walk in my room.During the continued interview with Resident #18, Unit Manager #33 knocked on the Resident's door one time and entered the Resident's room. The Unit Manager did not announce herself and asked for permission to enter.During an interview with the Unit Manager conducted on 09/16/25 at 10:43 AM, the Unit Manager apologized for not announcing herself and asking permission to enter the Resident's room. She further stated that the facility's expectation is to treat each resident with respect for their home by knocking on the door, announcing themselves, asking for permission and waiting for the Resident's response in giving permission to enter their room. 3) A urinary Foley bag refers to the urine collection bag attached to a Foley catheter, a flexible tube inserted into the bladder to drain urine when a person cannot urinate normally. The Foley catheter system includes the tube, a small balloon to keep it in place inside the bladder, and a drainage tube leading to the collection bag, which can be worn on the leg or a larger night bag for overnight use. During an observation conducted on 09/15/2025 at 7:42 AM, the Surveyor observed Resident #126's urinary foley bag lying flat on the floor, full of urine, and without a privacy bag. Continued observations were conducted on 09/16/25 at 9:09 AM, 09/18/25 at 8:14 AM & 09/19/25 at 8:39 AM that showed Resident #126's urinary foley bag lying flat on the floor and without a privacy bag. On 09/16/25 at 10:55 AM, this Surveyor observed License Practical Nurse (LPN) #29 attached Resident #126's urinary foley bag to a hook under the Resident's motorized wheelchair as he/she was leaving to attend an outside medical appointment. The urinary foley bag did not have a privacy covering. During an interview with LPN #29 conducted on 09/16/25 at 10:57AM, the LPN stated that she could not access the supply room to retrieve a privacy urinary foley bag. During an interview conducted on 09/17/25 at 6:32 AM, this Surveyor advised the Director of Nursing (DON) of the observations of the lack of a privacy urinary foley bag. The DON stated that he would educate the staff on providing a privacy urinary foley bag. 4) During an observation of Resident #162's medication administration conducted on 09/17/25 at 8:08 AM, Licensed Practical Nurse (LPN) #31 administered escitalopram 20 mg (milligram), escitalopram 10 mg, metamucil, and Rena Vite 0.8 mg to the Resident. The LPN failed to inform the Resident of the medications that were to be administered. During an observation of Resident #114's medication administration conducted on 09/17/25 at 8:27 AM, Licensed Practical Nurse (LPN) #31 administered metformin hydrochloride 500 mg, metoprolol succinate 50 mg, finasteride 5 mg, B-12 100 mcg losartan potassium 25 mg, tiotropium bromide hydrate 18 mcg (microgram), and fluticasone propionate salmeterol 100-50 mcg to the Resident. The LPN failed to inform the Resident of the medications that were to be administered. During an interview conducted on 09/17/25 at 8:40 AM, the LPN stated the she should have informed the Residents of their medications.5) During an observation of Resident #229's medication administration conducted on 09/17/25 at 8:47 AM, Registered Nurse (RN) #32 administered clonazepam 0.5 mg, lacosamide 10 mg, valporate acid 250 mg/5 ml solution, oxcarbazepine 600 mg, multivitamin, atenolol 25 mg, and levETIRAcetam 100 mg to the Resident. The RN failed to inform the Resident of the medications that were to be administered. 6) During an observation of Resident #183's medication administration conducted on 09/17/25 at 9:18 AM, RN#32 amlodipine 5 mg, fluoxetine 20 mg, oxybutynin 10 mg, oxybutynin 5 mg, Xarelto 20 mg, and oxycodone hydrochloride 10 mg to the Resident. The RN failed to inform the Resident of the medications that were to be administered.During an interview conducted on 09/17/25 at 9:36 AM, the RN acknowledged that he did not inform the Residents of the medications administered. He stated that the expectation is to inform the Resident of all medication administered.

Based on interviews and record reviews, it was determined that the facility failed to 1. have quarterly Care Plan Meetings with the Interdisciplinary Team, 2. ensure care plan meetings were held in a timely manner and 3. review and revise the care plan to meet resident's needs. This was found to be evident for 5 (Resident #140, #120, #201, #232 and #285) out of 11 residents reviewed for care planning during the annual survey.The findings include:1.Care Plan Meetings are meetings with a team of care providers including the attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of food and nutrition services, the resident, and the resident's representative if applicable to ensure the care plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly. During an interview with Resident #140 on 09/16/25 at 10:54 AM he/she denied having any recent care plan meetings. During a medical record review on 09/18/25 at 8:13 AM it was discovered that Resident #140 hadn't had a care plan meeting since 03/23/25. The last two care plan meetings were held on 07/02/24 and 03/23/25. He/she didn't have any care plan meetings between 07/03/24 and 03/22/25. The Resident only had one care plan meeting in 2025 and that meeting occurred on 03/23/25. During an interview with the Social Work Director on 09/18/25 at 1:37 PM the Director advised care plan meetings should be completed every three months. The Director confirmed that there were care plan meetings missed for Resident #140. The Director was not sure why the care plan meetings were not completed because Resident #140 was covered by a previous social worker that was no longer at the facility. 2. During a medical record review on 09/18/25 at 7:30 AM it was discovered that Resident #120 had not had a care plan meeting since 03/06/25. During an interview with the Social Work Director on 09/18/25 at 1:33 PM the Director confirmed that there was a care plan meeting missed for Resident #120. The Director reported Resident #120 should have had a care plan meeting in June and was due for another in September. The Social Work Director reported I can't give an answer as to why it was missed since Resident #120 was covered by a previous social worker that was no longer at the facility at that time. 3. During a medical record review on 09/18/25 at 10:43 AM it was discovered that Resident #201 had a care plan meeting on 06/18/24 and no other care plan meetings until 03/20/25. No care plan meetings were found from 06/19/24 through 03/19/25 and no care plan meetings were found from 03/21/25 until the interview with the Social Work Director on 09/18/25. During an interview with the Social Work Director on 09/18/25 at 1:56 PM the Director advised care plan meetings should be completed every three months. The Director confirmed that there were care plan meetings missed for Resident #201. The Director agreed that Resident #201 should have had a care plan meeting in September 2024, December 2024, June 2025 and was due for one in September 2025. The Social Work Director reported they were unsure the care plan meetings were missed for Resident #201 because he/she was covered by a previous social worker that was no longer at the facility during that time. 4. According to CMS (Centers for Medicare & Medicaid Services) care plan meetings, which are part of the comprehensive care planning process for long-term care facilities, require regular review and revision based on resident assessments. These meetings ensure that residents receive person-centered care that meets their individual needs and preferences. During an interview conducted on 09/16/25 at 9:49 AM, Resident #232's Power of Attorney (POA) reported that he/she did not have quarterly care plan meetings. A review of Resident #232's care conference notes were conducted on 09/23/25 at 9:08 AM showed the following Care Plan meetings were held on 06/11/24, 04/03/25, and 05/29/25. On 09/23/25 at 9:30 AM this Surveyor requested Care Plan meeting notes from 09/24 through 09/25. On 09/24/25 at approximately 11:00 am the Director of Nursing (DON) provided the Care Plan meeting notes. A review of the Care Plan meeting notes revealed that there were 2 Care plan meetings held for Resident #232 from 09/24 through 09/25. There was a Care Plan meeting held on 04/03/25 and 05/29/25. During an interview, the DON reported that the Care Plan Meetings notes for the period of 09/24 through 09/25 showed a Care Plan meeting was held on 04/03/25 and 05/29/25. This Surveyor expressed concern that the Resident and/or Resident Representative had not received quarterly Care Plan meetings. 5. According to CMS (Centers for Medicare and Medicaid Services), in long-term care facilities, care plans should be reviewed and updated at least every 90 days, or more frequently if a resident's condition changes significantly. On 9/23/25 at 9:32 AM, a review of Resident #285's progress notes revealed multiple falls on 1/30/25, 2/17/25, 3/17/25, 6/7/25 and 7/31/25. However, the fall risk evaluation dated 2/17/2025, indicated a score of 5, classifying the Resident which as low risk. On 9/23/25 at 9:52 AM, a review of Resident #285's care plan, initiated on 2/3/2025 indicated an actual fall related to gait imbalance. Although the Resident experience multiple falls during their stay, there was no evidence that the care plan was updated after the fall on 3/17/25. On 9/24/25 at 10:09 AM, in an interview with the Director of Nursing (DON), he stated that the care plans were updated by the Unit Managers and himself. He also noted that it was expected for the care plan interventions to be updated after each fall incident. On 9/24/25 at 11:11 AM, the DON provided the surveyor with a copy of Resident #285's fall care plan with revisions and acknowledged the concern.

Based on observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This was evident during the initial tour of the kitchen during the annual survey.The findings include:During an initial tour of the kitchen on 09/15/25 at 8:44 AM, the surveyor and Certified Dietary Manager (CDM) observed the following opened and unlabeled items in the walk-in freezer: one box of pizza dough, one box of tortilla chips, one box of hamburger patties, and one box of French toast.In an interview conducted on 09/16/25 at 8:58 AM, the CDM confirmed the faility's food storage policy is to securely close packages once opened and to label the package with an open date.

Based on observations, interviews and record reviews, it was determined that the facility failed to 1) ensure appropriate personal protective equipment (PPE) was readily accessible and used by staff prior to entering the room of a resident on transmission based precautions, 2) ensure staff practiced infection control, 3) ensure that the environment was maintained in a manner that minimized the potential spread of infection and 4) ensure appropriate infection prevention and control practices were followed. This was evident for 1) 1 out of 2 residents (Resident #288) reviewed for transmission-based precautions, 2) 2 out of 7 residents (Resident #126, #150) observed for infection control, 3) 1 random observation of the laundry room, and 4) 1 out of 46 residents (Resident #14) reviewed during the annual survey.The findings include: 1) On 09/18/25 at 8:25 AM, the surveyor observed GNA #26 enter Resident #288's room (210A) without donning a gown, gloves, or N95 mask. Signage posted on the resident's door clearly indicated the need for contact and droplet precautions. GNA #26 was wearing only a surgical mask. In an interview on 09/18/25 at 8:27 AM, GNA #26 stated she believed PPE was only needed in Resident #288's room when providing direct care. In an interview on 09/15/25 at 8:55 AM, the surveyor raised concerns with the Infection Preventionist, who stated that staff are expected to don full PPE, including a gown, gloves, and an N95 mask, before entering the room of any resident on droplet precautions. In an interview on 09/19/25 at 6:50 AM, Unit Manager #1 confirmed there were no N95 masks on the PPE cart outside of room [ROOM NUMBER]A and stated that N95 masks were stored on the locked medication cart. Unit Manager #1 also stated that nursing staff would provide N95 masks to visitors and staff when requested. At 6:53 AM, the surveyor observed N95 masks being added to the PPE cart for room [ROOM NUMBER]A after the issue was discussed. In an interview on 09/19/25 at 7:39 AM, the Director of Nursing (DON) stated that the facility keeps N95 masks on the locked medication cart so residents don't touch them. The DON also stated that staff or anyone entering the room needs to ask the nurse for an N95 mask before going in. The DON further stated the expectation is that nurses are monitoring who is going into the room and will provide the mask. When the surveryor asked if there was a sign on the door directing staff or visitors to request N95 masks from nursing staff, the DON said no. 2) A urinary Foley bag refers to the urine collection bag attached to a Foley catheter, a flexible tube inserted into the bladder to drain urine when a person cannot urinate normally. The Foley catheter system includes the tube, a small balloon to keep it in place inside the bladder, and a drainage tube leading to the collection bag, which can be worn on the leg or a larger night bag for overnight use. A urinary foley bag should be hung below the level of the bladder, such as on the side of a bed frame, a bed or a chair, or inside a clean trash can, to ensure proper gravity drainage. It must be kept off the floor to prevent contamination and infection. During an observation conducted on 09/15/2025 at 7:42 AM, the Surveyor observed Resident #126's urinary foley bag lying flat on the floor, full of urine, and without a privacy bag. During an interview conducted on 09/15/2025 at 8:11 AM, Registered Nurse (RN) # 9 entered Resident #126's room. This Surveyor pointed out to the RN that the urinary foley bag lay flat on the floor. The RN stated that she would hang the bag on the bottom bar under the Resident's bed. Continued observations were conducted on 09/16/25 at 9:09 AM, 09/18/25 at 8:14 AM & 09/19/25 at 8:39 AM that showed Resident #126's urinary foley bag lying flat on the floor. During an interview conducted on 09/17/25 at 6:32 AM, this Surveyor advised the Director of Nursing (DON) of the observations of the observations of the foley bag lying on the floor. The DON stated that he would educate the staff on placement of the foley bag. On 09/22/2025 at 11:13 AM the DON returned and showed this surveyor a text message from the Unit Manager that stated that Resident #126 requested that the urinary foley bag be on the floor because it drained better. The DON stated it was the Resident's right. This Surveyor stated that the facility had an obligation to practice safe care and to educate the Resident on infection control. It also was the responsibility of the facility to find out why the Resident reported the that the foley bag drained better lying on the floor. On 09/22/2025 at 1:07 PM the DON returned and stated that he spoke to the Resident and the Resident confirmed that the urinary foley bag drained better on the floor. The DON stated that he advised the Resident that it was a concern and would notify the physician to assess placement and to rule out an occlusion. The DON further stated that he educated the Resident on the infection control concern when the bag lay on the floor. During an observation conducted on 09/15/25 at 8:05 AM, Resident #126 had a sign on the entry door that stated EBP (Evidence Based Practice) Precautions. The sign had direction for direct care. When providing direct care you are required to wear PPE (personal protective equipment) that consists of gown and gloves. During an interview conducted on 09/15/25 at 8:06 AM the Resident reported that he/she needed to speak with the nurse because he/she did not feel well. This Surveyor observed a large amount of mucus dripping from his/her nose that dripped down the Resident's face and onto the chin. This Surveyor observed the Resident press the call bell on 09/15/25 at 8:08 AM. During an observation on 09/15/25 at 8:39 AM, Geriatric Nursing Assistant (GNA) #8 entered the Resident's room without wearing PPE. The Resident asked the GNA if she could clean his/her face, nose and chin to remove the mucus. The GNA placed one glove on her hand and cleaned the Resident. During an interview conducted on 09/15/25 at 8:41 AM, this Surveyor asked GNA #8 if she was aware that the Resident was on a precaution. The GNA stated yes but she did not need to wear the PPE because she was just cleaning the Resident. During an interview conducted on 09/17/25 at 6:39 AM, this Surveyor notified the DON of the observation and GNA #8's response to not having to wear PPE when providing direct care. The DON informed the Surveyor that he would speak to the GNA and provide education on EBP precautions. During an observation of a medication administration conducted on 09/17/2025 at 9:18 AM this Surveyor observed Registered Nurse (RN) #32 obtain Resident #183's blood pressure with a shared blood pressure cuff. The RN then went to Resident #150's room and obtained his/her blood pressure using the same blood pressure cuff that was used on Resident #183. The RN failed to sanitize the blood pressure cuff and equipment prior to obtaining Resident #150's blood pressure. During an interview conducted on 09/17/2025 at 9:37 AM, RN #32 acknowledged that he did not sanitize the community shared blood Pressure cuff and equipment prior to using it on Resident #150. Unit Manager #33 was present during interview and advised the Surveyor that she would provide education to the staff in practicing infection control. 3) During an observation of the laundry room on 09/22/25 at 7:51 AM it was observed that Housekeeper #27 was folding laundry. During the folding process several observations were made of the bottom of the sheets and gowns touching the floor while being folded. During an observation and interview with the Housekeeping Assistant Manager on 09/22/25 at 8:01 AM she agreed that linen should not touch the floor when being folded. She expressed the concern to Housekeeper #27 who then used the folding table which kept the linens off the floor while being folded. 4) Resident #14 was admitted to the facility with diagnoses including Chronic Respiratory Failure with Hypoxia and End Stage Renal Disease. On 09/15/25 at 9:31 AM during initial rounds the surveyor observed a nebulizer machine on the floor next to Resident #14's bed. On 09/15/25 at 9:55 AM the surveyor notified the Nurse Staff Educator who visited the resident's room and confirmed the findings. On 09/18/2025 at 8:03 AM a review Resident #14's clinical record revealed a physician's order for respiratory therapy as follows: Respiratory Therapy (RT) - Evaluation & treatment as recommended Order Date 08/06/25. 09/18/2025 at 10:21 AM during an interview the Director of Nursing informed the surveyor that he was made aware of the surveyor's findings and had conducted an Inservice training on 09/16/25 to educate the staff that Nebulizer machines must not be placed on the floor. The DON gave the surveyor a copy of the Inservice document.

Based on interviews and record reviews it was determined the facility failed to ensure Resident Care Plans were developed. This was found to be evident for 1 (Resident #6) out of 1 Resident reviewed for Care Plans during the recertification survey.The findings include: A Care Plan is a comprehensive document that outlines the specific healthcare needs, goals, and interventions for an individual patient. It serves as a roadmap for healthcare providers, ensuring coordinated and personalized care. During a record review conducted on 09/22/25 at 12:43 PM, it was discovered that Resident #6 had a diagnosis of schizoaffective disorder. During a review of Resident #6's Care Plan conducted on 09/22/2025 at 1:10 PM it was discovered that the Resident did not have a care plan for schizoaffective disorderDuring an interview conducted on 09/22/25 at approximately 1:30 PM, this Surveyor and Director of Nursing (DON) reviewed Resident #6's Care Plan with revisions. The DON confirmed that the Resident did not have a Care Plan for a schizoaffective disorder. The DON stated that he would add a Care Plan with interventions.

Based on interviews and record reviews it was determined that the facility failed to ensure a Resident received treatment as ordered for a pressure ulcer. This was found to be evident for 1 (Resident #126) out of 1 Resident reviewed for pressure ulcer during the recertification survey.The findings include:A pressure ulcer is damage to an area of the skin caused by constant pressure on the area for a long time. This pressure can lessen blood flow to the affected area, which may lead to tissue damage and tissue death. Pressure ulcers often form on the skin covering bony areas of the body, such as the back, tailbone, hips, buttocks, elbows, heels, and ankles. Patients who cannot get out of bed or change their position, or who always use a wheelchair have an increased risk of ulcers. Pressure ulcers often heal slowly and if not treated can damage tissues deep under the skin, including fat, muscle, and bone. Also called bedsore, decubitus ulcer, and pressure sore. Pressure ulcers are classified in stages by the depth of the tissue damage to the area. The stages range from 1 to 4.The four stages of pressure ulcers are:Stage 1: Redness on the skin that does not blanch (turn white) when pressed. May feel warm to the touch.Stage 2: partial-thickness skin loss. Open sore or blister that may be filled with fluid.Stage 3: Full-thickness skin loss, Subcutaneous tissue (fat) is visible, and May have undermining or tunneling. Stage 4: Full-thickness tissue loss. Muscle, bone, or tendon is exposed. May have significant damage to surrounding tissues.During an interview conducted on 09/15/2025 at 10:14 AM, Resident #126 stated that he/she had a Pressure Ulcer that had worsened now to a stage 4.A Care Plan is a comprehensive document that outlines the specific healthcare needs, goals, and interventions for an individual patient. It serves as a roadmap for healthcare providers, ensuring coordinated and personalized care. A review of Resident #126's Care Plan was conducted on 09/15/2025 at 2:44 PM. The Care Plan stated that the Resident has actual impairment to skin integrity r/t decreased functional mobility as evidenced by pressure injuries to the Sacrum, left ischium, Right Ischium, right heel, right plantar foot, left pinky finger and right upper back/Flank. Resident is at risk for peristomal MASD r/t Colostomy exudate. During an interview conducted on 09/16/25 at 10:33 AM, Resident #126 stated that the nurse did not have Dakins to cleanse his/her sacrum pressure ulcer. During an interview conducted on 09/16/25 at 10:37 AM, License Practica Nurse (LPN) #29 confirmed that she did not use Dakins because it was not available. She stated that the Dakins was in the locked supply room the she did not have access to. She then showed this Surveyor a squirt bottle labeled Skin Integrity Wound Cleanser. She stated that she used that solution instead. A review of Resident #126's Medication Administration Record (MAR) was conducted on 09/16/2025 at 2:54 PM. The MAR showed the following order Cleanse Medial sacrum with NSS [normal saline solution], pat dry, apply Santyl to wound bed, then cover with 1/4 strength Dakin's moist dressing, cover with 4x4 gauze and secure with bordered gauze. every day shift for Wound Tx [treatment] AND as needed every day shift -Order Date09/05/2025 0725.During an interview conducted on 09/17/25 at 6:30 AM, the Director of Nursing (DON) stated that LPN#29 should have access to the supply room but that the Dakins should have been stored in the treatment cart. The DON stated that he would confirm that the facility had Dakins in the facility.During a follow up interview on 09/22/25 at approximately 9:00 AM, the DON stated that he confirmed that the facility does have a supply of Dakins and its location in the treatment cart. The DON further stated he would educate LPN #29 on the location of the Dakins and access to the supply room.

Based on observation, interview and record review, it was determined that the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident. This was found evident for 1 (Resident #20) out of 1 resident reviewed for ADL care. The findings include:According to the Centers for Medicare & Medicaid Services (CMS), the facility must provide care and services to assist residents with Activities of Daily Living (ADLs), including hygiene, mobility, elimination (toileting), dining, and communication. According to CMS, Oral care refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues. This involves not only activities such as brushing of teeth or oral appliances, but also maintenance of oral mucosa.According to CMS, a dependent resident is an individual who requires staff assistance to complete all or most Activities of Daily Living (ADLs) because they are unable to perform these tasks independently. This may include total dependence, where staff provide full physical assistance for care such as bathing, dressing, toileting, transferring, eating, or mobility.On 09/16/2025 at 9:11 AM, an observation of Resident #20 in his/her room showed that the Resident's teeth contained food particles.On 09/17/2025 at 9:34 AM, during an interview with Resident #20's representative, he/she stated that he/she did not believe the facility was adequately brushing the Resident's teeth.On 09/17/2025 at approximately 12:00 PM, a record review of Resident #20's Minimum Data Set (MDS), under the Functional Abilities section, showed that for Oral hygiene, the Resident was documented as Dependent. On 09/22/2025 at 11:22 AM, another observation of Resident #20 showed pieces of food stuck to the Resident's teeth.On 09/22/2025 at 11:25 AM, an interview was conducted with Geriatric Nursing Assistant (GNA) #21 in Resident #20's room. GNA #21, who was assigned to the Resident on this day, stated that she normally completed ADL tasks, including brushing teeth, after breakfast. She reported that breakfast for the residents on this floor is typically served at 8:00 AM. GNA #21 confirmed that the last time she had worked with Resident #20 was on 09/19/2025 and that she had not provided oral care during that shift because the Resident was asleep for most of the day. She further confirmed that it is expected for oral care to be completed for residents at least once daily.On 09/22/2025 at 11:54 AM, an interview was conducted with Unit Manager #6 regarding the expectations for oral care. He stated that it is his expectation for residents to have their teeth brushed daily. On 09/22/2025 at 12:00 PM, another observation of Resident #20 in his/her room showed that food particles were still present on the Resident's teeth.On 09/22/2025 at approximately 12:02 PM, a follow-up interview was conducted with Unit Manager #6. When asked about the expectation for providing oral care to a resident who is asleep, he stated that oral care is still expected to be completed even if the resident is sleeping for extended periods. He explained that the GNA can use a wetted sponge with fluoride to gently sweep along the inside of the resident's mouth to clean it while the resident is asleep.On 09/22/2025 at 12:29 PM, this surveyor conducted an interview with Unit Manager #6. The surveyor explained that multiple observations had been made of Resident #20 with food particles in the mouth and teeth appearing unbrushed. GNA #20 confirmed in an interview that she had not brushed Resident #20's teeth on 09/19/2025 because the resident was asleep. The surveyor explained that this is a concern, as it appears this dependent Resident is not receiving oral care at least once a day as expected by the Unit Manager, even when there are methods available to provide oral care while residents are sleeping. The Unit Manager acknowledged the concern, stated he understood, and reported he would ensure the Resident's teeth are brushed as required.On 09/22/2025 at 2:14 PM, this surveyor conducted an interview with the Administrator. The surveyor brought to the Administrator's attention the concern that a dependent resident was not receiving oral care. The Administrator acknowledged the concern and confirmed that it is his expectation that residents have their teeth brushed at least twice a day.

Based on record reviews and interviews it was determined that the facility failed to ensure staff provided services that met professional standards of practice. This was found to be evident for 1 (Resident #88) out of 1 Resident reviewed for services meet professional standards of practice during the recertification survey.The findings include: During a review of Resident #88's medical record conducted on 09/18/2025 at 8:18 AM it was discovered that the Resident experienced a medical emergency and was transferred to a local hospital on [DATE]. A review of Resident's #88 medical records conducted on 09/18/25 at 8:35 AM revealed a physician certification form dated 06/05/23. The form deemed the Resident unable to understand and sign admission documents and other information, unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risks, and benefits of the treatment, unable to effectively communicate a decision. The form was signed by 2 physicians. On 09/22/25 at 6:30 AM this Surveyor requested Resident #88's bed hold notice for the transfer to the hospital on [DATE]. On 09/22/25 at 8:00 AM, the Director of Nursing (DON) provided this Surveyor with a Maryland Bed Hold Policy, Temporary Bed Hold Authorization, and Authorization to Record. A review of the Temporary Bed Hold Authorization showed a box checked that stated I do not wish to authorize the Facility at this time to retain my/the Resident's bed if I/the Resident is hospitalized or goes on therapeutic leave. However, should the Resident be hospitalized or go on therapeutic leave, I will be consulted at the time as to whether or not I would choose to hold the bed. The form was signed by Resident #88 on 04/15/25 at 3:19 PM EDT. The Facility Representative Name and signature was that of the admission Coordinator. The admission Coordinator signed the form on 04/15/25 at 3:42 PM EDT. A review of the Authorization to Record form had a box checked off that stated I hereby authorize the Facility or any of its staff to take photographs or other audio-visual images for use on the facility's social media or other marketing materials. The form was signed by Resident #88 on 04/15/25 at 3:19 PM EDT. The Facility Representative Name and signature was that of the admission Coordinator. The admission Coordinator signed the form on 04/15/25 at 3:42 PM EDT. During an interview with the Nursing Home Administrator (NHA) conducted on 09/22/25 at approximately 9:15 AM, this Surveyor expressed concern that Resident #88 was certified as not having capacity to understand and sign documents. The NHA stated that he understood the Surveyor's concern and would have the admission Coordinator come to speak to the Surveyor. During an interview conducted on 09/22/25 at approximately 10:00 AM the admission Coordinator reported that she needed to close out the forms, so she had the Resident to sign the forms. She further stated that she understood that the Resident did not have the capacity to understand and sign the forms. This Surveyor expressed concern about the admission Coordinator's professional standards of practice. The Surveyor stated that it was unacceptable to have a Resident sign a form who had been certified by physicians to not have capacity to understand and to sign forms.

Based on observations and interviews it was determined the facility failed to ensure a call bell was answered in a timely manner. This was found to be evident for 1 (Resident #126) out of 1 Resident observed for call bell response time during the recertification survey.The findings include: During an interview conducted on 09/15/2025 at 8:06 AM, Resident #126 stated that he/she is fully dependent on the staff for all his/her needs. The Resident stated that staff response time to call bells was very delayed. The Resident stated that he/she requested to leave the door open halfway to be able to call out for help after waiting long periods of time when he/she pushes the call bell and it goes unanswered. The Resident reported that he/she needed to speak with the nurse because he/she did not feel well. This Surveyor observed a large amount of mucus dripping from his/her nose that dripped down the Resident's face and onto the chin. This Surveyor observed the Resident press the call bell on 09/15/25 at 8:08 AM. The Resident entry door was halfway open. This Surveyor and the Resident observed 3 staff walk pass the Resident's door however no one came to answer the Resident's call bell. The Resident informed this Surveyor that one of the staff that walked passed the room was the Unit Manager. During the continued interview and screening of the Resident, this Surveyor observed at 8:39 AM Geriatric Nursing Assistant (GNA) #8 enter the Resident's room. The GNA stated that she was with another Resident. The Resident asked the GNA if she could clean his/her face, nose and chin to remove the mucus. The GNA cleaned the Resident and asked if the Resident needed anything else. The Resident asked the GNA if she could have the nurse come to see him/her, she agreed and exited the Resident's room. On 09/15/25 at 8:42 AM Registered Nurse (RN) #9 entered the Resident's room. The Resident notified the nurse that he/she did not feel well. The RN stated that she would obtain vitals and conduct an assessment. During an interview this Surveyor expressed concern that there was a 31-minute call bell response time. The RN reported that she saw the call bell light on, but she was conducting medication administration at the time. She further stated that she saw the Unit Manager in the hallway and assumed the Resident's needs had been addressed. On 09/17/25 at approximately 8:00 AM, this Surveyor reported the observation of the delayed call bell response time to the Director of Nursing (DON). The DON stated that he would investigate the matter.

Based on interviews and record reviews it was determined that the facility failed to ensure showers were provided for a Resident. This was found to be evident for 1 (Resident #126) out of 1 Resident reviewed for self-determination during the recertification survey.The findings include: During an interview conducted on 09/16/2025 at 8:15 AM, Resident #126 reported that he/she had not received showers although he/she had requested showers. A care plan meeting in a nursing home is a quarterly, person-centered discussion among a resident, their family, and the nursing home's interdisciplinary team to review and update the resident's personalized care plan. The goal is to ensure the care plan meets the Resident's current physical, medical, emotional, and personal needs and preferences, fostering their well-being and maintaining their independence. During an interview conducted on 09/17/25 at 10:43 AM the Resident's family member stated that the Resident had not been offered showers. He/she further stated that it was discussed in the Care Plan meeting a week ago.A Care Plan is a comprehensive document that outlines the specific healthcare needs, goals, and interventions for an individual patient. It serves as a roadmap for healthcare providers, ensuring coordinated and personalized care. A review of Resident #126's Care Plan conducted on 09/17/25 at 11:00 AM showed a Care Plan for the Resident's refusal of showers. During an interview conducted on 09/19/2025 at 7:20 AM the Director of Nursing (DON) explained the facility's shower policy. He stated that all Residents are scheduled 2 showers a week unless contraindicated. A physician order is placed with the days of the week and shift that the showers were provided. When asked if Resident #126 had been offered showers the DON stated that the Resident had been offered showers but had refused. This Surveyor requested documentation of the refusal. A review of the Resident #126's physician orders conducted on 09/19/25 at 07:24 AM, it was discovered that the Resident did not have an order for showers. Activities of Daily Living (ADLs) are fundamental self-care tasks, such as bathing, dressing, and eating, that are necessary for independent living and are often used in healthcare to assess a person's functional abilities. ADL task is a form that is completed by nursing staff that documents ADLs that were performed. A review of Resident #126's ADL task form for the last 30 days conducted on 09/19/2025 at 8:05 AM showed that the Resident did not refuse baths/showers. During an interview conducted on 09/19/25 at approximately 9:00 AM, the DON stated that the he had been advised that the Resident refused showers and as a result the Resident had a Care Plan for refusing showers. However, the DON confirmed that there was no documentation that the Resident refused showers. The DON and this Surveyor reviewed Resident #126's physician orders, the DON confirmed that the Resident did not have active order for showers. This Surveyor expressed concern that without an order for a shower how would the staff know to offer a shower. The DON agreed and stated that he would have an order placed for showers.On 09/19/25 at approximately 11:15 AM the DON returned and reported to this Surveyor that he spoke with Resident #126 and stated that the Resident expressed that he/she wanted to have showers. The DON stated that he advised the Resident that he would make sure the Resident was offered an opportunity to have a shower. The DON further stated that the Resident now had an order for showers.

Based on medical record review and interview, it was determined that the facility failed to ensure that Advance Directives were discussed with residents and/or responsible representatives. This was for 1 (Resident #2) of 8 residents reviewed for Advance Directives.The findings include:Resident # 2's clinical record revealed that the resident was admitted to the facility in [DATE] and their most recent re-admission was in [DATE]. The resident's diagnoses include Anoxic Brain Damage and End Stage Renal Disease.On [DATE] at 3:22 PM a review of Resident #2's clinical record revealed a MOLST (Maryland Orders for Life-Sustaining Treatment) form. The MOLST, which was dated [DATE], revealed verbal consent by the resident's Responsible Representative for CPR in the event of cardiac and/or pulmonary arrest (CPR). The clinical record failed to reveal the presence of an Advance Directive or that the Advance Directive was discussed with the Resident and/or Responsible Representative.Further, a review of the resident's Social Services assessments dated [DATE] and [DATE], Section A #5 of Social Services Assessment and Documentation revealed that information was not provided to Resident and/or Responsible Representative on Advance Directive.On [DATE] at 12:26 PM during an interview, the Social Services Director (SSD) stated that Advance Directive, is discussed upon admission/readmission, and at care conferences and educational material is offered. Further, information regarding the status the resident's Advance Directive is documented under Section A #5 of Social Services Assessment and Documentation. The SSD reviewed Resident #2's clinical Record and confirmed the surveyor's findings.

Based on record reviews and interviews it was determined that the facility failed to ensure the Ombudsman was notified of transfers and discharges. This was found to be evident for 2 (Resident #88 & #232) out of 2 Residents reviewed for hospitalization during the recertification survey.The findings include: During a review of Resident #88's medical record conducted on 09/18/2025 at 8:18 AM it was discovered that the Resident experienced a medical emergency and was transferred to a local hospital on [DATE]. During a review of Resident #232's medical record conducted on 09/18/25 at 8:47 AM it was discovered that the Resident was transferred to a local hospital on [DATE]. During an interview conducted on 09/18/25 at approximately 9:00 AM, this Surveyor asked the Nursing Home Administrator (NHA) to provide the Ombudsman notification for transfers and discharges.On 09/18/25 at approximately 11:45 AM the Nursing Home Administrator (NHA) provided this Surveyor with a printout of an email dated 09/18/25 at 11:26 AM from the Social Service Director to the Ombudsman. A review of the email showed 8 attachments and a note that stated, Please see attached discharge transfer report from January 2025 to the present. During an interview, the NHA acknowledged that the notification to the Ombudsman was emailed after this Surveyor requested the notification. During an interview conducted on 09/18/25 at approximately 1:30 PM, the Social Service Director reported that he had not provided notification of transfers and discharges to the Ombudsman since March 2024.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately coded for residents. This was evident for 2 (Resident #123 and #168) out of 46 sampled residents reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a federally mandated comprehensive clinical assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. 1.On 09/19/2025 at 3:05 PM, a review of Resident #168's clinical record revealed the following physician order: Date 03/21/2025 for ADMIT to Hospice of the Chesapeake with a hospice diagnosis. Further review of Resident #168's clnical record showed that a Significant Change MDS assessment was completed on 03/31/25, and under section O, the resident was coded as receiving hospice care. However, a review of a subsequent MDS quarterly assessment dated [DATE] indicated that in section O, hospice care was marked as No. On 09/22/2025 at 10:19 AM an interview with MDS Coordinator #24 confirmed the MDS inaccuracy and stated that it was an oversight. MDS Coordinator #24 further stated that the hospice coding should have been marked as Yes for Resident #168 and that she would modify/correct the MDS quarterly assessment. 2. An ostomy is any type of surgically created opening of the gastrointestinal or genitourinary tract for discharge of body waste. During a review of medical records conducted on 09/22/25 at 11:42 AM it was revealed that the MDS assessment dated [DATE] for Resident #123 recorded that he/she had and Ostomy in Section H – Bladder and Bowel. The MDS Assessment had been signed off as completed on 09/04/25. During a continued review of medical records for Resident #123 it was discovered that he/she did not have an ostomy documented in his/her medical records. During an interview with the MDS Manager #24 on 09/22/25 at 2:01 PM she confirmed that the resident did not have an ostomy and it was inaccurately coded. The box should not have been checked showing that Resident #123 had an ostomy. During a medical record review for Resident #123 on 09/23/25 at 5:34 PM it was discovered the MDS Assessment had been corrected and no longer identified the resident as having an Ostomy.

Based on clinical record review and interviews, it was determined the facility failed to provide residents and/or responsible representatives with summaries of their Baseline Care Plans. This was evident for 2 (Resident #3 and #14) of 46 residents reviewed during the annual /recertification survey.The findings include:A Baseline Care Plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident and/or their responsible representative.Resident #3 was admitted to the facility in June 2025 with diagnoses including Chronic Respiratory Failure and Anoxic Brain and is ventilator dependent.On 09/18/25 at 10:55 AM the surveyor reviewed Resident #3' clinical record. The record failed to reveal any evidence that the resident's Baseline Care Plan was discussed with the Resident and/or Responsible Representative and a copy given to them.On 09/19/25 at 8:42 AM during an interview the Director of Social Services stated that Baseline Care Plans(BCPs) are developed within 48 hours of a resident's admission to the facility. The Care Team, which includes the Social Worker and Unit Manager, would discuss the BCPs with the Resident and/or Responsible Representative and a copy would be given to them.The Director of Social Services reviewed Resident #3's clinical resident's record and confirmed the surveyor's findings stating, there is no record to show that it was done. 2) Resident #14 was admitted to the facility in August of 2025 and was his own Responsible Party.On 09/18/2025 at 11:10 AM a review of the resident's clinical record failed to reveal any evidence that Resident #14's Baseline Care Plan was discussed with him/her and that a copy was given to him/her. 09/19/2025 at 8:42 AM during an interview the Director of Social Services reviewed Resident #14's clinical record and confirmed the surveyor's findings.

Based on observations, interviews, and medical record review it was determined that the facility failed to maintain water temperatures less than 120 degrees Fahrenheit (F) in residents' rooms and failed to have a system in place to monitor the temperature of the boiler that supplies hot water to resident rooms. The failure identified has the potential to affect all residents in the facility. Water temperatures exceeding 120 degrees Fahrenheit were identified in 8 out of 8 rooms (Rooms 418, 417, 457, 461, 111, 204, 301 and 541A). In addition, the facility failed to provide supervision and interventions to ensure the safety of resident #208 when served a hot beverage(tea) in his room that caused 2nd degree burns to the lower extremities. As a result of these findings, a state of immediate jeopardy was declared on 2/27/23 at 2:45 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 5:06 PM and it was not accepted. The facility submitted a second plan at 5:19 PM and it was accepted by the state agency at 5:30 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of F. An extended survey was completed on 2/28/23, 3/1/23 and 3/3/23. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The findings include: Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Temperature Time Required for a 3rd Degree Burn to Occur 155 F 68 C 1 sec 148 F 64 C 2 sec 140 F 60 C 5 sec 133 F 56 C 15 sec 127 F 52 C 1 min 124 F 51 C 3 min 120 F 48 C 5 min 100 F 37 C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. 1). The surveyor investigated a facility reported incident from 8/13/22 that Resident #191 in room [ROOM NUMBER] reported to facility staff that Staff #46 used hot water to wash him/her up that burned him/her. The Surveyor checked water temperatures with the Director of Maintenance on 2/27/23. The Director of Maintenance (DOM) with the Surveyor present checked the water temperature in room [ROOM NUMBER] at 9:35 AM and the water temperature was 156 degrees F with the facility thermometer. The DOM told the Surveyor he was going to get another thermometer. The DOM returned with another facility thermometer and rechecked the water temperature in room [ROOM NUMBER] at 9:40 AM and the water temperature was 163 degrees F. The DOM then obtained the following water temperatures with the facility thermometer: 1.room [ROOM NUMBER]-9:41 AM-133 degrees F 2. room [ROOM NUMBER]-9:44 AM-143 degrees F 3. room [ROOM NUMBER]-9:45 AM-145 degrees F During an interview with the DOM on 2/27/23 at 9:46 AM, the DOM stated water temperatures in resident rooms should be less than 120 degrees F. The Surveyor requested the DOM notify the Administrator about the findings of high-water temperatures. The Surveyor with another surveyor present checked additional resident rooms on all floors of the facility and obtained the following water temperatures on 2/27/23: 1.room [ROOM NUMBER]-9:52 AM-144 degrees F 2.room [ROOM NUMBER]-9:56 AM- 158 degrees F 3. room [ROOM NUMBER]-10:00 AM- 138 degrees F 4. room [ROOM NUMBER]A- 10:02 AM-154 degrees F The Surveyor returned to the conference room and called the Director of Nursing (DON) at 10:09 AM and asked to speak to the DON, Administrator and DOM in the conference room. The Surveyor reviewed the water temperatures obtained by the DOM and the Surveyors with the DOM, DON, and Administrator on 2/27/23 at 10:25 AM. The DOM was asked about the process for monitoring water temperatures and who was responsible. The DOM stated one person on the maintenance team depending who is here in the morning obtains water temperatures for 2 resident rooms on each unit daily. At that time the Administrator stated the plan now is to shut off the boiler that goes to resident rooms and call the contractor immediately. The DOM was asked if he keeps a log of the boiler temperatures and the DOM stated no. The 2 Surveyors then accompanied the Administrator, DON and DOM to the basement and boiler #3 that the DOM stated sends the hot water to resident rooms on 2/27/23 at 10:42 AM. The temperature gauge read 218 degrees F. The DOM stated the temperature gauge should read 190 on Boiler. The Surveyor again asked the DOM if he had any logs on water temperatures on boiler #3. The DOM stated no he did not have logs. After surveyor intervention, Interview with the Administrator on 2/27/23 at 10:48 AM confirmed boiler #3 has been shut off and the contractor has been called. Review of Residents ' medical records in the rooms identified revealed the Residents range from severely cognitively impaired to alert and oriented. Review of the most recent comprehensive medical assessments for residents living in the affected rooms revealed that two of eight residents could move independently in their rooms. One of those two mobile residents had a diagnosis of dementia (room [ROOM NUMBER]A). Six of eight residents were totally dependent on staff for bathing. As a result of these findings, a state of immediate jeopardy was declared on 2/27/23 at 2:45 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 5:06 PM and it was not accepted. The facility submitted a second plan at 5:19 PM and it was accepted by the state agency at 5:30 PM. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The provisions of the plan to remove the immediacy had a completion date of 3/2/23 and included the following: 1.Boiler was immediately turned off and contractor contacted to present to facility for same-day service. 2. All areas of building audited by Maintenance Director on 2/27/23 to ensure no further water temperatures were recorded out of acceptable range-120 degrees or less 3. Maintenance Director and Staff Development Coordinators were educated by Nursing Home Administrator (NHA) on acceptable temperature ranges for water in patient care areas (120 degrees or less), how to properly take and record temperatures in resident rooms/ care areas, how to take and record temperatures from Boiler servicing resident care areas (acceptable ranges per manufacturer guidelines), and how to use TELS system to communicate water temperatures found to be out of range. Education of all facility staff working the 3-11 shift on 2/27/23 was immediately performed by Staff Development Coordinators on acceptable temperature ranges for water and how to use the TELS system to communicate water temperatures found to be out of range. Staff Development Coordinators will ensure education of all facility staff will be completed by 3/2/23. Any staff member unable to be reached by 3/2/23 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 NHA, Director of Nursing, or Staff Development Coordinators weekly for a period of 3 months. 4. Maintenance technicians will continue to conduct daily audits of water temperatures in patient care areas and from Boiler to determine compliance with water temperatures remaining within acceptable range. In addition, validation audits will be performed by Asst. NHA, Staff Development Coordinators, and/or Maintenance Director accompanying the Maintenance Technician on temperature checks 3 times per week x 3 months to validate values. Findings will be reported by NHA at the monthly Quality Assurance Performance Improvement (QAPI) Meeting for a period of 3 months to monitor progress towards improvement and recommendations. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. 2). The BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. The test is usually administered by a social worker who asks a series of questions while noting the answers on the BIMS scorecard. Each question is scored according to a numeric value. The total BIMS score ranges between zero to fifteen points and is categorized into three cognitive groups: Intact, Moderate, and Severe. The objective of a BIMS assessment is not to diagnose cognitive illnesses like dementia or Alzheimer's but rather to assist facility staff with detecting early symptoms and the potential need for further evaluation. Record review on 03/09/2023 at 10:00 AM the surveyor review indicated that Resident #208 had a BIMS score of 15 on the Minimum Data Set (MDS) assessment dated [DATE]. Resident #208 required supervision; defined as oversight, encouragement or cueing in the eating section. Resident #208 has a documented medical history of; lack of coordination, muscle weakness (generalized), malignant neoplasm of vertebral column, unspecified abnormalities of gait and mobility and a history of cerebral infarction. Further review of the facility ' s investigation notes on 03/09/2023 at 2:00 PM revealed that Resident #208 asked the Geriatric Nursing Assistant (GNA) # 59 for a cup of tea after dinner. Further review of the record indicated that GNA# 59 went to the kitchen and retrieved a paper cup and filled the cup with hot water from the coffee/water machine located on a counter in the kitchen. The GNA made the tea and placed it on the resident's bedside table. According to the nurse's note dated 01/31/2023 at 9:58 AM, the Licensed Practical Nurse (LPN) #61 reported, During wound care the resident was noted with blisters to the right leg and right upper thigh. Upon assessment no other new skin issue was noted. Denies any pain or discomfort. Resident stated he/she mistakenly spilled hot tea to the right leg and right upper thigh. The wound physician #52 was made aware and visited the resident at bedside. A new medication order was given for Silvadene every shift. Resident #208 is the self-Responsible Party (RP). The sister of the resident was unable to be reached, a message was left for her to call the facility back. The resident remains in stable condition. On 03/09/2023 at 10:00 AM the surveyor reviewed Resident # 208's wound care medical record. It was revealed that on 01/31/2023, the resident had a 2nd degree burn with a ruptured blister on the resident's right posterior thigh and a second degree burn with an intact blister located on the right medial leg. During the surveyor's interview conducted on 03/09/2023 at approximately 10:45 AM, the Director of Nursing (DON) stated that the 7 AM - 3:00 PM wound care nurse (Staff # 53) assessed Resident #208 and identified second degree burns on the right thigh and right leg. The wound care nurse Staff # 53 immediately called the wound care physician (# 52) and the DON. The DON stated that she went to the resident's room and assessed the resident at bedside and initiated an incident report. The GNA (# 59) was suspended and later resigned. A plan of correction was created that consisted of: 1. Staff members who went against current procedures were reprimanded appropriately including GNA # 59. 2. In order to keep the Curtis Hot Water Boiler at the appropriate temperature, the setting will permanently be left on Holding. The machine was found to be set to boiling which produced hot water exceeding the safe temperature zone for hot beverages. 3. All staff members are allowed to retrieve their own beverages from the kitchen, they must sign a form indicating name, floor, position, and date prior to retrieving beverages. 4. To ensure that residents receive hot beverages at the correct temperature, staff will be required to sign for the hot beverage when requested in between meals. a. All hot beverages provided to residents must be in a designated handled cup with lid and tempted to ensure the resident's beverage will not exceed 145 degrees Fahrenheit upon receival. b. All staff members who retrieve a hot beverage from the kitchen for any resident must verify and sign that beverage was retrieved in the proper cup for delivery. The name of the resident, diet order/texture must be listed on the sign out form. A dietary staff member is required to sign for verification of appropriate beverage temp. 5. Carafes with hot water in the safe temperature zone may be held in the nourishment rooms for use in between mealtimes to assist the facility in meeting residents' dietary preferences. The surveyor interviewed staff member #58, Certified Dietary Manager, on 3/9/23 at 2PM.Staff # 58 showed this surveyor the coffee machine. He stated that when the kitchen staff turn on the coffee maker, it automatedly reaches a temperature of 168 degrees Fahrenheit (F). Staff # 58 stated that that temperature is too hot for a resident or anyone else to drink. The coffee is then poured into a designated handled cup and placed into a holding area where the temperature drops to 140-145 degrees Fahrenheit. At that point the coffee or hot water is ready to be taken to the residents. Staff # 58 stated he has temperature logs that are taken each day before food or hot drinks are served. He stated that with this incident, GNA # 59 came down to the kitchen and did not notify kitchen staff of what his/ her needs were and took water independently from the hot water dispenser without placing it in the holder to drop the temperature. The Director of Nursing and Certified Dietary Manager (#58) both stated this type of incident has never happened before. During an interview conducted on 03/09/2023 at 10:30 AM, the resident stated that he was reaching for something on the bedside tray table and mistakenly knocked the cup of hot tea onto himself which burned his right leg. The resident further stated that he continues to suffer from pain from the burns to his right leg and was currently in pain. On 3/9/2023 at 10:40 AM the surveyors told the RN Unit Manager (#60) that Resident #208 was in pain, and she replied that he gets pain meds before dialysis. Which is on Monday, Wednesday, and Friday (MWF). Oxycodone is administered every 4 hours before dialysis. The surveyors informed the Unit Manager (#60) and Licensed Practical Nurse (LPN) #61 that the resident was currently expressing pain due to his burns.

Based on observations, staff interviews and review of medical record documentation, the facility failed to 1. maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with confused and wandering residents. Surveyors repeatedly observed these incidents on 2 of 5 floors. This has the potential to impact all residents, 2. ensure only authorized staff maintain a safe and effective system for securing medications in designated carts. This was found to be evident for 1 out of 2 medication carts located on the second-floor nursing unit observed during a tour of the facility. 3. label medication bottles when opened, discard expired medications and maintain proper temperatures for medications requiring refrigeration. This was found evident in 4 of 10 medications carts and 1 of 3 medication storage units reviewed for medication storage on an annual survey. The Maryland Office of Health Care Quality (OHCQ) determined that concerns 1. met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 1:45 PM on 2/10/23. The findings include: 1a. During tour and observation of the third floor ventilator unit on 2/8/23 at 11:31 AM, surveyor observed an unlocked and unattended treatment cart. In the medication cart were multiple medicated resident creams, gauze pads and scissors. Licensed Practical Nurse (LPN) Staff #13 was interviewed on 2/8/23 at 11:34 AM stating the treatment cart was shared with her and the other units and was not aware that it was open. b. Surveyor proceeded down the hallway and noted that the door to the medication room was ajar, and not pulled shut and locked. In the room the medication refrigerator was also unlocked, the padlock was hanging to the side. Inside the refrigerator included: Latanoprost eye drops, Humalog, Epogen and Veltessa patches. LPN staff #13 was notified of the observations of the medication room. She stated that she has not been in there today and was not aware that it was unlocked, and again that it is shared with all the 3rd floor staff. c. On 2/9/23 upon entering the non-vent 3rd floor unit, where there are noted residents that wander and have varying behaviors including aggression, at 11:43 AM proceeding towards the 320 rooms, the surveyor observed an unattended maintenance cart in front of room [ROOM NUMBER]. On the cart there was an open Exacto knife and a screwdriver. Residents #252 and #119 were observed in the immediate vicinity. Record review on 2/10/23 at 8:20 AM regarding Resident # 252 revealed diagnosis including; cerebrovascular accident (stroke) and 15/15 on a Brief Interview of Mental Status (BIMS) Assessment on the 1/4/23 admission Minimum Data Set (MDS) assessment. However, a 1/3/23 dated psychogeriatric note and admission assessment noted that s/he does not appear to have any clear knowledge about medical or psychiatric medical issues or treatment plan. Regarding Resident #119, s/he was noted as ' rarely understood ' and in physician monthly assessments and answers ' yes/no secondary to aphasia ' . Per assessments in the electronic health record, Resident #119 is dependent on staff for activities of daily living and becomes frustrated and is care planned for behaviors including having verbal and physical and verbal altercations. Resident #119 was observed wheeling his/herself down the hall independently. At 11:45 AM RN staff # 18 walked past the maintenance cart towards the nursing station and did not address the items on the cart. At 11:50 AM maintenance staff #17 came out of room [ROOM NUMBER] where he was observed at the window doing repairs and grabbed blinds to replace in the room. At 11:54 AM staff #17 again exited the room and the surveyor reviewed concerns with staff #17 that the cart was unattended with residents around. He stated that he was just trying to make the room nice, however, acknowledged the safety hazard of the equipment in the hallway. d. Surveyor proceeded to tour the ventilator unit on unit 3. At 12:05 PM the medication room door was again observed ajar and not fully closed and the medication refrigerator padlock was observed off the door. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) was notified of all the observations from 2/8/23 and today on 2/9/23 at 12:15 PM. They (DON and NHA) said that they would look into the surveyors & #39; concerns. e. Tour of the facility and unit 3 on 2/10/23 at 6:42 AM, surveyor observed an unlocked and unattended treatment cart in front of room [ROOM NUMBER]. The Surveyor was able to go through and document all the medications in each drawer before staff # 18 from the day shift approached and asked if the surveyor needed assistance. Prior to approaching the surveyor, staff #18 was observed walking up and down the hall, checking on his residents and passing the unlocked cart and the surveyor 3 times. The Surveyor asked staff #18 where the night shift nursing staff was and he stated that he did not know. Surveyor asked for the DON at that time. The treatment cart contained nail clippers, sodium chloride flushes, multiple medicated creams for residents, intravenous fluid tubing and wound dressings. In addition, there were (3) tuberculin syringes, (1) insulin syringe and (2) 25-gauge safety syringes. The DON arrived on the unit and was notified by the surveyor of the repeated observations at 6:55 AM. She stated that she was in at 4:00 AM this morning doing training regarding our findings. f. On 2/10/23 at 8:11 AM, the surveyor observed a treatment cart unattended and unlocked on the 4th floor hallway with rooms #421-438. The surveyor observed no staff around the treatment cart. All 5 drawers were able to be opened. First drawer had a boxed of: Silver sulfadiazine cream, Permethrin cream triamcinolone 0.1%, the 2nd drawer had normal saline, the 3rd drawer had dressing supplies such as, kerlix, gauze, the 4th drawer had slipper, normal saline syringes, suture removal kit, the 5th had wound cleaner spray and heparin syringes. The surveyor conducted an interview at 8:13 AM with LPN staff #19. She stated that the treatment cart was named team 2 cart and she was responsible for the treatment cart. When asked if the treatment cart should be left open she stated, no but the cart is locked. The LPN was then able to open all the drawers. She pointed to the silver lock in the right upper drawer and said, if it is pushed in it is locked. The LPN was able to demonstrate opening the cart with a key, the lock protruded out, then engaging the lock in again and stated, now it is locked. After this, all 5 drawers could be opened. LPN, staff #19, stated this lock must not be working. The surveyor interviewed the 4th Floor Nurse Supervisor, Registered Nurse (RN) staff #20, on 2/10/23 at 8:18 AM, who walked to the treatment cart. RN# 20 was notified that the drawers to the cart were able to be opened when the lock was engaged. RN #20 demonstrated opening and locking the treatment cart and it locked. LPN #19 informed her when she did that it did not work. RN #20 then performed a locking and unlocking cart again and this time when the lock was engaged all 5 drawers were able to be opened. RN #20 attempted to unlock and lock again and again all drawers could be opened when lock was engaged. The RN #20 stated the cart should be locked when unattended and would notify maintenance that the cart was not locking correctly. She also said she would let management know. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy and the facility was verbally notified of this determination at 1:45 PM on 2/10/23. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 5:00 PM on 2/10/23, after 2 initial plans were submitted at 3:25 PM and 4:26 PM, respectively. The plan included the assurance no further maintenance carts, medication or treatment carts, doors and or refrigerators in the facility were left unattended or unlocked and reeducation of all licensed nurses, maintenance staff and certified medication aids regarding the expectation on securing medication and treatment carts, doors, and refrigerators. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The Immediate Jeopardy was removed on 2/15/23 after on-site confirmation of the completion of the facility's plan of removal. The facility plans of removal included the following: Education of all licensed nurses working on the 7-3 shift for 2/10/23 was immediately performed by the DON. Education of all licensed nurses will be completed by 2/15/23. Education will be validated by quizzes performed randomly by DON or staff development coordinators weekly for a period of 3 months. The DON, ADON, staff development coordinators and unit managers will conduct daily audits on all shifts for 3 months to determine compliance. All the findings will be reported monthly at the Quality Assurance Performance Improvement (QAPI) meeting for 3 months to monitor progress towards improvement and recommendations. 42783 44440 2a. On 2/22/23 at 9:36 AM, the surveyor reviewed the medication storage on the 3rd floor vent wing and the medication cart designated for this unit with Licensed Practical Nurse (LPN) Staff #68. The review revealed opened bottles of each of the medications listed, located in the second drawer of the medication cart; Melatonin 5mg, Loratadine 10mg, [NAME]-Vite, and Folic Acid 400mcg (Microgram). All the bottles were opened with no date written on them to indicate when the medication was first opened. These bottles were brought to the attention of Staff #68. On 2/22/23 at 10 AM, the surveyor reviewed the medication cart located on the 4th floor, dedicated to the team one hallway, with (LPN) Staff #69. The surveyor noted in the second drawer of the medication cart, a bottle of Lactulose 10mg/15mg had an open date indicating the bottle was opened on 2/14/23, however the expiration date on the bottle was labeled 2/9/23. It appeared the bottle was opened after the medication expired. The surveyor brought this to Staff #69 & #39's attention. On 2/22/23 at 10:59 AM, the surveyor reviewed the medication cart findings with the Director of Nursing (DON). The DON stated that it is her expectation that all medication should be labeled with the date they are opened. The Assistant Director of Nursing (ADON) was also present and explained it could be possible for the pharmacy to deliver a medication, the medication not be opened, the medication expire, and then be opened by the staff however, the staff should have checked the expiration date before opening. On 2/24/23 at 7:51 AM, the surveyor reviewed the medication storage cart designated to the 2nd floor Pavilion unit. The surveyor noted the sodium bicarbonate 325mg bottle, located in the second draw, had an expiration date of 1/23. Registered Nurse (RN) Staff #70 observed the date and indicated the date was alongside the lot number and wasn't sure if it was expired. On 2/24/23 at 8:29 AM, the surveyor showed the RN Manager Staff #27 the expired sodium bicarbonate 325mg bottle. Staff #27 states she would have to speak with the DON for guidance. On 2/24/23 at 8:30 AM, the surveyor reviewed the medication storage on the 3rd floor Pavilion and reviewed the dedicated medication cart for that unit with Licensed Practical Nurse (LPN) Staff #71 . The surveyor observed a docusate sodium 50mg(milligram)/5ml (milliliter) bottle with an expiration date of 10/2022. Staff #71 acknowledged the expired medication and stated he would get rid of it. On 2/27/23 at 8:50 AM, the surveyor reviewed the concern with the DON that staff were not confident identifying expiration date on medication bottles in which the lot number and expiration date were along the same line and that expired medications were found in medication carts. The surveyor reviewed the sample of the bottle with the DON. The DON stated an in-service would be needed for any staff unable to identify if a medication was expired. 2b) On 2/27/23 at 8 AM, the surveyor conducted a review of the 4th floor medication storage room with LPN Staff #19. Staff #19 unlocked the refrigerator and upon opening the door, the surveyor observed condensation on the back wall of the refrigerator. The thermometer in the refrigerator registered at 50 degrees Fahrenheit (F). The surveyor reviewed the temperature logbook which indicated it was 40 degrees Fahrenheit on 2/27/23. The surveyor informed Staff #19 of the findings. Staff #19 stated she would speak with the night nurse responsible for recording temperatures. On 2/27/23 at approximately 8:10 AM, the surveyor interviewed LPN staff #76. Staff #76 stated he last took the temperature at 4 AM and could not think of any reason the refrigerator would have been left open and was unsure of how the temperature was 10 degrees F different. On 2/27/23 at approximately 8:15 AM, the surveyor interviewed the covering floor manager LPN Staff #10. The surveyor informed Staff #10 of the refrigerator temperature at 8 AM. Staff #10 stated she would call maintenance to come and take a look. On 2/27/23 at 2:34 PM, the surveyor interviewed the Maintenance Director Staff #21. During the interview Staff #21 stated he was aware of the reported refrigerator issues and he had addressed the refrigerator issue. He stated that when he checked the refrigerator it was registering at 45 degrees F and he had to adjust the temperature. Staff #21 stated the refrigerator temperature should be 40 degrees F and he was planning on returning to check the temperature. The DON was present during this interview. On 2/27/23 at 2:34 PM, the surveyor interviewed the Maintenance Director Staff #21. During the interview Staff #21 stated he was aware of the reported refrigerator issues and he had addressed the refrigerator issue. He stated that when he checked the refrigerator it was registering at 45 degrees F and he had to adjust the temperature. Staff #21 stated the refrigerator temperature should be 40 degrees F and he was planning on returning to check the temperature. The DON was present during this interview. On 2/27/23 at 2:34 PM, the surveyor interviewed the Maintenance Director Staff #21. During the interview Staff #21 stated he was aware of the reported refrigerator issues and he had addressed the refrigerator issue. He stated that when he checked the refrigerator it was registering at 45 degrees F and he had to adjust the temperature. Staff #21 stated the refrigerator temperature should be 40 degrees F and he was planning on returning to check the temperature. The DON was present during this interview.

Based on review of MD 054, facility investigation documentation and the medical record, and staff interviews, it was determined that the facility staff failed to provide [CONDITION(S)] services for a resident (Resident # 19). This was evident for 1 of 7 residents reviewed for [CONDITION(S)] services during the survey.This incident resulted in actual harm to the resident. The resident was sent to the hospital via 911 for elevated blood pressure and change in mental status, and was admitted . A review of the facility's plan of correction implemented immediately after the facility gained knowledge of the incident, resulted in the deficiency being cited as an IJ past non-compliance. The date of compliance was 3/5/21. The findings include: [CONDITION(S)] is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. End-Stage [CONDITION(S)] ([CONDITION(S)]) is the stage of kidney impairment that appears irreversible and permanent, and requires a regular course of [CONDITION(S)] or kidney transplantation to maintain life. On 9/20/2021 a review of Resident #19's medical records revealed the Resident was admitted to the facility from the hospital on 2/13/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #19's hospital discharge summary dated 2/13/21 revealed the Resident was receiving [CONDITION(S)] services 3 days a week on Tuesdays, Thursdays and Saturdays and was recommended to continue [CONDITION(S)] at the facility. A review of the facility initial admission provider H&P e-signed by MD # 23 on 2/15/21 indicated End-stage [CONDITION(S)] - hemodialysis dependent. On 9/20/2021 a review of the Physician Active Orders revealed orders for [CONDITION(S)] 3x a week (TTHS), one time a day every Tue, Thu, Sat, with order date 2/13/21 and start date 2/16/21. On 9/21/21 a review of the progress notes revealed an admission note by nursing on 2/13/21 at 4:24 PM that indicated Patient is on [CONDITION(S)] the shunt is in the upper left arm. A review of the Treatment Administration Record (TAR) revealed treatment orders for [CONDITION(S)] 3x a week (TTHS). One time a day every Tue, Thu, Sat with start date 2/16/2021 at 9:00 AM. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/21, further review of Resident #19's records revealed that on 2/13/21, Resident #19's BUN was 45 mg/dL and his/her Creatinine was 5.2 mg/dL. After Resident #19 missed his/her [CONDITION(S)] session on 2/16/2021, labs drawn in the facility on 2/17/2021 revealed a BUN of 81 mg/dL, Creatinine of 9.15 mg/dL, and Potassium of 5 mmol/L. Further review of the progress notes revealed a Concurrent Review Note on 2/22/21 at 11:33 AM that indicated Resident #19 was transferred to the hospital via 911 due to elevated blood pressure and altered mental status. Resident was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/23/21 a review of Resident # 19's hospital record revealed at the time of readmission to the hospital on 2/22/21 the emergency room physician documented: Chief complaint noted Altered Mental Status 1. Plan: Change in mental status/metabolic [CONDITION(S)] likely due to uremia patient's creatinine is currently 15.6 from a baseline of 5.60 likely due to missed [CONDITION(S)]. Nephrology has been consulted. BUN (Blood Urea [MEDICATION(S)]) is also 151. Uremia is a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys. 2. End-stage [CONDITION(S)] Nephrology consulted, patient has altered mental status and [CONDITION(S)]. [CONDITION(S)] is a condition in which the potassium level in the blood is above normal. Having too much Potassium in the blood can be life-threatening. 3. [CONDITION(S)] likely due to missed [CONDITION(S)], patient is for emergency [CONDITION(S)], Recheck potassium after [CONDITION(S)], current potassium 7.9 with EKG changes. Normal Potassium level is 3.5 mmol/L to 5.0 mmol/L. BUN and Creatinine are blood laboratory tests that are used to evaluate kidney function. Normal BUN level is 8 mg/dL to 22 mg/dL and normal Creatinine level is 0.5 mg/dL to 1.30 mg/dL. Further review of the Resident's hospital record revealed the Resident had emergency [CONDITION(S)] on 2/22/2021. Nephrologist documented on 2/23/2021: It is not clear when the last [CONDITION(S)] performed. I called patient's son who thinks the [CONDITION(S)] was not done in rehab facility. I called the facility and I was told that charge nurse will call me Will provide HD 2/24 (I would hold off on HD 2/23 to avoid rapid drop in BUN resulting in [CONDITION(S)] disequilibrium). During an interview with the Director of Nursing (DON) on 9/21/21 at 1:35 PM, she could not confirm whether Resident # 19 had [CONDITION(S)] while at the facility. The DON stated that she could not pull up any records from [CONDITION(S)] and when she contacted the [CONDITION(S)] center, the staff told her they had no records on Resident #19. During an interview with Licensed Practical Nurse (LPN # 19) and in the presence of the Corporate Clinical Consultant (Staff # 4) on 9/21/21 at 2:00 PM, LPN # 19 stated that he took care of the Resident on 2/16/2021, 2/18/2021, and 2/20/2021, but could not recall if the Resident went to [CONDITION(S)] or not on those days. When asked what the process was for sending residents to [CONDITION(S)], LPN #19 stated that [CONDITION(S)] sends a schedule to the unit, and transport staff then comes to the unit to take the resident to [CONDITION(S)]. The nurse will also document in the progress notes when the resident left the unit for [CONDITION(S)] and when they returned. Surveyor reviewed progress notes written on 2/16/2021, 2/18/2021, and 2/20/2021 by nursing with both staff # 4 and LPN # 19, there was no documentation in the notes to show that Resident #19 had gone for [CONDITION(S)] on any of those days. When asked how the [CONDITION(S)] center knew that a resident or new admit required [CONDITION(S)], Staff # 4 stated that prior to admission, the admission office sends required documentation to the [CONDITION(S)] center for approval. Nursing staff notifies the [CONDITION(S)] center when the resident is admitted and they then put the resident on the [CONDITION(S)] schedule that is sent to the units. When asked if Resident # 19's name was on the [CONDITION(S)] schedule, LPN # 19 stated I do not recall anything about the resident. Interview with the Administrator on 9/22/2021 at 9:37 AM confirmed the Resident did not receive [CONDITION(S)] while a resident at the facility, and that this was discovered when the resident was sent to the hospital on 2/22/2021. Per the Administrator, a facility wide audit was done immediately and no other residents were found to have missed [CONDITION(S)]. When asked how Resident # 19 could miss all 3 [CONDITION(S)] sessions, the Administrator stated that they identified that Resident # 19 was never put on the [CONDITION(S)] schedule because the [CONDITION(S)] center staff did not receive the 24 hour report sent by the night supervisor that would have notified them that the resident was in the facility. The Administrator further stated that on 2/24/21 the facility developed a Plan of Correction (POC) and a QAPI plan. The facility was alleging compliance as of 3/5/2021. Immediate actions taken by the facility include: 1) Resident # 19 was transferred to the hospital related to a change in condition. MD and RP notified. 2) A one-time, 100 % audit was done on 2/24/21. No other residents were affected. 3) - Business office was assigned the responsibility to send the census to the vendors ([CONDITION(S)]). This in-service was completed on 2/24/21 by Corporate Clinical Consultant and the Director of Patient Accounts. - Additionally, Supervisors have been in-serviced by the Corporate Clinical Consultant and the Assistant Director of Nursing to include [CONDITION(S)] personnel when they send the 24-hour report. This in-service was completed on 2/24/21. - [CONDITION(S)] was also educated on 2/24/21 on pulling the reports from PCC [electronic health record] for list of residents. This education was completed by Corporate Clinical Consultant. - 100% education was done by Staff Development/Supervisor for all nurses for [CONDITION(S)] process. This education was completed on 3/5/2021. 4) - An audit will be done by the Corporate Clinical Consultant to check that Business Office sent the census to the vendors ([CONDITION(S)]). This audit will be done 3 times a week for 2 weeks from 2/24/21 and weekly thereafter for 4 weeks. - An audit will be done by the Corporate Clinical Consultant to cross check resident's active [CONDITION(S)] orders with USRC's [[CONDITION(S)] provider] weekly [CONDITION(S)] roster. This audit will be done on a weekly basis for a period of 8 weeks. Results of these audits will be reported to the QA Committee for a period of 8 weeks. The QA Committee will determine what, if any additional interventions are required at the end of the 8 weeks period. Responsible Person: Corporate Clinical Consultant Responsible Person for Monitoring: Licensed Nursing Home Administrator Date of Compliance: 3/5/2021. 5) The facility changed the [CONDITION(S)] Residents Process to include the following: A. Review admission packets thoroughly and identify [CONDITION(S)] days and last [CONDITION(S)] treatment. B. Ensure all [CONDITION(S)] orders are transcribed correctly in PCC to include [CONDITION(S)] site. C. Communicate with US Renal to confirm the resident is scheduled for his/her next [CONDITION(S)] treatment. D. Review transports sheets provided by US Renal. E. Cross-reference the [CONDITION(S)] Roster for your unit to confirm residents are receiving treatment. F. Nurses assigned to [CONDITION(S)] residents should confirm they are assessed and ready for treatment prior to transport. G. GNAs (Geriatric Nursing Assistants) should be made aware which residents receive [CONDITION(S)] treatments to make sure ADL care is provided and residents are ready for transport at the assigned times. H. Any changes (changes in condition, transfer out, refusals) should be reported to US Renal, unit manager, and nurse assigned as soon as possible. Appropriate documentation included in PCC. I. If the resident's [CONDITION(S)] treatment changes, please document in PCC and communicate to nurse assigned, Unit Manager, etc. J. Nurse should document appropriately on MAR and indicate any coding specific to the resident's care. The facility conducted a root cause analysis and developed an action plan for: Missed [CONDITION(S)]. The findings of the root cause analysis was: Miscommunication with [CONDITION(S)]. On 9/23/2021 at 10:43 AM the Administrator was asked and provided evidence that each measure identified in their action plan was completed with the date of completion. The action plan start date was 2/24/2021. The Goal: No resident should miss [CONDITION(S)]. The target completion date: 3/5//2021. Action Plan/ Audits: 1) Verify with Business Office that census is sent and HD got it. Target date: 4/30/202. Date completed 4/7/2021. 2) Education for Business office and Supervisors. Target date 3/5/2021. Date completed 2/24/2021. 3) Weekly audit of [CONDITION(S)] residents list versus PCC. Start date: 2/24/201. End Date 4/30/2021. 4) Business Office will send the census to HD (Vendors) and this will be audited 3 times a week for 2 weeks and weekly thereafter for 4 weeks. Start date 2/24/2021. End Date 4/7/2021. The Administrator provided the [CONDITION(S)] audits that were conducted as per the Action Plan. The Administrator indicated that the Action Plan and audit results were reviewed in monthly QAPI (Quality Assurance Performance Improvement) meetings until completion. Nursing staff who work various shifts were interviewed regarding the [CONDITION(S)] process. Staff confirmed receiving education regarding the [CONDITION(S)] process. The Business Office manager, Nursing Supervisors, and the [CONDITION(S)] manger interviewed, verbalized understanding of the [CONDITION(S)] process. On 9/23/21 it was determined the facility met minimum standards for plans of correction and the concern was, therefore, deemed past noncompliance.

Based on observation, staff interviews, interviews of residents and visitors, interview of the Ombudsman and interview of Emergency Medical Services (EMS) personnel it was determined the facility failed to take appropriate action to ensure clinical interventions were initiated and implemented to monitor residents for heat related illness and failed to promptly initiate clinical interventions to prevent dehydration of residents when the facility's air conditioning unit that supplies cool air to residents' rooms failed during predicted extreme outdoor temperatures. Resident #4 was affected by the deficient practice. The following room numbers exceeded temperatures of 81 degrees Fahrenheit during observation on 7/21/17 between 6:30 p.m. through 9:15 p.m.: 223, 258, 259, 321, 322, 323, 332, 333, 334, 335, 344, 346, 348, 350, 351, 352, 354, 357, 358, 404, 412, 415, 417, 418, 440, 446, 448, 449, 454, 452, 454, 453, 452, 522, 523, 545, 558 exceeded temperatures of 85 degrees Fahrenheit. On 7/24/17 at 4:00 P.M. the nursing home administrator was advised that it was determined a condition of immediate jeopardy existed beginning 7/20/17 at 10:00 A.M. placing residents at risk for heat related illness, dehydration and death due to the facility's failure to take prompt and appropriate action when the potential existed for extreme room temperatures when the air conditioning unit to residents' rooms failed. The Office of Health Care Quality remained onsite until immediate jeopardy was abated on 7/24/17 at 8:30 P.M. The findings include: Interview of the Ombudsman on 7/22/17 at 1:00 P.M. revealed that on Thursday morning (7/20/17) at 3:00 A.M. a resident of the facility left a message that the building was hot as hell. The Ombudsman visited the building at approximately 11:30 A.M. through 4:00 P.M. The Ombudsman confirmed that the building was hot during that time. Residents and visitors complained to the Ombudsman in regard to the hot temperatures in the building. Interview of the Assistant Administrator on 7/24/17 at 1:45 P.M. revealed that he became aware that there was a problem with the air conditioning in residents' rooms at approximately 10:00 A.M. on 7/20/17. He stated the Director of Nursing was made aware and he started contacting air conditioning service vendors. During a tour of the facility on 7/21/17 between 11:45 A.M. and 12:00 P.M. multiple patients' rooms were noted to be warm. Residents and visitors complained to the surveyors that rooms were warm. Multiple residents on the 4th floor were noted to be without water pitchers at the bedside. Observation and medical record review of 4 tube fed residents on the 3rd floor (Resident #8, Resident #9, Resident #10 and Resident #11) that are dependent on facility staff for nutrition and hydration, did not have physician's orders [REDACTED]. At that time, the surveyors determined that there had been no plan initiated to monitor residents for heat related complications, including monitoring residents' vital signs, and there was not a process to ensure that residents were given additional fluids to prevent dehydration. At that time, the surveyors met with the nursing home administrator and the director of nursing and requested the facility's plan going forward to ensure that residents were monitored for heat related problems, as well as, interventions that would be put into place to ensure residents' hydration would be increased. Review of the facility's temperature logs revealed that on 7/20/17 at 10:00 A.M. through 7/21/17 at 5:00 P.M. the temperatures were recorded at or below 83 degrees Fahrenheit. On 7/21/17 at 6:15 P.M. the surveyor obtained the facility's digital thermometer and calibrated the thermometer to ensure accuracy. The surveyor toured the facility at 6:30 P.M. and checked temperatures of 11 rooms on the 3rd floor (room numbers: 323, 333, 334, 335, 344, 344, 346, 348, 350, 351, 352, 354) and 4 rooms on the 4th floor (room numbers: 440, 448, 454, 542). The room temperatures ranged from 86F to 95F. The Nursing Home Administrator was notified of the findings. Interview of the Director of Nursing on 7/21/17, after the 6:15 P.M. tour of the facility, revealed interventions had been initiated to monitor residents' vital signs every 4 hours starting at 6:00 P.M. On 7/21/17 at 7:30 P.M. the surveyor toured the facility and checked temperatures of 5 rooms on the 3rd floor (room numbers: 321, 322, 332, 357, 358), 6 rooms on the 4th floor (room numbers: 446, 448, 449, 452, 453, 454); and, 4 rooms on the 5th floor (room numbers 522, 523, 545, 558). The room temperatures ranged from 85F degrees to 91F. On 7/21/17 at 8:45 P.M., the surveyor observed delivery of portable cooling units to the facility. (The Nursing Home Administrator had contacted the vendor on 7/21/17 at 3:13 P.M. to make arrangements to obtain the portable cooling units). On 7/21/17 at 9:15 P.M. the Chief Executive Officer (CEO) questioned the accuracy of the room temperatures the surveyor had obtained at 6:30 P.M. and 7:30 P.M. The CEO accompanied the surveyor to 5 rooms on the 4th floor (room numbers: 404, 412, 415, 417, 418). The temperatures ranged from 83 degrees in 1 room to 93 degrees in 2 rooms. Although the facility was aware that the air conditioning unit that provides cool air to residents' rooms was not operational as early as 7/20/17 at 10:00 A.M., it was not until more than 24 hours later, and after the intervention of the Office of Health Care Quality and Emergency Medical Services (EMS) personnel, that action was taken to obtain portable cooling units, monitor residents' vital signs to alert staff of any heat related complications and increase hydration to prevent dehydration. The failure to initiate and implement clinical interventions related to prolonged exposure to high temperatures can lead to heatstroke which occurs when the body overheats. Heatstroke requires emergency treatment and if left untreated, can lead to damage to the brain, heart, kidneys and muscles. The longer treatment is delayed can increase the risk of serious complications, including death. Symptoms to look for in heatstroke include a high body temperature, altered mental status, alteration in sweating, nausea and vomiting, flushed skin, rapid and shallow breathing, elevated heart rate and headache. Additional findings include: Resident #4 has [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 7/21/17 and 7/24/17. The hospital medical record was provided by the admitting hospital on [DATE]. Medical record review revealed that on 7/21/17 the resident was transferred to the hospital after the physician assessed the resident with oral foaming, decreased responsiveness, fever and rigidity. Review of the hospital medical record revealed that Resident #4 arrived at the hospital on [DATE] at 1:01 P.M. The resident was admitted with [MEDICAL CONDITION], high fever and [MEDICAL CONDITION] for which cardioversion was done. The resident's tympanic temperature was elevated at 41.1 degrees Celsius (105.98 degrees Fahrenheit). The resident's respiratory rate was elevated at 26 breaths per minutes, oxygen saturation was low at 77%, heart rate was elevated at 161 beats per minute and blood pressure was low at 73/39. The resident was intubated in the emergency department to assist with breathing. Resident #4 was subsequently admitted to the hospital intensive care unit with [DIAGNOSES REDACTED]. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted on 7/24/17 at 8:30 P.M. while surveyors remained onsite. The plan included: - The Air Conditioning unit was repaired and functional on 7-21-17. Resident rooms were all checked and were in compliance on 7-22-17. - All residents have the potential to be impacted. Air Conditioning has been repaired and restored. This was completed on 7/22/17. - Administrative Leadership (Administrator, Assistant Admin, Director of Nursing, Assistant Director of Nursing and all department managers) and Maintenance staff have been educated on the facility's policy and procedure during a heat event (Heat Stroke Prevention Plan) by the facility Administrator on July 24, 2017. - The facility will do daily temperature monitoring checks of at least 3 rooms on each resident floor for a period of three months. This monitoring will be done by the Administrator or his designee. Any temperatures outside of the regulatory range of 71 to 81 degrees will be corrected immediately. - Results of these audits will be reported to the QA (Quality Assurance) Committee for a period of 3 months the QA Committee will determine what, if any additional interventions are required at the end of the three-month period. - Additionally, the entire facility staff will be in-serviced on the Heat Stroke Prevention Plan by July 26, 2017. Staff will check temperature of 3 rooms per floor per shift until facility wide in-service has been completed to ensure compliance and building is within regulations. Responsible Person for Implementation: Maintenance Director Responsible Person for Monitoring: Administrator Date of Compliance: 7/24/2017

Based on medical record review and staff interview it was determined the facility failed to appropriately manage a resident with a pigtail catheter in the pleural space. This was evident for 1 of 8 sampled residents selected for review. Resident #718 was affected by the deficient practice. Resident #718 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission to the facility, the resident had a thoracentesis with right side pigtail catheter placement for drainage of pleural fluid. A pleural effusion is a collection of excess fluid between the parietal and visceral pleural layers of the lung. A pigtail catheter is a flexible tube, passed through a body channel, such as the pleural layers, for the withdrawal of fluids from a body cavity. Review of the hospital transfer summary revealed that the Pulmonologist was consulted and evaluated the resident and recommended the pigtail catheter be continued until the drainage of pleural fluid is less than 150 cc per day. Review of the physician's admission orders [REDACTED]. The order was then discontinued on 4/28/17. Medical record review on 5/31/17 revealed that the resident was seen and examined by the attending physician on 5/1/17. Included in the physician's plan, was to monitor the resident's pleural output on a daily basis in order to ensure the resident's output was not increasing. The attending physician further noted that the resident would follow-up with the Pulmonologist. On 5/1/17 the attending physician gave an order to flush the pigtail catheter with 10 cc of normal saline every shift to maintain patency. The physician failed to ensure there was an order to monitor the resident's pleural drainage. The physician further noted that the resident would follow up with the Pulmonologist in order to see if they will perform a talc pleurodesis versus a permanent catheter. Medical record review on 5/31/17 revealed that on 5/22/17, more than three weeks after the resident was admitted to the facility, the physician gave an order to measure and document the amount and color of pleural fluid drainage every shift. Medical record review on 5/31/17 revealed between 4/28/17 through 5/22/17, there is no documented evidence that the facility staff was monitoring the resident's pleural fluid output every shift. The resident was seen and examined by the physician on 5/8/17 and 5/15/17. The attending physician documented that the resident continued to put out a significant amount of straw-colored pleural fluid drainage. There is no documented evidence that the physician consulted with nursing staff regarding the nursing staff's failure to measure the resident's pleural fluid drainage every shift. On 5/31/17 at 2:00 P.M. the Licensed Practical Nurse (LPN), Staff #1, that was caring for the resident was interviewed regarding the care of Resident #718's pigtail catheter. The surveyor asked Staff #1 to describe how he/she cared for the resident's pigtail catheter. Staff #1 explained that he/she monitored the pigtail catheter drain output, ensured the connections were secured with tape and the pigtail catheter dressing was intact. When asked if the tubing had ever been found disconnected, Staff #1 stated that the tubing had been found disconnected the day before on 5/30/17 with the tubing connected to the drainage receptacle found on the floor. Staff #1 stated that he/she reconnected the tubing to the pigtail catheter and secured the connection with tape. Observation of the drainage receptacle on 5/31/17 at 2:00 P.M. revealed that there was 650 cc of drainage in the receptacle. Review of the treatment administration record (TAR) on 5/31/17 at 2:00 P.M. revealed that Staff #1 had documented that the resident's pigtail catheter had drained 650 cc of pleural fluid on the 7:00 AM - 3:30 PM shift 5/28/17, 5/29/17, 5/30/17 and 5/31/17. Further interview of Staff #1 on 5/31/17 revealed that the drainage amount had remained at 650 cc 5/28/17 - 5/31/17 and that there had actually been no drainage from the resident's pigtail catheter on the 7:00 AM - 3:30 PM shift 5/28/17 - 5/31/17. Further review of the TAR on 5/31/17 at 2:00 P.M. revealed that Staff #1 had documented that the resident's pigtail catheter had been flushed with 10 cc of normal saline on the 7:00 AM - 3:30 PM shift 5/23/17 through 5/26/17 and 5/29/17 through 5/31/17. Staff #1 was asked by the surveyor the procedure for flushing the resident's pigtail catheter. Staff #1 was unable to describe the procedure for flushing the resident's pigtail catheter and further advised the surveyor that he/she had not flushed the resident's pigtail catheter. Staff #1 was asked if he/she had been educated on the care of the resident's pigtail catheter to which he/she replied he/she had not. After surveyor intervention, the Unit Manager, Staff #2, explained the procedure for flushing the resident's pigtail catheter drain, at the resident's bedside, in the presence of the surveyor. On 5/31/17 at 3:30 P.M. the resident was seen and examined at the bedside by the attending physician. Resident #718 gave the surveyor permission to observe. The attending physician removed the resident's pigtail catheter dressing. The dressing was saturated with a moderate amount of drainage which had soaked through to the bed linens. Interview of the physician revealed that nursing should be monitoring the amount of drainage from the resident's pigtail catheter every shift. Observation of the resident on 6/2/17 at 2:00 P.M. revealed that the pigtail catheter drainage receptacle was lying face down on the floor. At 2:40 P.M. the nurse caring for the resident, Staff #3, was interviewed regarding the care he/she provided to the resident. The nurse stated that he/she had not received instruction from the Unit Manager, Staff #2, related to the care of Resident #718's pigtail catheter. When Staff #3 was asked how much drainage the pigtail catheter had drained during the shift, he/she stated about 500 and some. When Staff #3 was asked how much drainage was in the drainage receptacle at the beginning of the shift he/she stated he/she had not checked the amount of drainage at the beginning of the shift. Therefore, Staff #3 would not be able to accurately determine the amount of pleural drainage for the shift. Review of the TAR on 6/2/17 at 2:00 P.M., however, revealed that Staff #3 had documented that the pleural drainage was 650 cc for the shift. Further review of the TAR on 6/2/17 at 2:40 P.M. revealed that Staff #3 had documented that the resident's pigtail catheter had been flushed with 10 cc of normal saline. Staff #3 was asked by the surveyor the procedure for flushing the resident's pigtail catheter. Staff #3 was unable to describe the procedure for flushing the resident's pigtail catheter and further advised the surveyor that he/she was not sure how to flush the resident's pigtail catheter. The failure of the facility staff to implement basic infection control and nursing practices in the care of the pigtail catheter placed the resident at risk for complications, including but not limited to pneumonia, empyema,[MEDICAL CONDITION], and death. Had the pleural drainage been less than 150 cc per day, the failure to monitor the drainage delayed removal of the pigtail catheter, thus increasing the above risks. If the pleural drainage had been more than 150 cc per day, the failure to monitor the drainage placed the resident at risk for complications, including but not limited to dehydration, electrolyte abnormalities, and death. As of 6/2/17, the facility had failed to arrange for the resident to follow up with the Pulmonologist. The facility's failure to appropriately manage Resident #718's pigtail catheter in the pleural space resulted in determination by the [NAME]land Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:08 PM on 6/2/17. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 7:00 PM on 6/2/17 while surveyors remained onsite. The plan included: 1. Resident #718 still resides at the facility. Resident has been reviewed by his attending physician, the Medical Director and the Infectious Disease Doctor to ensure the resident is still clinically stable and acceptable for a nursing facility. Resident's labs came back today and all were normal. Nursing staff are now currently monitoring the residents output per shift correctly after being educated and flushing the line 10cc per shift per physician order. 2. Any residents with a pigtail catheter have the potential to be effected. No other current residents in the facility currently have a pigtail catheter. 3. All nursing staff prior to their next shift will be in-serviced by Director of Nursing or designee on proper care for a pigtail catheter and on the importance of proper and accurate documentation. Before the in-service is completed the staff's knowledge is tested via a competency assessment specific to the pigtail catheter. This evaluation consists of numerous questions that were covered during the in-service. Staff member #3 has been terminated and will be reported to the Board of Nursing. 4. The Director of Nursing or designee will audit all residents with pigtail catheter 3x per week to ensure proper care, output, infection control and documentation is done accordingly to the physicians orders. Results of this audit will be reported to the QA (Quality Assurance) Committee and Medical Director for a period of 3 months. The QA committee will determine what, if any additional interventions are required at the end of the three-month period.

Based on medical record review and staff interview it was determined the facility failed to appropriately manage a resident with a pigtail catheter in the pleural space. This was evident for 1 of 8 sampled residents selected for review. Resident #718 was affected by the deficient practice. Resident #718 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission to the facility, the resident had a thoracentesis with right side pigtail catheter placement for drainage of pleural fluid. A pleural effusion is a collection of excess fluid between the parietal and visceral pleural layers of the lung. A pigtail catheter is a flexible tube, passed through a body channel, such as the pleural layers, for the withdrawal of fluids from a body cavity. Review of the hospital transfer summary revealed that the Pulmonologist was consulted and evaluated the resident and recommended the pigtail catheter be continued until the drainage of pleural fluid is less than 150 cc per day. Review of the physician's admission orders [REDACTED]. The order was then discontinued on 4/28/17. Medical record review on 5/31/17 revealed that the resident was seen and examined by the attending physician on 5/1/17. Included in the physician's plan, was to monitor the resident's pleural output on a daily basis in order to ensure the resident's output was not increasing. The attending physician further noted that the resident would follow-up with the Pulmonologist. On 5/1/17 the attending physician gave an order to flush the pigtail catheter with 10 cc of normal saline every shift to maintain patency. The physician failed to ensure there was an order to monitor the resident's pleural drainage. The physician further noted that the resident would follow up with the Pulmonologist in order to see if they will perform a talc pleurodesis versus a permanent catheter. Medical record review on 5/31/17 revealed that on 5/22/17, more than three weeks after the resident was admitted to the facility, the physician gave an order to measure and document the amount and color of pleural fluid drainage every shift. Medical record review on 5/31/17 revealed between 4/28/17 through 5/22/17, there is no documented evidence that the facility staff was monitoring the resident's pleural fluid output every shift. The resident was seen and examined by the physician on 5/8/17 and 5/15/17. The attending physician documented that the resident continued to put out a significant amount of straw-colored pleural fluid drainage. There is no documented evidence that the physician consulted with nursing staff regarding the nursing staff's failure to measure the resident's pleural fluid drainage every shift. On 5/31/17 at 2:00 P.M. the Licensed Practical Nurse (LPN), Staff #1, that was caring for the resident was interviewed regarding the care of Resident #718's pigtail catheter. The surveyor asked Staff #1 to describe how he/she cared for the resident's pigtail catheter. Staff #1 explained that he/she monitored the pigtail catheter drain output, ensured the connections were secured with tape and the pigtail catheter dressing was intact. When asked if the tubing had ever been found disconnected, Staff #1 stated that the tubing had been found disconnected the day before on 5/30/17 with the tubing connected to the drainage receptacle found on the floor. Staff #1 stated that he/she reconnected the tubing to the pigtail catheter and secured the connection with tape. Observation of the drainage receptacle on 5/31/17 at 2:00 P.M. revealed that there was 650 cc of drainage in the receptacle. Review of the treatment administration record (TAR) on 5/31/17 at 2:00 P.M. revealed that Staff #1 had documented that the resident's pigtail catheter had drained 650 cc of pleural fluid on the 7:00 AM - 3:30 PM shift 5/28/17, 5/29/17, 5/30/17 and 5/31/17. Further interview of Staff #1 on 5/31/17 revealed that the drainage amount had remained at 650 cc 5/28/17 - 5/31/17 and that there had actually been no drainage from the resident's pigtail catheter on the 7:00 AM - 3:30 PM shift 5/28/17 - 5/31/17. Further review of the TAR on 5/31/17 at 2:00 P.M. revealed that Staff #1 had documented that the resident's pigtail catheter had been flushed with 10 cc of normal saline on the 7:00 AM - 3:30 PM shift 5/23/17 through 5/26/17 and 5/29/17 through 5/31/17. Staff #1 was asked by the surveyor the procedure for flushing the resident's pigtail catheter. Staff #1 was unable to describe the procedure for flushing the resident's pigtail catheter and further advised the surveyor that he/she had not flushed the resident's pigtail catheter. Staff #1 was asked if he/she had been educated on the care of the resident's pigtail catheter to which he/she replied he/she had not. After surveyor intervention, the Unit Manager, Staff #2, explained the procedure for flushing the resident's pigtail catheter drain, at the resident's bedside, in the presence of the surveyor. On 5/31/17 at 3:30 P.M. the resident was seen and examined at the bedside by the attending physician. Resident #718 gave the surveyor permission to observe. The attending physician removed the resident's pigtail catheter dressing. The dressing was saturated with a moderate amount of drainage which had soaked through to the bed linens. Interview of the physician revealed that nursing should be monitoring the amount of drainage from the resident's pigtail catheter every shift. Observation of the resident on 6/2/17 at 2:00 P.M. revealed that the pigtail catheter drainage receptacle was lying face down on the floor. At 2:40 P.M. the nurse caring for the resident, Staff #3, was interviewed regarding the care he/she provided to the resident. The nurse stated that he/she had not received instruction from the Unit Manager, Staff #2, related to the care of Resident #718's pigtail catheter. When Staff #3 was asked how much drainage the pigtail catheter had drained during the shift, he/she stated about 500 and some. When Staff #3 was asked how much drainage was in the drainage receptacle at the beginning of the shift he/she stated he/she had not checked the amount of drainage at the beginning of the shift. Therefore, Staff #3 would not be able to accurately determine the amount of pleural drainage for the shift. Review of the TAR on 6/2/17 at 2:00 P.M., however, revealed that Staff #3 had documented that the pleural drainage was 650 cc for the shift. Further review of the TAR on 6/2/17 at 2:40 P.M. revealed that Staff #3 had documented that the resident's pigtail catheter had been flushed with 10 cc of normal saline. Staff #3 was asked by the surveyor the procedure for flushing the resident's pigtail catheter. Staff #3 was unable to describe the procedure for flushing the resident's pigtail catheter and further advised the surveyor that he/she was not sure how to flush the resident's pigtail catheter. The failure of the facility staff to implement basic infection control and nursing practices in the care of the pigtail catheter placed the resident at risk for complications, including but not limited to pneumonia, empyema,[MEDICAL CONDITION], and death. Had the pleural drainage been less than 150 cc per day, the failure to monitor the drainage delayed removal of the pigtail catheter, thus increasing the above risks. If the pleural drainage had been more than 150 cc per day, the failure to monitor the drainage placed the resident at risk for complications, including but not limited to dehydration, electrolyte abnormalities, and death. As of 6/2/17, the facility had failed to arrange for the resident to follow up with the Pulmonologist. The facility's failure to appropriately manage Resident #718's pigtail catheter in the pleural space resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:08 PM on 6/2/17. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 7:00 PM on 6/2/17 while surveyors remained onsite. The plan included: 1. Resident #718 still resides at the facility. Resident has been reviewed by his attending physician, the Medical Director and the Infectious Disease Doctor to ensure the resident is still clinically stable and acceptable for a nursing facility. Resident's labs came back today and all were normal. Nursing staff are now currently monitoring the residents output per shift correctly after being educated and flushing the line 10cc per shift per physician order. 2. Any residents with a pigtail catheter have the potential to be effected. No other current residents in the facility currently have a pigtail catheter. 3. All nursing staff prior to their next shift will be in-serviced by Director of Nursing or designee on proper care for a pigtail catheter and on the importance of proper and accurate documentation. Before the in-service is completed the staff's knowledge is tested via a competency assessment specific to the pigtail catheter. This evaluation consists of numerous questions that were covered during the in-service. Staff member #3 has been terminated and will be reported to the Board of Nursing. 4. The Director of Nursing or designee will audit all residents with pigtail catheter 3x per week to ensure proper care, output, infection control and documentation is done accordingly to the physicians orders. Results of this audit will be reported to the QA (Quality Assurance) Committee and Medical Director for a period of 3 months. The QA committee will determine what, if any additional interventions are required at the end of the three-month period.

Based on family and staff interviews and review of medical records and other pertinent documentation, it was determined the facility (SNF/NF #3) violated resident rights when the facility failed to implement a safe and effective system to evaluate resident needs and ensure that accepting any given resident was safe. The facility admitted residents with 1. no evidence of consent, 2. insufficient evidence of communication between facilities prior to transfer, 3. insufficient evidence of clinical reviews of resident needs prior to admission, and 4. in those cases where the resident did not have capacity, there was no evidence of notice to the responsible party, for the admission. With no admission contract signed at or before admission, the facility had no evidence to support the resident and/or responsible parties consented to receive any treatment in the facility. This concern was evident for 15 of 29 residents (#506, #251, #196, #28, #102, #502, #408, #85, #505, #81, #152, #217, #345, #312 and #151) reviewed for admission practices. The egregious rights violations associated with noncompliant admission practices resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 3:00 PM on [DATE]. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 7:21 PM on [DATE] while surveyors remained onsite. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of E level for the remaining residents. The findings include: 1. Resident #506 was discharged from a sister skilled nursing facility (SNF/NF #1) on [DATE] to another skilled nursing facility (SNF/NF #2). With no consent and no evidence of any clinical review, Resident #506 was diverted from SNF/NF #2 to this facility (SNF/NF #3) where he/she was accepted for admission. 1a. Medical record review in SNF/NF #1 revealed that the social services assistant (SSA) #1 had completed a discharge checklist where he/she indicated that he/she verified in the record that Resident #506 had been certified as lacking capacity. The discharge planning checklist indicated that Resident #506 was to be discharged from the sending facility (SNF/NF #1) and that the responsible party neither participated in, nor consented to, the discharge from SNF/NF/NF #1. In the discharge checklist item that questioned if the responsible party (RP) did not consent, if no, who consented? The staff documented, 30 Day Discharge. Review of the sending facility (SNF/NF #1) record revealed that when Resident #506's Medical Orders for Life Sustaining Treatment (MOLST) were executed, consistent with the discharge checklist documentation, they were executed by his/her surrogate on [DATE] as she did not have capacity. 1b. In interview on [DATE] at 9:50 AM, SNF/NF #2 social services staff indicated that they had received a request to accept Resident #506 for transfer from the sending facility (SNF/NF #1). SNF/NF #2 received and reviewed paperwork from the sending facility and then reported back that they would accept Resident #506. In interview on [DATE] at 10:40 AM, the Director of Nursing (DON) at SNF/NF #2 reported that she then contacted the responsible party and he/she was irate and the RP stated that he/she did not give consent to move Resident #506. Social service staff at SNF/NF #2 reported in interview at 10:40 AM on [DATE], that SNF/NF #2 staff then notified the sending facility (SNF/NF #1) that they could not accept Resident #506 for admission without consent. SNF/NF #2 social services staff reported that Social Services Assistant (SSA) #1 and another employee (both from the SNF/NF #1) brought Resident #506 anyway to SNF/NF #2 and still wanted to leave him/her. The social service staff at SNF/NF #2 stated that she told SSA #1 that there was no consent for this transfer and again declined to accept the transfer of Resident #506. In interview at SNF/NF #1 on [DATE] at 9:00 AM, SSA #1 reported that she did remember taking Resident #506 from SNF/NF #1 to SNF/NF #2 before bringing Resident #506 to this sister-facility (SNF/NF #3). She stated that SNF/NF #2 was supposed to take the resident but when they got there, SNF/NF #2 wouldn't take her/him because they didn't have the paperwork. SSA #1 stated that after social service staff at SNF/NF #2 said they weren't going to accept the transfer, the van driver called back to SNF/NF #1 and was then given instructions to divert Resident #506's transfer to this sister facility location (SNF/NF #3). 1c. SNF/NF #1 and SNF/NF #3 are sister facilities. Medical record review and staff interviews revealed that this facility (SNF/NF #3) accepted the admission of Resident #506 on [DATE] after the resident was declined admission at SNF/NF #2. In an interview conducted with the SNF/NF #3 Nursing Home Administrator (NHA) on [DATE] at 1:50 P.M., he indicated that SNF/NF #3 frequently accepts residents based on telephone communications. He further reported to the surveyor that for Resident #506, there was no documentation exchanged between SNF/NF #1 and SNF/NF #3 prior to accepting Resident #506 for admission. Additionally, per information provided by the Nursing Home Administrator on [DATE], the facility failed to execute an admissions contract prior to or at the time Resident #506 was admitted to the facility. The OHCQ determined that accepting an incapacitated resident who was actually diverted from another nursing home's parking lot, with no consent, no notification to the responsible party and no admission agreement, and for whom the Administrator stated that they had no documentation of any clinical review prior to acceptance, evidenced an admission systems failure that endangered resident safety and constituted Immediate Jeopardy. After notifying SNF/NF #3 of the Immediate Jeopardy at 3:00 PM on [DATE], the SNF/NF #3 facility then produced documentation that the Administrator had before stated did not exist. A single page form was provided that indicated that a clinical packet had been attached to an email communication sent somewhere on [DATE], but the single page did not specify where though it noted an email address. The facility did not provide the surveyor copies of the clinical packet or the email. The single page form with a [DATE] date, also inaccurately stated, patient can come to us today. Family has agreed. We should receive patient today. However, the family had not agreed and the patient was not sent directly to this facility (SNF/NF #3) on [DATE]. The patient was actually sent to SNF/NF #2 the following day and was then diverted to this facility (SNF/NF #3) from SNF/NF #2 on [DATE]. With no evidence that SNF/NF #3 had received and reviewed documentation about Resident #506's certification status related to capacity to make decisions, review of the resident's medical record revealed [REDACTED].#3 on [DATE] indicating that Resident #506 had capacity to make decisions. No corresponding physician progress notes [REDACTED]. At the time of acceptance, Resident #506 did not have capacity and facilities must have effective communication systems in place to obtain this type of critical clinical information before acceptance. However, the record revealed that the facility (SNF/NF #3) accepted the resident without capacity first, with no notification to the responsible party (RP), as well as, no consent from the RP, and then certified that the resident had capacity. (There is no evidence that the resident's capacity was evaluated by SNF/NF#3's physician prior to arrival). Although ,[DATE] residents reviewed during the survey did not have signed admission agreements, in interview on [DATE], the SNF/NF #3 Nursing Home Administrator (NHA) reported that the agreement for Resident #506 was not signed because the Resident refused to sign without his/her son present. Without a safe and effective admission process, the facility was unaware of this concern as well (that the resident would not sign the admission agreement) until after the acceptance and admission of the resident. Resident #506 remained in SNF/NF #3 for nearly a month, and the facility never obtained the signed admission agreement that was required to have been executed at or before admission. 2. Medical record review and telephone interview with the responsible party on [DATE] at 11:45 AM revealed that Resident #196 was transferred to SNF/NF #3 from another sister facility (SNF/NF #4) on [DATE] at 8:45 PM by car, accompanied by 2 employees from SNF/NF #4. Per information provided by the Nursing Home Administrator on [DATE], SNF/NF #3 failed to execute an admission agreement for Resident #196. In a telephone interview with Resident #196's responsible party on [DATE] at 11:45AM, the responsible party for Resident #196 stated that he/she was notified that SNF/NF #4 would not keep the resident so he/she had no choice in the decision to transfer. 3. Resident #28 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident's responsible party prior to or at the time of admission to the facility. The resident's most recent readmission to the facility was on [DATE] at which time no attempt was made by the facility to execute an admission contract. The resident expired at the facility on [DATE]. 4. Resident #102 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident prior to or at the time of admission to the facility. On [DATE] the resident was discharged to an acute care hospital. On [DATE] the resident was again admitted from an acute care hospital. The facility failed to execute an admission contract with the resident prior to or at the time of admission to the facility. On [DATE] the resident was transferred to the hospital for a change in medical condition and did not return to the facility. 5. Resident #502 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident prior to or at the time of admission to the facility. On [DATE] the resident was transferred to the hospital for a change in medical condition and did not return to the facility. 6. Resident #408 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident prior to or at the time of admission to the facility. The resident's most recent readmission to the facility was on [DATE] at which time no attempt was made by the facility to execute an admission contract. On [DATE] the resident was discharged to the hospital and did not return to the facility. 7. Resident #85 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. Review of the social service admission note revealed that that upon assessment the resident was alert and oriented x 1 and unable to respond to assessment. The facility failed to execute an admission contract with the resident's responsible party prior to or at the time of admission to the facility. The resident's most recent readmission to the facility was on [DATE] at which time no attempt was made by the facility to execute an admission contract. The resident currently remains at the facility. 8. Resident #505 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. Review of the social service admission note dated [DATE] revealed the resident was dependent for decision making. The facility failed to execute an admission contract with the resident's responsible party prior to or at the time of admission to the facility. On [DATE] the resident was readmitted to the facility and transferred to the hospital within one hour of being in the facility due to [MEDICAL CONDITION]. The resident did not return to the facility. 9. Resident #81 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident and/or the resident's responsible party prior to or at the time of admission to the facility. The resident's most recent readmission to the facility was on [DATE] at which time no attempt was made by the facility to execute an admission contract. The resident currently remains at the facility without a signed admission contract. 10. Resident #152 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident and/or the resident's responsible party prior to or at the time of admission to the facility. The resident was discharged to the hospital on [DATE] and did not return to the facility. 11. Resident #217 was admitted to SNF/NF #3 on [DATE] from another skilled nursing facility. Review of a hospital psychiatric consult dated [DATE], the resident lacks capacity to make medical decisions. The resident's family member was the surrogate decision maker. The facility failed to execute an admission contract with the resident's responsible party prior to or at the time of admission to the facility. On [DATE] the resident was transferred to the hospital and did not return to the facility. 12. Resident #345 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The facility failed to execute an admission contract with the resident and/or the resident's responsible party prior to or at the time of admission to the facility. The resident left the facility against medical advice on [DATE]. On [DATE] the resident was again admitted to the facility from an acute care hospital. The facility failed to execute an admission contract with the resident and/or the resident's responsible party. On [DATE] the resident was transferred to the hospital and did not return to the facility. 13. Resident #151 was admitted to SNF/NF #3 on [DATE] from a sister facility (SNF/NF #4). The resident had a court appointed guardian that was effective on [DATE]. The facility failed to execute an admission contract with the resident's guardian prior to or at the time of admission to the facility. The resident currently remains in the facility. 14. Resident #312 was admitted to SNF/NF #3 on [DATE] from an acute care hospital. The resident had a court appointed guardian that was effective on [DATE]. The facility failed to execute an admission contract with the resident and/or the resident's guardian prior to or at the time of admission to the facility. The resident was discharged to another skilled nursing facility on [DATE]. 15. Resident #251 was admitted to SNF/NF #3 on [DATE] from a sister facility (SNF/NF #4). The resident had a court appointed guardian at the time of admission to the facility. The facility failed to execute an admission contract with the resident's guardian prior to or at the time of admission to the facility. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. At that time the facility failed to execute an admission contract. On [DATE] the resident was discharged home with his/her guardian. The egregious rights violations associated with noncompliant admission practices resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 3:00 PM on [DATE]. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 7:21 PM on [DATE] while surveyors remained onsite. The plan included: - Patient Care Concerns Staff have conducted a review of all residents in-house and have found documentation to indicate whether the admission contract is signed, and if not, the efforts to obtain signatures on that contract. - Admissions staff were in-serviced on the importance of obtaining consent to treat for incapable residents prior to admission. In the event that there is no consent to treat from the responsible party prior to admission, the Admissions staff will notify the Administrator prior to the admission so that action can be taken to obtain the consent prior to admission. - All admission staff members were also inserviced on the admission criteria policy to ensure that the facility meets residents' needs. - For transfers between NMS facilities, NMS has added an additional process in the electronic medical records of documenting that the patient can be cared for at the receiving facility as well as documentation that the receiving facility has accepted the resident. - Before or upon admission, the admission staff member or designee will meet with the resident or responsible party/family member to sign the admission contract. The Administrator or designee will audit three admissions per week to ensure that there is documented consent to treat and the admission contract is signed. - Results of these audits will be reported to the Quality Assurance Committee for a period of 3 months. The Quality Assurance Committee will determine what, if any additional interventions are required at the end of the three month period. bb

Based on interviews, review of the medical records, and review of other pertinent documentation, the facility failed to ensure that residents were free from unnecessary medications for 2 of 74 sampled residents during stage II of the survey. Both examples led to the determination of a scope of immediate jeopardy. The findings include. 1) The facility's systemic failures in this case led to the determination that immediate jeopardy (IJ) existed. The facility was notified of this determination on 10/25/2012 at 3:30 PM. Additionally, the facility was previously cited during a survey dated 07/27/2012 regarding the management of another resident's anticoagulant medication and the facility did not fully implement the plan of correction as proffered in its allegation of substantial compliance submitted on 09/15/2012. The facility provided a preliminary plan of correction and the IJ was abated on 10/25/2012 at 8:30 PM. Resident #517 was a [AGE] year-old female admitted to the facility from a hospital on [DATE] with exacerbation of right hip osteo[DIAGNOSES REDACTED], Resident #517's clinical history included chronic [MEDICAL CONDITION] (blood clot), [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION] and substance abuse. After admission to the facility, on 10/08/2012 resident #517 was started on anticoagulation therapy ([MEDICATION NAME] 5mg by mouth daily at bedtime) to address her diagnosed chronic [MEDICAL CONDITION]. Labs for [MEDICATION NAME] Time/International Normalization Ratio (PT/INR) provide two measures for assessing the therapeutic anticoagulation effect after initiation of [MEDICATION NAME]. PT reflects the time it takes for plasma to clot and the INR is a standardized ratio where the higher the INR value, the higher the anticoagulation effect. Normal PT and INR for residents (not on anticoagulation therapy) is generally PT = 10 - 14 seconds and INR = 0.8 - 1.2. Facility specific documentation revealed that the facility defined its INR therapeutic anticoagulation window for residents on [MEDICATION NAME] as INR = 2.0 - 3.0 for " standard " anticoagulation; and 2.5 - 3.5 and for the " aggressive " anticoagulation. These INR values are within generally accepted standards for tracking anticoagulation effects related to [MEDICATION NAME] usage. The therapeutic window for appropriate [MEDICATION NAME] anticoagulation is quite narrow. For the resident with a history of [MEDICAL CONDITIONS], obtaining therapeutic anticoagulation levels decreases the risk for life threatening [MEDICAL CONDITION] occurrence, but over anticoagulation increases the risk for life threatening bleed events. Therefore, careful titration of [MEDICATION NAME] dosing with regular monitoring of the PT/INR is required to safely administer the drug. On 10/8/12, the physician ordered the nursing staff to obtain a PT/INR for Resident #517. The blood test was obtained on the morning of 10/09/12 and revealed a PT of 11.2 and an INR of 1.1. On 10/09 after the INR of 1.1 had been obtained and reported, a new order was entered to increase [MEDICATION NAME] to 7mg by mouth each evening at bedtime. Additionally, a repeat PT/INR was scheduled for the morning of 10/12/12. However, this order was discontinued on 10/12 and the lab reported that they never received the blood specimen. Thus, no PT/INR labs were completed after 10/09/12. Medical record documentation revealed that the physician saw resident #517 at least five times during the period when the resident's PT/INR was not monitored. physician progress notes [REDACTED]. Based on interview during a 10/25/2012 conference call and review of medical record documentation, resident #517 was also ordered [MEDICATION NAME] 500 mg IV daily to treat her osteo[DIAGNOSES REDACTED]. [MEDICATION NAME] interacts with [MEDICATION NAME] and its discontinuation on 10/16 should also have prompted clinical assessment of resident #517's INR. Nonetheless, the physician did not assess and evaluate the resident's clinical anticoagulation therapy. In an interview with the surveyor on 10/23, the Assistant Director of Nursing reported that, because the resident had a central line, (internal jugular triple lumen) the nurse would have drawn the labs instead of the lab phlebotomy staff and it was believed the nurse may have missed the lab draw. A nursing note entered on 10/12 at 0335 AM stated that the lab was drawn, but then in the same note, it was also stated that the draw was going to be done in the morning. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In a follow up telephone conference with the facility on 10/25 during the deliberation phase of the survey process, the facility reported that the night nurse did sign off that the 10/12 lab was drawn and the electronic system automatically discontinued the one-time PT/INR order. Despite these conflicting indications that the lab may have been drawn, the facility indicated that they spoke with the lab, and that the lab had no record of ever receiving the 10/12 blood specimen. After the 10/12 lab order for PT/INR was discontinued on the morning of 10/12, no new orders were entered into the medical record for 12 additional days. Thus, administration of [MEDICATION NAME] 7mg by mouth daily at bedtime began on 10/10/2012 and continued unabated without any assessment of resident #517's PT and INR levels from 10/09/2012, until after surveyor intervention 14 days later on 10/23/2012. No new labs were ordered after the 10/12 order was discontinued, no-one became aware that the 10/12 lab was never received by the lab, and no-one questioned the continued daily administration without any assessment of the anticoagulation effect of the high risk medication for 14 consecutive days. PT/INR labs were not ordered and drawn until 10/23 at 2:26 PM, after surveyor questioning about the anticoagulation monitoring system. About two hours later, the lab results were reported to nursing at 4:56 PM, revealing critically high anticoagulant markers for resident #517 (PT = 125.5 and INR = 12.4). At 6:09 PM, Vitamin K 5mg by mouth was ordered as an intervention for the elevated INR, and it was administered to the resident at 6:30 PM. Review of the facility anticoagulation management policy conducted on 10/23 revealed a process to track and assess each INR lab, but there were no systems in place to catch cases where, despite anticoagulation medication orders, there were no corresponding lab orders, and therefore, no lab findings to assess. Additionally, the facility had filed a Plan of Correction (with allegation of substantial compliance 09/15/2012) for another deficiency related to anticoagulation management that was identified during a 07/27/2012 onsite survey. Interview and review of pertinent documentation revealed that the facility did not fully implement the corrective action plan as described in the submitted plan (see also Tag F520). In summary, no-one was monitoring [MEDICATION NAME] management as was proffered in the 09/15/2012 plan of correction, no-one on the interdisciplinary team questioned the missing PT/INR lab from 10/12/2012, and no-one on the team questioned continued administration of the high risk medication for 14 consecutive days without any labs ordered or drawn to assess the medication effect, until the surveyor intervened. The failure of the facility to develop and maintain an effective system for the interdisciplinary team to appropriately assess the full clinical effect of high risk anticoagulation medication, placed resident #517 in a clinically compromised state at significant risk for life threatening bleed events. 2) Resident #483 was an [AGE] year old male admitted from an acute care hospital for weakness following surgery. The hospital discharge summary revealed that prior to surgery, this resident lived alone in an apartment. While in the hospital, his stay was complicated by a urinary tract infection which was treated with antibiotics. He had some suspected baseline dementia with a superimposed [MEDICAL CONDITION] that was likely secondary to the urinary tract infection. [MEDICAL CONDITION] is the waxing and waning of an individual's mental status. In the hospital he had 2 separate episodes of agitation and confusion which required behavioral interventions and a one-on-one sitter. [MEDICATION NAME] 2 milligrams was given as needed, then started every night beginning 9/4/12. His mental status greatly improved and the resident was discharged to the facility for rehabilitation on 9/5/12. The physician at the nursing home reviewed the resident's medications upon admission and continued [MEDICATION NAME] for a "[MEDICAL CONDITION]". The resident was evaluated by the psychiatric nurse practitioner (NP) on 9/7/12 who attributed the resident's drooling to the antipsychotic medication [MEDICATION NAME]. The nurse practitioner wrote a new order for [MEDICATION NAME] 0.5 mg at night for drooling, a known extrapyramidal side effect of [MEDICATION NAME]. Extrapyramidal side effects are symptoms which can occur in persons taking antipsychotic medications. In the psychiatric evaluation which was documented on 9/7/12 at 8:28 PM it states "he drools and reports of gum pains. He became very angry and agitated because other people removed his rubbing alcohol." The interaction with the interviewer was cooperative. The psychiatric nurse practitioner diagnosed him with mood disorder due to a general medical condition. Recommendations included continued mental health services and continued psychiatric medications. There was no clinical rationale documented in the medical record which supported the continued use of [MEDICATION NAME] in light of the development of an adverse drug reaction identified by the psychiatric nurse practitioner. Although the attending physician visited the patient seven times, there is no discussion of the use of [MEDICATION NAME] or [MEDICATION NAME] in his documentation. Review of the nursing notes and behavior flow sheets indicated pleasant mood everyday from admission on 9/5/12 until confusion on 9/20/12. There is no documentation of agitation and there is no documentation of drooling. The medical record indicates that the [MEDICATION NAME] is being administered for a "[MEDICAL CONDITION]." On 11/7/12 at 11:00 AM, when asked "What is the [MEDICAL CONDITION] referenced in the chart," the attending physician responded that it was "agitation." Agitation is not a [MEDICAL CONDITION]. The physician stated that the resident had episodes of waxing and waning in the hospital with agitation, and it improved, therefore, the [MEDICATION NAME] was continued in the nursing home. The attending physician stated that he does not remember seeing [MEDICAL CONDITION] in this resident in the facility. The Psychiatric NP was also interviewed at the same time and was asked why she started the resident on [MEDICATION NAME]. She stated "people are routinely put on [MEDICATION NAME] with [MEDICATION NAME]. She stated that the patient was drooling and this is also a sign of antipsychotic use." The physician was asked if he saw the resident drooling and he stated "I do not remember drooling. I cannot recall if I saw EPS (extrapyramidal symptoms)." The physician did agree to the medication order. On admission, the resident's weight was 208.6 pounds. The resident was weighed again on 9/13/12 and the weight was 194 pounds. There is no documentation that the attending physician was notified of the 14.6 pound weight loss in 8 days, and interview of the attending physician on 11/1/12 at 6:41 PM revealed that he was not notified of the weight loss. There was no documentation indicating that the etiology of the weight loss was evaluated. Review of the medical record reveals the resident had a fall on 9/14/12, 9/19/12 and 9/20/12. On 9/20/12, the resident had a change in mental status and became confused. On 9/21/12, the resident remained confused and had a critically elevated potassium level of 7.7 meq/L at 3:56 PM. When the physician examined the resident at 6:30 PM, the resident was not responding to verbal or tactile stimuli and was sent to the emergency room via 911. The resident was admitted to the hospital with [REDACTED]. The use of antipsychotic medication in the frail elderly requires a careful evaluation of the benefits of the drug as well as the risks associated with their use. In the case of resident #483, [MEDICATION NAME] was initiated to address [MEDICAL CONDITION] during an acute hospitalization . The hospital reported that the [MEDICAL CONDITION] was resolving and its underlying cause had been treated. However, the facility elected to continue this potentially dangerous medication without a clear indication for its use, despite the development of side effects associated with the drug that required the administration of another medication ([MEDICATION NAME]).and other clinically significant changes in the resident ' s condition (including weight loss, falls and a decline in his mental status). The practice of managing a potentially dangerous medication in this fashion exposed this resident to the likelihood of serious injury, harm, impairment or death. Immediate jeopardy was identified, and the facility was notified of the same on November 9, 2012 at 1:15 PM. The facility had responded with an acceptable plan of correction by 5:20 PM. Per the facility's plan of correction the immediate jeopardy was abated as of 11/13/12.

Based on interviews, review of the medical records, and review of other pertinent documentation, it was determined that the facility failed to promptly notify the attending physician of significant laboratory abnormalities in 1 out of 10 residents reviewed during the extended survey. This failure resulted in the determination that an immediate jeopardy existed and the facility was notified of the same on 11/1/12 on 6:15 PM. An acceptable plan of correction was provided and the immediate jeopardy was abated as of 11/8/12 per the facility's plan of correction. Resident #483 was an [AGE] year old male admitted from an acute care hospital for weakness following surgery. The hospital discharge summary revealed that prior to surgery, this resident lived alone in an apartment. While in the hospital, his stay was complicated by a urinary tract infection which was treated with antibiotics. He had some suspected baseline dementia with a superimposed [MEDICAL CONDITION] that was likely secondary to the urinary tract infection. [MEDICAL CONDITION] is the waxing and waning of an individual's mental status. In the hospital he had 2 separate episodes of agitation and confusion which required behavioral interventions and a one-on-one sitter. [MEDICATION NAME] 2 milligrams was given as needed, then started every night beginning 9/4/12. His mental status greatly improved and the resident was discharged to the facility for rehabilitation on 9/5/12. On the morning of 9/21/12 at 8:18 AM, the nursing note revealed the following: "Resident remain (s) confused at this time. Writer called M.D. regarding resident's potassium level and Potassium 40 meq that resident is on. M.D. stated to keep resident on Potassium supplement and he will be in today to see resident. UA (Urinalysis) result was also addressed with no new orders given at this time as resident is currently on [MEDICATION NAME] 500 mg qd (every day). Will continue with POC (Plan of Care) and await sensitivity". This was written by nurse # 9. At 9:45 AM it is noted in the nursing notes that the resident's mood is confused. At 11:45 AM, the resident's blood pressure medications were held secondary to a low blood pressure 106/76. Per the nursing note the CRNP (certified registered nurse practitioner) was at bedside and was made aware. Review of the Nurse Practitioner's 9/21/12 note states "he did appear to be quite weak. He was unable to feed himself, as his hands were very weak and shaky." Review of systems is documented as "severe weakness". The attending physician was also notified. No new orders were given at this time. On the afternoon of 9/21/12 at 3:56 PM, the laboratory called and informed nurse #18 of a "critically elevated" blood potassium level of 7.7 meq/L (reference range 3.5 - 5.1 meq/L). There was no evidence of hemolysis, which is the breakdown of the red blood cells, noted in this blood specimen which could have artificially elevated the result. A blood potassium level of7.7 meq/L represents represents a medical emergency due to the adverse effects of such a concentration of potassium. When the potassium level is above 7.0 meq/L, muscle weakness, paralysis, cardiac arrythmias and death may result. Specifically, without warning, a potassium level of 7.7 meq?L can lead to abnormal rhythms of the heart, resuting in sudden death. Review of the medical record and interview of the facility's staff revealed that although the nursing staff was notified of the potassium level of 7.7 meq/L on 9/21/12 at 3:56 PM, the physician was not made aware of this critically elevated potassium level until sometime between 5:30 and 6:00 PM. Additionally, while the facility was made aware of significantly elevated BUN and creatinine levels at 4:45 PM, the facility failed to notify the physician of these results. The physician first became aware of these abnormal BUN and creatinine results when he arrived at the facility at approximately 6:30 PM. Based on these lab results and an evaluation of the patient's condition, the physician provided an emergency treatment for [REDACTED]. The attending physician was interviewed on 11/1/12 at 4:46 PM. He stated "I do not remember the potassium discussion in the morning. I was called in the afternoon about the critical potassium level". He stated "I do not know the time that I was called, but I left the hospital and came directly to the nursing home once I was notified." He stated he decided to come see the patient, because he doubted the accuracy of the potassium level based on the resident's previous levels. He stated "I came in to do an EKG, (electrocardiogram) but there was no EKG machine and there was no Calcium [MEDICATION NAME] and I couldn't risk waiting." Based on the last potassium of 4.1, he decided to treat with [MEDICATION NAME] 50 and Insulin, and that would bring the level down 0.5 to 1.0 point. According to the nursing note written at 7:02 PM, the resident had an altered mental status, was not responding as usual, was drowsy, and was not responsive to verbal or tactile stimuli when the physician arrived. When asked when he saw the elevated BUN and creatinine, he stated "I believe I saw a hard copy of the lab when I arrived". The physician stated "in light of a BUN of 60 and a creatinine of 3 then the potassium would seem to be more real. I would have treated right away and then sent the patient out." The physician knew about the BUN and creatinine levels at 6:30 PM, however the facility knew about the BUN and creatinine levels at 4:42 PM. Potassium is excreted through the kidneys. A BUN of 60 and creatinine of 3 was evidence that the kidney's ability to excrete potassium was impaired. After the resident was given IV medication at the bedside to lower the potassium, he was immediately ordered to be sent emergently via 911 to the nearest emergency department. At the hospital, the resident received additional interventions to treat his critically elevated potassium level and he was subsequently admitted . In summary, Resident #483 was in the facility for 16 days. He experienced a change in condition, which resulted in a dangerous, life threatening potassium level of 7.7 meq/L, during which facility staff failed to promptly intervene. The staff's actions placed this resident at grave risk and exposed him to the likelihood of a serious, potentially fatal outcome.

Based on medical record review and facility staff interview, the facility failed to provide coordinated interdisciplinary management of 1 of 74 residents' care sampled during the survey. The failure to promptly and effectively address the resident's mouth pain as described below was determined to represent actual harm to the resident. The findings include: 1) Resident #483 was an [AGE] year old male admitted from an acute care hospital for weakness following surgery. The hospital discharge summary revealed that prior to surgery, this resident lived alone in an apartment. While in the hospital, his stay was complicated by a urinary tract infection which was treated with antibiotics. He had some suspected baseline dementia with a superimposed [MEDICAL CONDITION] that was likely secondary to the urinary tract infection. [MEDICAL CONDITION] is the waxing and waning of an individual's mental status. In the hospital he had 2 separate episodes of agitation and confusion which required behavioral interventions and a one-on-one sitter. [MEDICATION NAME] 2 milligrams was given as needed, then started every night beginning 9/4/12. His mental status greatly improved and the resident was discharged to the facility for rehabilitation on 9/5/12. A nursing admission assessment was done on 9/5/12 by Nurse #18 and a narrative summary was documented at 9:11 PM. Resident was alert and oriented x 2, surgical site on lower abdomen with 16 staples with light drainage with surrounding tissue red, a suprapubic catheter, a Foley catheter, [MEDICAL CONDITION] on bilateral ankle, partial teeth upper and lower, and a sore on his tongue. A Falls Assessment was done indicating that the resident had no history of falls, mental status oriented at all times, no impairments and on (1) antihypertensive medication with a total falls risk score of 8 which put this resident at low risk, according to the assessment. Review of the physician's orders [REDACTED]. The resident's oral assessment was documented as normal, despite the narrative which stated the resident had a sore on his tongue. Nurse #18 clarified the medications with the attending physician. The physician ordered a CBC (Complete Blood Count), BMP (Basic Metabolic Profile) and a Vitamin D level for the next morning. Review of the nursing note written on 9/6/12 at 11:14 PM stated "CBC/BMP Lab received." There was no documentation regarding the results of the Vitamin D level. Review of all lab results in the medical record, including the lab results dated 9/6/12 did not have a Vitamin D level. Resident #483 was seen by his attending physician on 9/6/12 for an initial assessment. The review of systems is documented as "reviewed and negative". The physician reviewed the resident's medications, ordered a repeat urinalysis, routine labs, physical therapy/ occupation therapy evaluation and follow up with urology. Although completed on 9/6/12, this assessment was not documented in the resident's medical record until 9/8/12 at 1:34 AM. A nutritional admission assessment was done on 9/6/12 at 11:25 AM by Dietitian #21. The resident's weight upon admission was 208.6 pounds. It stated oral problems as " resident has a chewing problem, missing several teeth and stated he has a hard time chewing tough foods. He complains about the taste of the food." The resident is on a mechanically altered diet. The resident scored a high risk nutritionally due to (5) or more drugs per day and scored a moderate risk for conditions and [DIAGNOSES REDACTED]. The dietitian's note states "resident's current weight is considered obese and resident states he has not experienced any significant weight changes recently. Weight loss may be expected as resident is receiving diuretic and has bilateral [MEDICAL CONDITION] on his ankles." There is no documentation as to the extent of the [MEDICAL CONDITION]. The Dietitian Note of 9/13/12 at 4:16 PM states "3rd weight day 194.4 lbs. Reweight 194 lbs." The nursing note dated 9/12/12 at 10:13 PM states weight is 194.4 lbs. There is no documentation that the physician was notified of the 14.6 pound weight loss in 8 days. Interview of the attending physician on 11/1/12 at 6:41 PM revealed that he was not notified of the weight loss. Interview of Dietitian #7 occurred on 11/7/12 at 11:45 AM during which she stated " I was concerned if it was correct or wrong. The admission weight was wrong." When asked who made the decision that the admission weight was wrong she stated "we did". I could look at him and see it was wrong, he did not lose the weight. The weight loss was not accurate. It's all because I didn't believe these weights were right". When asked if the attending physician was notified she stated "no, the medical director was". The Medical Director was asked if he was told about the weight loss and his reply was "yes, I was made aware because he has an unusual name and I remember that. It was probable that the weight was wrong". At that time, the Nursing Home Administrator (NHA) stated that the dietitian who did the assessment was new. Review of the dietitian's credentials revealed that she was not licensed in the State of Maryland until October 2012. She did the assessment on 9/6/12. Dietitian #7 stated that she collaborated with dietitian #21. There is no documentation from Dietitian #7 that she signed off on the assessment. On 11/7/12 at 11:20 AM, the Nursing Administrator (NHA) indicated that there was a problem with the scales at the facility. He stated he called outside contractors, after the weight loss was found in this resident, to come in and check and re-calibrate all scales. The NHA stated they replaced parts and are now up-to-date. When asked how far off the scales were, the NHA stated "they don't tell you how far off they are". Review of the invoice presented to the Chief Nurse of the Office of Health Care Quality from the NHA revealed that all scales were checked and no problems were found except for a battery issue in 1 of the scales. On 11/9/12, the NHA confirmed that the scale contractors did not find any scales out of calibration. The resident was evaluated by the psychiatric nurse practitioner (NP) on 9/7/12 who attributed the resident's drooling to the antipsychotic medication [MEDICATION NAME]. The nurse practitioner wrote a new order for [MEDICATION NAME] 0.5 mg at night for drooling, a known extrapyramidal side effect of [MEDICATION NAME]. Extrapyramidal side effects are symptoms which can occur in persons taking antipsychotic medications. In the psychiatric evaluation which was documented on 9/7/12 at 8:28 PM it states "he drools and reports of gum pains. He became very angry and agitated because other people removed his rubbing alcohol." The interaction with the interviewer was cooperative. The psychiatric nurse practitioner diagnosed him with mood disorder due to a general medical condition. Recommendations included continued mental health services and continued psychiatric medications. There was no clinical rationale documented in the medical record which supported the continued use of [MEDICATION NAME] in light of the development of an adverse drug reaction identified by the psychiatric nurse practitioner. Although the attending physician visited the patient seven times, there is no discussion of the use of [MEDICATION NAME] or [MEDICATION NAME] in his documentation. Review of the nursing notes and behavior flow sheets indicated pleasant mood everyday from admission on 9/5/12 until confusion on 9/20/12. There is no documentation of agitation and there is no documentation of drooling. The medical record indicates that the [MEDICATION NAME] is being administered for a "[MEDICAL CONDITION]." On 11/7/12 at 11:00 AM, when asked "What is the [MEDICAL CONDITION] referenced in the chart," the attending physician responded that it was "agitation." Agitation is not a [MEDICAL CONDITION]. The physician stated that the resident had episodes of waxing and waning in the hospital with agitation, and it improved, therefore, the [MEDICATION NAME] was continued in the nursing home. The attending physician stated that he does not remember seeing [MEDICAL CONDITION] in this resident in the facility. The Psychiatric NP was also interviewed at the same time and was asked why she started the resident on [MEDICATION NAME]. She stated "people are routinely put on [MEDICATION NAME] with [MEDICATION NAME]. She stated that the patient was drooling and this is also a sign of antipsychotic use." The physician was asked if he saw the resident drooling and he stated "I do not remember drooling. I cannot recall if I saw EPS (extrapyramidal symptoms)." The physician did agree to the medication order. The resident was seen again by his attending physician on 9/9/12 when he complained of "sore gums that have been hurting since he was intubated in the hospital" was noted. The physician wrote that he will get [MEDICATION NAME] to alleviate the pain and continue to monitor. The physician saw the resident the next day 9/10/12 and the resident was upset that he had not received pain relief for his sore gums. According to the physician's note, the gums were swollen and tender to touch. The assessment and plan was "#1 sore gums, having difficulty with pharmacy in obtaining the [MEDICATION NAME], still awaiting arrival. The physician saw the resident again on 9/13/12 with a complaint of "gum pain persists, still have not obtained the [MEDICATION NAME] from the pharmacy. The patient is still asking for something for his mouth. Other than tender gums all other tender review systems are negative". General examination "alert, awake, oriented x 3, very upset because of the mouth sores and pain. The physician saw the resident on 9/16/12 and states "finally obtained the [MEDICATION NAME] and is using it. Still has a mild pain in his mouth." There is no documentation of pain or complaints of sore gums in the nursing notes for the above time period. Interview of the attending physician on 11/1/12 at 6:41 PM revealed that the physician gave a verbal order to the nurse for the [MEDICATION NAME] on 9/9/12. The physician orders [REDACTED]. The ADON stated on 11/7/12 at 11:15 AM that the [MEDICATION NAME] order was written in the wrong patient's chart. That was why this patient never received it. There was also an issue with the [MEDICATION NAME] not being on the pharmacy's formulary, therefore, the order was switched to [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 9/13/12 at 9:00 AM and 1:00 PM "awaiting" was signed off. The physician stated on 11/7/12 at 11:16 AM that there was a problem with the dosage per the pharmacy and the order had to be changed. The resident ultimately received this pain relief medication on 9/16/12 at 8:00 PM, which was 1 week after he started complaining of sore gums and mouth pain. In addition, the physician did not document the above progress notes until 10/16/12 which was 25 days after the resident was discharged to the hospital. Given the lack of contemporaneous communication from the physician, the rest of the interdisciplinary team was not privy to the resident's repeated complaints of mouth pain to the physician. Review of the medical record revealed that the resident had a fall on 9/14/12, 9/19/12 and 9/20/12. On 9/19/12, a urinalysis was ordered for suspicion of a possible urinary tract infection [MEDICAL CONDITION]. On 9/20/12, when the resident suffered his 3rd fall within 6 days and had a change in mental status, the attending physician ordered [MEDICATION NAME] 500 mg for 7 days for UTI, the [MEDICATION NAME] dose of Bactrim was discontinued and blood work was ordered for the next morning. However the physician failed to evaluate the use of [MEDICATION NAME] as a potential cause of this resident ' s change in condition, namely a change in mental status and the new onset of falls. The ordered blood work was drawn on the morning of 9/21/12 at 7:00 AM. On the morning of 9/21/12 at 8:18 AM, the nursing note revealed the following: "Resident remain (s) confused at this time. Writer called M.D. regarding resident's potassium level and Potassium 40 meq that resident is on. M.D. stated to keep resident on Potassium supplement and he will be in today to see resident. UA (Urinalysis) result was also addressed with no new orders given at this time as resident is currently on [MEDICATION NAME] 500 mg qd (every day). Will continue with POC (Plan of Care) and await sensitivity". This was written by nurse # 9. At 9:45 AM it is noted in the nursing notes that the resident's mood is confused. At 11:45 AM, the resident's blood pressure medications were held secondary to a low blood pressure 106/76. Per the nursing note the CRNP (certified registered nurse practitioner) was at bedside and was made aware. Review of the Nurse Practitioner's 9/21/12 note states "he did appear to be quite weak. He was unable to feed himself, as his hands were very weak and shaky." Review of systems is documented as "severe weakness". The attending physician was also notified. No new orders were given at this time. On the afternoon of 9/21/12 at 3:56 PM, the laboratory called and informed nurse #18 of a "critically elevated" blood potassium level of 7.7 meq/L (reference range 3.5 - 5.1 meq/L). There was no evidence of hemolysis, which is the breakdown of the red blood cells, noted in this blood specimen which could have artificially elevated the result. A blood potassium level of 7.7 meq/L represents a medical emergency due to the adverse effects of such a concentration of potassium. When the potassium level is above 7.0 meq/L, muscle weakness, paralysis, cardiac arrhythmias, and death may result. Specifically, without warning a potassium of 7.7 meq/L can lead to abnormal rhythms of the heart resulting in sudden death. Review of the medical record and interview of the facility's staff revealed that although the nursing staff was notified of the potassium of 7.7 meq/liter on 9/21/12 at 3:56 PM, the physician was not made aware of this critically elevated potassium level until sometimes between 5:30 and 6:00 PM. Additionally while the facility was made aware of significantly elevate BUN and creatinine at 4:45 PM, the facility failed to notify the physician of these results. The physician first became aware of these abnormal results when he arrived at the facility at approximately 6:30 PM. Based on these lab results and an evaluation of the patient's condition, the physician provided an emergency treatment for [REDACTED]. The attending physician was interviewed on 11/1/12 at 4:46 PM. He stated "I do not remember the potassium discussion in the morning. I was called in the afternoon about the critical potassium level". He stated "I do not know the time that I was called, but I left the hospital and came directly to the nursing home once I was notified." He stated he decided to come see the patient because he doubted the accuracy of the potassium level based on the resident's previous levels. He stated "I came in to do an EKG, (electrocardiogram) but there was no EKG machine and there was no Calcium [MEDICATION NAME] and I couldn't risk waiting." Based on the last potassium of 4.1, he decided to treat with [MEDICATION NAME] 50 and Insulin, and that would bring the level down 0.5 to 1.0 point. According to the nursing note written at 7:02 PM, the resident had an altered mental status, was not responding as usual, was drowsy, and was not responsive to verbal or tactile stimuli when the physician arrived. When asked when he saw the elevated BUN and creatinine, he stated "I believe I saw a hard copy of the lab when I arrived". The physician stated "in light of a BUN of 60 and a creatinine of 3 then the potassium would seem to be more real. I would have treated right away and then sent the patient out." The physician knew about the BUN and creatinine levels at 6:30 PM, however the facility knew about the BUN and creatinine levels at 4:42 PM. Potassium is excreted through the kidneys. A BUN of 60 and creatinine of 3 was evidence that the kidneys ability to excrete potassium was impaired. After the resident was given IV medication at the bedside to lower the potassium, he was immediately ordered to be sent emergently via 911 to the nearest emergency department. At the hospital, the resident received additional interventions to treat his critically elevated potassium level and he was subsequently admitted . In summary, Resident #483 was in the facility for 16 days. During that time, he was continued on an antipsychotic medication without an adequate indication for its use, was started on a medication to counteract the adverse drug reaction due to the antipsychotic medication, suffered mouth pain for 1 week without relief despite repetitive complaints to his attending physician, had a 14.6 pound weight loss in 8 days, suffered 3 falls within 6 days and had a change in condition which resulted in a dangerous, life threatening potassium level of 7.7 meq/L during which facility staff failed to promptly intervene. The staff's actions placed this resident at grave risk and exposed him to the likelihood of a serious, potentially fatal outcome. See Federal Tag F329.

Based on medical record review, interviews of facility staff, it was determined that the facility staff failed to: 1) failed to ensure that a resident with end stage [MEDICAL CONDITION] received [MEDICAL TREATMENT] as ordered by the physician, and failed to ensure that a resident received a medication to treat [MEDICAL CONDITION] associated with [MEDICAL CONDITION] as ordered by the physician, and 2) failed to follow physician's orders [REDACTED]. This was evident for 2 out out of 22 sampled residents selected for review. The findings include: 1. Resident #20 is an [AGE] year old with a [DIAGNOSES REDACTED]. Review of Resident #20's medical record on 7/17/12 revealed that, on 5/10/12, the resident was readmitted to the facility after being hospitalized and diagnosed with [REDACTED]. The resident was started on [MEDICAL TREATMENT] during the hospitalization as a result of acute [MEDICAL CONDITION]. Review of Resident #20's hospital discharge instructions revealed that the resident was to receive [MEDICAL TREATMENT] 3 times per week and [MEDICATION NAME] 20,000 units intravenously with each [MEDICAL TREATMENT] treatment 3 times per week. [MEDICATION NAME] is used to treat [MEDICAL CONDITION] (low red blood cell count) in patients with [MEDICAL CONDITION]. On 5/22/12, twelve days after Resident #20 was readmitted to the facility, the nurse, (Staff #13), documented in the progress note that the resident was noted to have missed [MEDICAL TREATMENT]. The nurse further documented that the physician was informed. The physician, (Staff #4), assessed Resident #20 and documented: "CONDITION ON DISCHARGE: Unstable/missed (missed) [MEDICAL TREATMENT] treatments". Interview of the Administrator of the [MEDICAL TREATMENT] unit, (Staff #11), the vice president of clinical services, (Staff #12), and the nursing home administrator, (Staff #5), on 7/17/12, confirmed that Resident #20 did not receive [MEDICAL TREATMENT] treatments as ordered by the physician 5/10/12 through 5/22/12. In addition to the facility staff's failure to ensure that Resident #20 received [MEDICAL TREATMENT] treatments, the resident did not receive [MEDICATION NAME] 5/10/12 through 5/22/12. Resident #20 was subsequently transferred to the hospital via 911 on 5/22/12 and admitted with [DIAGNOSES REDACTED]. The resident was dialyzed at the hospital every day for three days and was readmitted to the facility on [DATE]. 2. Review of the medical records and staff interviews revealed that Resident # 12 weighed 150 pounds at the time of her admission on 1/18/2012. Review of the physician's orders [REDACTED]. Reviews of the medical records revealed that the next weight is documented on 1/26/2012 as 135 pounds. On 1/31/2012, a re-weigh is documented as 135.8 pounds. Further reviews of the records and telephone interview of the Vice President of Clinical Services (Staff # 12) and the Director of Nurses (Staff # 7 ) conducted on 7/30/2012 at 1:00 PM failed to reveal that the Resident was weighed 3 days post admission per physician's orders [REDACTED].