Every finding on record at Complete Care at Laplata LLC

Based on complaints, reviews of clinical records and interviews with staff, it was determined that the facility staff failed to 1) follow a physician's order to withhold a medication when a resident's blood pressure met the specific blood pressure parameter, 2) document the location of an intermuscular injection site in the resident's clinical record, and 3) withhold an anticoagulant 5 days before a resident's surgical procedure. This was evident for 2 (Resident #3 and #4) of 4 residents reviewed during a complaint survey. The findings include: 1) On 6/17/26 the Office of Health Care Quality received an anonymous complaint (3046526) indicating Resident #4 was not being provided with quality of care and developed a left upper arm wound. Review of Resident #4's medical record on 08/17/26 Resident #4 was admitted to the facility on [DATE] with diagnoses that include but not limited to Seizure Disorder, intellectual disability, hypotension, gastrostomy tube, colostomy, and glaucoma. Resident #4 has been deemed by two facility physicians of being incapable of making any medical decisions. Resident #4 is totally dependent upon the facility nursing staff for all aspects of his/her care. Further review of Resident #4's clinical record on 8/17/26 revealed a physician's order dated 10/22/2025 instructing the nursing staff to administer the medication, Midodrine, 5 milligrams (mg), via gastrostomy tube, every 8 hours for hypotension. Administer the medication if the systolic blood pressure (SBP) is less than 100. A review of Resident #4's July 2026 medication administration records (MAR) on 08/17/26 revealed the nursing staff failed to withhold the dose of Midodrine on the following dates and times: 07/02/26, 6 am dose, documented blood pressure: 111/77.07/02/26, 2 pm dose, documented blood pressure: 102/87.07/05/26, 6 am dose, documented blood pressure: 106/62.07/05/26, 10 pm dose, documented blood pressure: 103/58.07/07/26, 6 am dose, documented blood pressure: 110/60.07/08/26, 6 am dose, documented blood pressure: 105/60.07/09/26, 10 pm dose, documented blood pressure: 102/6207/12/26, 6 am dose, documented blood pressure: 118/60. 07/14/26, 6 am dose, documented blood pressure: 117/68. These findings were shared with the facility administrator, director of nurses (DON) and the Nurse Consultant at the exit conference on 08/18/26. 2) Further review of anonymous complaint (3046526) revealed Resident #4 was identified with necrotic tissue to the left upper arm on 06/09/26 at 6:58 pm. The left upper arm surrounding tissues were noted to be inflamed, deep purple in color, and tender and firm to touch. There was no drainage noted. Further review of Resident #4's clinical record revealed that on 05/25/26 at 5:50 am, Resident #4 was observed with seizure like activity that included involuntary facial movement x3. LPN#1 documented administering a dose of intermuscular Ativan (Ativan is a medication to treat active seizures) to Resident #4. Further review of Resident #4's medical record failed to reveal any nursing documentation of the injection site LPN#1 administered the dose of Ativan on 05/25/26. In an interview with LPN#1 on 08/18/26 at 11:03 am, LPN#1 confirmed that s/he failed to document the site s/he administered a dose of Ativan on 05/25/26 at 5:50 am when Resident #4 was having a seizure. During the interview, LPN#1 stated that s/he recalled giving a dose of Ativan to Resident #4's right upper arm on 05/25/26. 3) On 7/29/26 the Office of Health Care Quality received a complaint (3121185) with allegations that Resident #3 was not receiving quality of care that included missing an angiogram procedure. Review of Resident #3's clinical record on 08/17/26 revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that include but are not limited to cellulitis of the lower limbs, peripheral artery disease, and a pressure ulcer to the left heel. A review of Resident #3's 06/08/26 quarterly MDS assessment revealed the staff identified Resident #3 with a BIMS of 15/15 indicating cognitively intact. BIMS (Brief Interview for Mental Status) is a 15-point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. In an interview with Resident #3 on 08/18/26 at 1 pm, Resident #3 stated that s/he was to have a procedure to check the blood flow to his/her legs in May 2026, but it was cancelled because the nurses failed to withhold the anticoagulant 5 days before the procedure.In a telephone call with Resident #3's vascular physician's office on 08/18/26 at 1:24 pm, the vascular physician's administrative aide stated that one of the nursing home staff members called and cancelled Resident #3's angiogram on 05/21/26. No reason was given. Later, a confirmation date of 05/26/26 was scheduled for Resident #3's angiogram and that Resident #3 should not receive a dose of his/her anticoagulant starting on 05/22/26.In an interview with the C wing nurse manager who oversees Resident #3's care on 08/18/26 at 2:16 pm, the C wing nurse manager stated that s/he missed the pre-operative orders given on 05/18/26 by Resident #3's vascular physician instructing the nursing staff to withhold Resident #3's anticoagulant, Eliquis, for 5 days before the scheduled angiogram. The C wing nurse manager stated that s/he had to cancel and reschedule Resident #3's angiogram to 05/26/26 and starting on 05/22/26 the nursing staff withheld Resident #3's doses of Eliquis.

Based on interviews, observations, and record review, the facility failed to ensure residents were informed of meal selections by posting current menus for resident review prior to meal service. This was evident for 1 (Resident #8) of 8 residents reviewed during the complaint survey and had the potential to affect residents who relied on posted menus to make meal selections.The findings include:On 6/10/26 at approximately 11:30 AM, an interview with Resident #8 revealed current menus were not posted for at least one week and residents were not able to review meals in advance. Resident #8 stated s/he requested a salad for lunch because s/he did not know what meal was being served. Resident #8 stated that when lunch was served, s/he learned a different meal option was available and stated s/he would have selected that meal had they known it was being served.On 6/10/26 at 11:55 AM, the surveyor observed three menus posted outside the nurses' station on the 200 unit. The menus were dated 6/1/26, 6/2/26, and 6/3/26.On 6/10/26 at 12:15 PM, an interview with the Food Service Director (FSD) revealed the facility recently transitioned to a new food service contractor and meal-tracking system and experienced difficulties printing menus. The FSD stated current menus were not posted due to issues with the printing system.The surveyor requested and reviewed the facility's menu for the current week. Review revealed the lunch meal scheduled for 6/10/26 was cranberry glazed chicken, roasted brussels sprouts, garlic red roasted potatoes, fruited gelatin, dinner roll with margarine, and beverage. During the interview, the FSD stated the lunch meal had been changed due to unavailable food items. During a follow up interview with the FSD, the surveyor asked how residents were informed of menu selections when menus were not posted. The FSD stated the menu was announced over the facility intercom prior to meal service times. The FSD further stated the menu announcement was not made today because she was on a telephone call with an outside food vendor. On 6/10/2026 at 12:47 PM, during a random tour of the facility, the FSD and surveyor observed outdated menus dated 6/1/26, 6/2/26, and 6/3/26 posted outside the nurses' station on the 200 unit. The FSD stated the outdated menus should have been removed.The findings were reviewed with the Administrator and Regional Director of Operations.At the time of exit conference, current menus were not posted for resident review prior to meal service.

Based on investigation into a complaint, observations, record review, and staff interview, the facility failed to reassess and continue an established intervention for contracture management following a resident's readmission from the hospital. This was evident for 1 (Resident #2) of 8 residents reviewed during the complaint survey.The findings include:Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body. A contracture is the abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching which can lead to permanent disability. On 6/9/26, complaint #3003711 was reviewed related to care concerns involving Resident #2.On 6/9/26 at 10:07 AM, the surveyor observed Resident #2 in bed. A right hand splint was not observed.On 6/9/26 at 3:37 PM, the surveyor again observed Resident #2 in bed. A right hand splint was not observed.On 6/10/26 at 8:05 AM, the surveyor observed Resident #2 in bed. A right hand splint was not observed.On 6/10/26 at 8:25 AM, review of Resident #2's comprehensive care plan revealed a focus stating the resident had a cerebral vascular accident (CVA/ stroke) affecting right-sided hemiplegia related to a head injury. Further review revealed interventions that included the use of a right hand splint to prevent contractures as ordered with initiated date 4/29/26.On 6/10/26 at 8:30 AM, review of Resident #2's clinical record revealed an Occupational Therapy (OT) Discharge summary dated [DATE]. The discharge summary indicated Resident #2 received OT services from 3/5/26 through 5/2/26 for contracture management, orthotic tolerance, and passive and active assisted range of motion. Further review revealed goals for Resident #2 to safely wear a resting hand splint on the right hand and documented the resident tolerated the splint for up to 3.5 hours at the time of discharge from OT services. The discharge summary indicated Resident #2 was discharged due to hospitalizationReview of Resident #2's May 2026 Treatment Administration Record (TAR) revealed a physician order dated 4/23/26 directing staff to apply a right hand splint to prevent contractures when the resident was out of bed and remove it per schedule. Further review revealed the order remained active through 5/3/26 and was not resumed following Resident #2's readmission to the facility on 5/19/26. As of 6/10/26, Resident #2 did not have an active order for a right hand splint.On 6/10/26 at 8:52 AM, an interview with the Director of Rehabilitation Services revealed Resident #2 previously received occupational therapy (OT) services which included use of a right hand splint. The Director of Rehabilitation Services stated that after discharge from OT services, Resident #2 should continue to wear the splint as part of contracture management. The Director of Rehabilitation Services further stated, We don't want the condition to get worse, and confirmed the right hand splint order had been discontinued. The Director of Rehabilitation Services stated the order was not discontinued by her.On 6/10/26 at 9:30 AM, an interview with the Physical Therapy Aide (PTA) #11 revealed Resident #2 was currently on caseload and primarily received therapy services at bedside due to his physical condition and stated, s/he doesn't wear splints that I know of.On 6/10/26 at 10:03 AM, an interview with the Director of Nursing (DON) revealed the resident would have required a new rehabilitation consult and evaluation following hospitalization before staff could resume use of the hand splint.A follow up interview with the DON revealed that Resident #2 was currently receiving physical therapy services and had been evaluated by speech therapy following readmission. The DON confirmed that OT services did not evaluate the resident following readmission, the resident did not have an active order for a right hand splint, and the resident would have required another screening or evaluation. The DON stated that because there was no order, staff would not have been applying the right hand splint. The DON further stated she would obtain an OT referral for reassessment for Resident #2.On 6/10/26 at 11:40 AM, the DON provided the surveyor with a copy of Resident #2's Therapy Referral Form dated 6/10/26. The form indicated a referral to OT for limited hand ROM/contractures and a description of problems section that indicated hand splint of right hand.The findings were reviewed with the Administrator, Regional Director of Clinical Operations and the Director of Nursing.At the time of exit conference, the surveyor did not observe evidence that Resident #2 had been evaluated by occupational therapy following readmission or that the established right hand splint intervention had been resumed.

Based on review of facility reported incident 3018652, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#6) of 8 residents reviewed for complaints during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A wanderguard bracelet is a discreet device worn by at-risk individuals that alerts staff when the resident approaches a monitored or restricted door. It prevents residents with memory impairment who exhibit wandering or exit seeking behaviors from exiting through the door into an unsafe environment.On 6/9/26 at 1:42 PM a review of facility reported incident 3018652 and Resident #6's medical record was conducted.Review of a 2/21/26 at 1638 (4:38 PM) nurse's note documented that Resident #6 was an elopement risk per the night supervisor and a wanderguard bracelet was placed on the resident's right ankle.Review of Resident #6's admission MDS with an assessment reference date (ARD) of 2/27/26, Section O, Restraints, P0200A an alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected #E. wander/elopement alarm was coded, 0 not used. The facility failed to capture the use of the wanderguard.On 6/10/26 at 12:14 PM an interview was conducted with MDS Coordinator #13. MDS #13 confirmed the findings and stated that she had seen the note and just forgot to code it on the MDS.

Based on review of facility reported incident 3018652, medical record, and interview, it was determined that facility staff failed to notify a resident's responsible party of the addition and discontinuation of treatment. This was evident for 1 (#6) of 8 residents reviewed during a complaint survey.The findings include:On 6/9/26 at 1:42 PM a review of facility reported incident 3018652 and Resident #6's medical record was conducted.A wanderguard bracelet is a discreet device worn by at-risk individuals that alerts staff when the resident approaches a monitored or restricted door. It prevents residents with memory impairment who exhibit wandering or exit seeking behaviors from exiting through the door into an unsafe environment.Review of a 2/21/26 at 1638 (4:38 PM) nurse's note documented that Resident #6 was an elopement risk per the night supervisor and a wanderguard bracelet was placed on the resident's right ankle.Further review of Resident #6's medical record failed to produce documentation that the responsible party was notified the wanderguard bracelet was applied.Review of Resident #6's May 2026 Treatment Administration Record (TAR) documented that the wanderguard bracelet was removed on 5/8/26.Review of progress notes and assessments in Resident #6's medical record failed to produce evidence that the responsible party was notified the wanderguard bracelet had been removed and discontinued.On 6/10/26 at 10:35 AM an interview was conducted with the Director of Nursing (DON). The DON acknowledged that the responsible party should have been notified when the wanderguard bracelet was applied and when it was removed and discontinued.

Based on review of complaint 3014373, facility reported incident 3018652, medical record review, and interviews, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (#1, #6) of 8 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.1)On 6/9/26 at 11:36 AM a review of complaint 3014373 was conducted along with Resident #1's medical record.Review of a 3/6/26 at 15:26 (3:26 PM) change in condition note documented, Fall. The note documented that no changes were observed. There was no further documentation of the fall. There was no documentation of how the resident fell, what precipitated the fall, where the fall occurred, the positioning of the resident after the fall, or if there were any injuries.On 6/9/26 at 12:00 PM an interview was conducted with the Assistant Director of Nursing (ADON) who confirmed Resident #1 did have a fall.On 6/9/26 at 1:14 PM the ADON brought the surveyor a copy of the fall that was in the Risk section of the electronic medical record. The ADON was asked if risk was part of the resident's medical record and the answer was, no. Risk is a part of the electronic medical record system. The electronic medical record system also contains reports and administrative files and is not considered part of the resident's electronic medical record.On 6/10/26 at 10:35 AM the concern related to the lack of documentation after the resident's fall was discussed with the Director of Nursing (DON). The DON agreed that there should have been documentation.On 6/10/26 at 1:35 PM the concern was reviewed with the Nursing Home Administrator (NHA). The NHA stated that she had only been at the facility for 3 days after the resident fell and the resident fell on a Friday. The NHA stated she found out when she came in on Monday. She said, You can't go backwards with documentation. The NHA agreed that there should have been more documentation in the medical record.2)On 6/9/26 at 1:42 PM a review of facility reported incident 3018652 and Resident #6's medical record was conducted.Review of a 2/21/26 at 1638 (4:38 PM) nurse's note documented that Resident #6 was an elopement risk per the night supervisor and a wanderguard bracelet was placed on the resident's right ankle.A wanderguard bracelet is a discreet device worn by at-risk individuals that alerts staff when the resident approaches a monitored or restricted door. It prevents residents with memory impairment who exhibit wandering or exit seeking behaviors from exiting through the door into an unsafe environment.Continued review of Resident #6's medical record failed to produce any further documentation in progress notes, nursing notes, or physician's notes about the wanderguard.Review of physician's orders revealed the order for the wanderguard was not written until 3/5/26. There was no documentation on the February 2026 Treatment Administration Record (TAR) that the wanderguard was monitored and checked for placement all 3 shifts from 2/21/26 until 2/28/26. Review of the March 2026 TAR failed to have documentation until 3/5/26.Further review revealed the wanderguard was discontinued on 5/8/26, however there was no documentation in the medical record as to why the wanderguard was discontinued.On 6/9/26 at 2:01 PM an interview was conducted with Registered Nurse (RN) #9 who stated that the day Resident #6 was admitted to the facility the resident stated he/she wanted to leave so she put the wanderguard on. RN #6 stated that the resident was discussed during the IDT (interdisciplinary team) meetings, and it was decided that since he/she was not displaying any wandering behaviors that the wanderguard could be discontinued. On 6/10/26 at 10:35 AM the DON was informed that documentation could not be found from the nurses about the use of the wanderguard. The DON stated that it should have been on the TAR and that she knows the staff was monitoring the resident even though there was no documentation. The DON agreed with and confirmed the surveyor's findings.

Based on observation, record review and interview, it was determined that the facility failed to ensure discontinued medications and medications belonging to discharged residents were appropriately removed and returned to the pharmacy and/or destroyed in accordance with facility expectations. This was found to be evident for 4 (Resident #37, #138, #122, and #5) out of 4 residents reviewed for medication storage and labeling.The findings include: Buspirone is a medication commonly used to treat anxiety disorders.Carvedilol is a medication used to treat high blood pressure and heart failure by helping the heart pump more effectively.Furosemide is a diuretic ( water pill) used to reduce excess fluid buildup associated with conditions such as congestive heart failure.Cyclobenzaprine is a muscle relaxant used to relieve muscle spasms and discomfort and may cause drowsiness.Valproic Acid is a medication used to treat seizure disorders and certain mood or behavioral conditions.Ipratropium-Albuterol Solution is an inhalation medication used to help open the airways and improve breathing in residents with respiratory conditions.On 04/30/2026 at 2:43 PM, this surveyor conducted an observation of the medication room for the facility's C/D Wing. During the observation, several blister packets of medications were observed sitting unsecured on the medication room counter. Each blister packet contained remaining medication and was labeled with resident names and medication information.The medications observed included the following:For Resident #37, Buspirone 5 mg, Take 1 tablet by mouth two times a day for anxiety.For Resident #138, Carvedilol 12.5 mg, Take 2 tablets by mouth twice a day for hypertension, Furosemide 40 mg, Take 1 tablet by mouth every day for CHF (Congestive Heart Failure), and Cyclobenzaprine 10 mg, Take 1/2 tablet by mouth every 12 hours as needed for muscle pain; may cause drowsiness. For Resident #122, Valproic Acid 250 mg, Take 1 capsule by mouth once a day for seizure prophylaxis and agitation for 7 days.On 04/30/2026 at 2:44 PM, this surveyor additionally observed Ipratropium-Albuterol Solution labeled for Resident #5 sitting on the medication room counter.On 04/30/2026 at 2:50 PM, record review revealed that Resident #37's order for Buspirone HCl Tablet 5 mg had been discontinued on 04/23/2026.On 04/30/2026 at 2:51 PM, record review revealed that Resident #138 had been discharged from the facility on 03/12/2026.On 04/30/2026 at approximately 2:52 PM, continued record review revealed that Resident #122's order for Valproic Acid 250 mg had been discontinued on 03/14/2026.On 04/30/2026 at 2:54 PM, record review revealed that Resident #5's order for Ipratropium-Albuterol Solution had been completed on 02/17/2026.On 04/30/2026 at approximately 3:15 PM, this surveyor conducted an observation and interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) in the medication room for the C/D Wing. The medications observed on the medication room counter were shown to the DON and ADON. It was explained that this is a concern because discontinued medications and medications belonging to discharged residents should have been removed from the medication room and returned to the pharmacy and/or destroyed according to facility process. The DON and ADON acknowledged the concern and confirmed their expectation would have been for these medications to have been appropriately returned to the pharmacy or destroyed. The DON and ADON then gathered the medications to be returned and/or destroyed.

Based on observation, interview, and record review, it was determined that the facility failed to be free of a medication error rate of 5% or more. This was found to be evident during the Medication Administration task completed during the Annual/Complaint survey and had the potential to affect all residents receiving medications in the facility. The findings include:Insulin is a medication used to control blood sugar levels in individuals with diabetes. Because insulin affects blood glucose levels, it must be administered exactly as ordered to prevent potential harm, including low or high blood sugar.Calcium-Vitamin D is a dietary supplement used to support bone health and help maintain adequate calcium and vitamin D levels in the body. A chewable formulation is intended to be chewed before swallowing.Med Pass 2.0 is a concentrated nutritional supplement used to provide additional calories and protein to residents who may be at risk for weight loss or poor nutritional intake.Polyethylene glycol is a laxative medication used to treat constipation by helping the body retain water in the stool to promote bowel movements.Oxybutynin Chloride ER is an extended-release medication used to treat overactive bladder symptoms, such as urinary urgency and frequency. Extended-release medications are designed to release slowly over time and should not be crushed.On 04/30/2026 at 9:14 AM, this surveyor observed LPN (Licensed Practical Nurse) #7 administer medications to Resident #50. LPN #7 reported that she was administering 21 units of insulin to the resident and was observed administering 21 units into the resident's right arm. After the medication pass, this surveyor reviewed the physician order in the MAR (Medication Administration Record) with LPN #7. The MAR directed staff to administer 18 units of insulin one time daily at 0800 for diabetes mellitus. LPN #7 reported that the MD (Medical Director) had verbally instructed her the previous day to increase the insulin dose from 18 units to 21 units but acknowledged that the physician order in the MAR had not yet been updated. It was explained that administration of insulin that did not match the active MAR order constituted a medication error.On 04/30/2026 at 9:42 AM, this surveyor observed LPN #7 prepare medications for Resident #124. The resident had an order for Calcium-Vitamin D Chewable 600-400 mg-unit supplement, one tablet by mouth twice daily for bone health. During the observation, LPN #7 stated that the resident preferred the regular tablet formulation instead of the chewable form and reported that this preference had existed since the medication was initially ordered on 02/03/2026. LPN #7 stated that the physician had been informed of the preference when the medication was first ordered. LPN #7 was observed removing a non-chewable Calcium-Vitamin D 600 mg tablet and placing it into the medication cup for administration instead of the chewable formulation ordered in the MAR. LPN #7 also prepared 120 mL of Med Pass 2.0 (four times a day for additional protein & calories) per physician order. During the preparation, LPN #7 additionally stated that Resident #124 typically refused Polyethylene Glycol 3350 Powder - 17 grams by mouth one time a day for constipation and reported that she usually asked the resident whether he/she wanted to take the medication.On 04/30/2026 at 9:47 AM, this surveyor observed LPN #7 administer medications to Resident #124. The resident received the non-chewable Calcium-Vitamin D tablet instead of the chewable formulation ordered. LPN #7 did not ask the resident whether he/she wished to take the Polyethylene Glycol powder medication. The Med Pass 2.0 supplement was observed left unattended on the resident's bedside table after the nurse exited the room.On 04/30/2026 at 9:52 AM, this surveyor interviewed LPN #7 regarding medication administration expectations. LPN #7 reported that medications should not be left unattended at bedside and acknowledged that anything requiring administration by nursing staff constituted a medication. It was explained that leaving the Med Pass supplement at bedside, administering a formulation of the Calcium-Vitamin D that differed from the physician order, and failing to offer the ordered Polyethylene Glycol medication were medication administration concerns. LPN #7 acknowledged understanding. On 04/30/2026 at approximately 1:00 PM, a record review of the facility's Medication Administration policy revealed the following compliance guidelines for medication administration: Compare medication source (bubble pack, vial, etc.) with the MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time, and Observe resident consumption of medication.On 04/30/2026 at approximately 1:15 PM, a record review of the facility's Verbal/Telephone Orders policy revealed the following: prescribed orders are to be repeated back to the physician or healthcare provider for clarification to avoid misunderstandings; orders are to be entered into the medical record manually or electronically; and verbal or telephone orders are to include the date, time, resident name, complete order, and signatures of the physician or healthcare provider and nurse, or be electronically signed in accordance with the facility's software system guidelines. The policy further stated that the physician is to sign the order at the next facility visit or within the timeframe required by the facility.On 05/01/2026 at 8:40 AM, this surveyor observed LPN #11 prepare medications for Resident #77. During the medication preparation, LPN #11 stated that due to the resident's dysphagia, certain medications would be crushed if able to be crushed. Record review revealed that Resident #77 had an active order for Oxybutynin Chloride ER (Extended Release) 24 Hour 10 mg tablet with instructions stating: Give 1 tablet by mouth one time a day. DO NOT CRUSH MEDICATION. On 05/01/2026 at 8:55 AM, this surveyor asked LPN #11 which medications should not be crushed. LPN #11 reported that extended-release medications and capsules should not be crushed. During the observation, LPN #11 was observed crushing the Oxybutynin ER tablet along with Resident #77's other medications. On 05/01/2026 at 9:00 AM, this surveyor observed LPN #11 administer the crushed Oxybutynin ER medication to Resident #77. On 05/01/2026 at 9:03 AM, this surveyor interviewed LPN #11 and explained that crushing the extended-release Oxybutynin medication constituted a medication error because the medication instructions specifically stated not to crush the tablet. LPN #11 acknowledged understanding and apologized for the error. On 05/01/2026 at approximately 11:00 AM, this surveyor conducted an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) regarding the medication administration observations. It was explained that the observed medication errors resulted in a medication error rate of 15.63 percent. The DON acknowledged understanding and confirmed that verbal insulin orders should not be administered until the MAR and physician orders are updated and verified. The DON further confirmed that medications should not be left unattended at bedside, physician orders should accurately reflect the formulation being administered and extended-release medications should not be crushed.

Based on review of employee records and staff interview, it was determined that the facility staff failed to complete required performance reviews of geriatric nursing assistants at least once every 12 months. This was evident for 4 (Employee #27 # 28, #29 and #30) of 5 employee records reviewed during recertification survey process. The findings include: Performance appraisals are to be completed at least every 12 months to identify in-service education needed to address competencies of the geriatric nursing assistants. On 05/01/2026 at 7:52 AM, a review of employee records revealed the following: Employee #27, hired on 04/18/2021, had documented performance evaluations dated 06/08/2025 and 04/24/2026. Employee #28, hired on 04/18/2021, had a documented performance evaluation dated 02/07/2025. Employee #29, hired on 09/03/2023, had no documented performance evaluation. Employee #30, hired on 11/12/2025, had no employee record available for review. On 05/01/2026 at 8:23 AM an interview was conducted with Staff #15, who reported being in the position for one year and stated that staff evaluations are conducted annually, as well as at 60-day and 90-day intervals for new hires.At that time, a review of staff records was initiated with Staff #15 for Employee #27; however, the records were not found in the personnel files at the time of review. Staff #15 stated that the records had been processed and were located at her desk.On 05/01/2026 at 8:48 AM the surveyor reviewed employee records with Staff #15, who confirmed that the expectation is to conduct staff performance evaluations annually, as well as at 60-day and 90-day intervals for new hires. Staff #15 also confirmed the hire dates for Employee #27, #28, #29, and #30. Staff #15 further stated that she has only been in the position for one year and is in the process of organizing records.

Based on record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 4 ( Resident #50, Resident #124, Resident # 32, Resident #11) out of 8 Residents reviewed for professional standards of practice during the recertification and complaint survey. The findings include: 1)According to the National Institute of Health (NIH) enteral feeding (tube feeding) delivers essential nutrients directly to the stomach or small intestine for individuals unable to meet nutritional needs orally. Common tubes include nasogastric (short-term) or PEG/J-tubes (long-term), which help manage conditions like dysphagia, stroke, or cancer. It can be delivered via pumps or gravity and is used until oral intake is safe. A PEG tube (percutaneous endoscopic gastrostomy) is a soft, flexible feeding tube inserted through the abdomen into the stomach, used for long-term nutrition, hydration, and medication delivery. It allows food to bypass the mouth and esophagus, typically for people with swallowing difficulties or chronic illnesses. Jevity 1.5 Cal is a high-calorie, fiber-rich formula designed for individuals who need extra calories and balanced nutrition, whether for short- or long-term tube feeding. Whether used as a sole source of nutrition or a supplement, Jevity 1.5 CAL nutrition provides concentrated calories and essential nutrients to help maintain a healthy weight and support overall well-being. During an observation conducted on 04/28/2026 at 3:21 PM, the Surveyor observed Resident #11's water bag dated 4/26/26 with a time of 8pm and a bottle of enteral feeding hanging labeled Jevity 1.5 dated 4/26/26 with a time of 8 pm, photos taken. A review of Resident #11's Medication Administration Record (MAR) was conducted on 04/28/26 at 3:33 PM. The following order was discovered: Enteral Feed Order every shift Jevity 1.5 CAL Administer continuous via Pump 60 ML [milliliter] per hour. 8 Hours per day Downtime: 4:00 AM and Up at 8:00 PM. (8:00 PM to 4:00 AM) -Order Date09/25/2025. During an interview conducted on 04/28/2026 at 3:55 PM, the Surveyor notified the Director of Nursing (DON) of the observation that Resident 11's enteral feeding was dated from 2 days ago and the concern that the Resident may not have received the ordered enteral feeding and water flush on 04/29/2026. The DON reported that she would investigate and return. The DON returned on 04/28/2026 at 4:22 PM and confirmed that Resident #11's enteral feeding and water bag was dated for 04/26/26 with a time of 8 PM. The DON stated that she had begun an in-service for enteral feedings and provided education for the nurse assigned to the Resident. 2)On 04/30/2026 at 9:36 AM, this surveyor observed LPN (Licensed Practical Nurse) #7 administer medications to Resident #50. It was observed that the privacy curtain between Resident #50 and his/her roommate was not pulled prior to medication administration. It was also observed that LPN #7 did not explain the medications to the resident before administration. Med Pass 2.0 is a concentrated nutritional supplement used to provide additional calories and protein to residents who may be at risk for weight loss or poor nutritional intake. On 04/30/2026 at 9:47 AM, this surveyor observed LPN #7 administer medications to Resident #124. It was observed that LPN #7 did not explain the medications to the resident prior to administration. Additionally, 120 mL of Med Pass 2.0, ordered four times daily for additional protein and calories, was left unattended at the resident's bedside without confirmation that the resident had consumed the supplement before LPN #7 exited the room. On 04/30/2026 at 9:52 AM, this surveyor interviewed LPN #7 regarding medication administration expectations. LPN #7 acknowledged that medications should not be left unattended at bedside and stated that anything requiring administration by nursing staff constitutes a medication. It was explained that leaving the Med Pass supplement unattended was a concern. LPN #7 further reported that she explains medications if residents ask about them or if there has been a change in the medication regimen. During the interview, it was also explained that not providing privacy during medication administration was a concern. LPN #7 acknowledged understanding of the concerns. Hydrocodone/Acetaminophen is a prescription pain medication used to treat moderate to severe pain. It combines hydrocodone, an opioid pain reliever, with acetaminophen, a medication that helps reduce pain and fever. On 04/30/2026 at 12:12 PM, this surveyor observed RN (Registered Nurse) #9 administer Hydrocodone/Acetaminophen 5 mg/325 mg, ordered every six hours as needed for pain, to Resident #32. The medication was administered from the medication cart located in the hallway rather than inside the resident's room. During the administration, at least one additional resident and one staff member were observed walking through the hallway while the medication administration occurred. On 04/30/2026 at 12:14 PM, this surveyor interviewed RN #9 regarding medication administration expectations. RN #9 reported that medications are normally administered in residents' rooms, although sometimes medications are given in the hallway if no one is present. It was explained that administering medications from the medication cart in the hallway did not ensure resident privacy, particularly since other individuals were present in the area during the medication administration. RN #9 acknowledged understanding of the concern. On 04/30/2026 at approximately 1:00 PM, record review of the facility's Medication Administration policy revealed the following compliance guidelines: Provide Privacy, Review the MAR (Medication Administration Record) to identify medication to be administered, and Observe resident consumption of medication. On 05/01/2026 at approximately 11:00 AM, this surveyor conducted an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) regarding the medication administration observations and concerns related to professional standards of practice. It was explained that concerns included failure to provide privacy during medication administration, failure to explain medications to residents, and failure to observe medication consumption. The DON acknowledged understanding of the concerns.

Based on review of records and interviews, it was determined that the facility failed to ensure a comprehensive resident care plan was developed and implemented. This was found to be evident for 2 (Resident #7, Resident #14) out of 28 Resident care plans reviewed during the recertification and complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. Care plans provide direction for individualized care of the resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Non-pharmacological interventions are crucial in care plans to provide holistic, person-centered care that reduces reliance on medication, manages symptoms effectively without side effects, and improves overall quality of life. They are essential for mental health goals as adjunct interventions for fostering long-term stability, skill-building, and social reintegration. 1)On 04/29/2026 at 11:36 AM, a review of Resident #7's medical record revealed the resident had orders for an antianxiety medication, an antipsychotic medication, and antidepressant medication for treatment of anxiety and bipolar disorder. According to the CMS definition, a Gradual Dose Reduction (GDR) involves the careful, stepwise tapering of a medication's dosage. This is done to assess whether a resident's symptoms, conditions, or associated risks can be effectively managed with a lower dose, or if the medication can be completely discontinued. A GDR utilized primarily in nursing homes to manage polypharmacy and avoid chemical restraints, it aims for safer care by reducing side effects. On 04/29/2026 at 11:55 AM, a review of Resident#7 medical record progress notes revealed that they are currently trialing a gradual dose reduction (GDR) of buspirone and was seen by the medical provider who documented the following: Patient (Pt) was seen for continued care of anxiety, deep vein thrombosis, and chronic pain. Pt is laying in bed, he/she appears comfortable. He/She is looking forward to working with therapy. He/ She complained of increased anxiety. GDR in progress and was started on 4/20/26. On 04/29/2026 at 11:58 AM, a review of the Resident #7's care plan showed that the resident had a care plan in place for taking: 1. antianxiety medication with the goal of being free from discomfort or adverse reactions related to antianxiety therapy. The interventions included: Administer medication as ordered, monitor and document and report any adverse reactions to medication or unexpected side effects. Monitor and record occurrence of target behavior symptoms. 2. Antipsychotic medication with the goal to be free of any complications including movement disorder, discomfort, hypotension, gait disturbance, constipation or cognitive or behavioral impairment. The interventions included administer medication as ordered, discuss with ordering provider and resident ongoing need for use of medication, review behaviors / interventions and alternative therapies attempted and their effectiveness. Monitor, document, and report any adverse reactions. 3. Antidepressant medication with a goal of being free from discomfort or adverse reactions related to the use of the medication. The interventions include administer medication as ordered, educate the resident about the risks, benefits, and side effects of the medication. Monitor, document and report any adverse reactions related to the use of the medication. During an interview with the Director of Nursing and Assistant Director of Nursing on 04/30/2026at 10:00 AM, concerns were discussed with Resident #7 not having specific non-pharmacological interventions included in their care plan. 2)Dementia refers to a variety of conditions that affect brain function, memory, and thinking skills. Alzheimer's disease is the most common type of dementia. The confusion that often accompanies dementia can present unique challenges for caregivers of those with dementia. During a record review conducted on 04/30/2026 at 11:11 AM, it was discovered that resident #14 had a diagnosis of Dementia. A dementia care plan in a long-term care facility is a personalized, written, or digital document that outlines the daily needs, medical care, and behavioral approaches for a resident living with cognitive impairment. It acts as a roadmap for staff, covering routines, nutrition, safety measures, and communication techniques, and it must be regularly updated as the disease progresses. During a review of Resident #14's care plan conducted on 04/30/2026 at 11:21 AM it was discovered that the Resident did not have a care plan for dementia. During an interview conducted on 05/01/2026 at approximately 8:50 AM, the Surveyor expressed concern that Resident #14 did not have a care plan for Dementia to the Director of Nursing (DON). The DON reported that she would investigate and return. The DON returned on 05/01/2026 at approximately 11:30 AM and confirmed Resident #14 did not have a Dementia care plan.

Based on record reviews and interviews it was determined the facility failed to ensure Residents were informed of risks and benefits of psychotropic medications. This was evident for 2 out of 5 residents (Resident #7, Resident #2) reviewed for unnecessary medications during the annual recertification survey.The findings include:All residents have the right to be informed of their health status and to accept or refuse medical treatment. The intent of this form (Psychotherapeutic Medication Informed Consent Form) is to provide informed consent for the administration of psychotropic medications. Two or more medications in the same drug class simultaneously may increase the risk of side effects and or adverse reactions. 1) On 04/29/2026 at 12:50 PM, a review of Resident #7 electronic medical record showed there was no Psychotherapeutic Medication Informed Consent Form scanned into their chart.On 04/29/2026 at 2:07 PM, an interview with the Director of Nursing (DON) revealed that if the consent form is not scanned in the electronic medical record, then the paper copy would be located in the physical chart on the unit.On 04/29/2026 2:53 PM, a review of Resident #7 paper chart, located on the unit, showed a blank paper Psychotherapeutic Medication Informed Consent Form in the chart that was labeled with the Resident #7's name that was not completed by the facility or signed by the resident. On 04/29/2026 at 2:55 PM, an interview with the Assistant Director of Nursing (ADON) confirmed that the Psychotherapeutic Medication Informed Consent Form in Resident #7's paper chart was not completed as required or signed by the resident. 2) On 04/30/2026 1:00PM, review of Resident #2's electronic medical record showed there was no Psychotherapeutic Medication Informed Consent Form scanned into their chart.On 04/30/2026 at 1:09 PM, a review of Resident #2's paper chart, located on the unit, showed a blank paper Psychotherapeutic Medication Informed Consent Form in the chart. It was labeled with Resident #2's name that was not completed by the facility or signed by the resident. On 04/30/2026 at 1:30 PM, during an interview with the DON and ADON concerns were addressed about the blank and unsigned Psychotherapeutic Medication Informed Consent Form found in Resident #2's paper chart.

Based on record review and interviews with facility staff, it was determined that the facility failed to coordinate with hospice representatives to ensure coordination of care and services provided by both hospice and the facility. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospice plan of care during the recertification annual survey process.The findings include:Terminal prognosis means a disease is expected to lead to death and is not expected to be cured or adequately treated. In essence, it indicates a life-limiting condition where death is anticipated, regardless of medical interventions.Hospice care is a specialized form of healthcare that provides comfort and support to terminally ill patients and their families. It focuses on managing pain, symptoms, and other physical, emotional, and spiritual needs during the end of life. On 04/29/2026 at 1:45 PM review of medical record revealed Resident #8 was admitted to Hospice of the Chesapeake on 4/19/2025. Matrix provided to the surveyor on 04/28/2026 indicated Resident #8 was receiving hospice care.On 04/29/2026 at 1:55 PM Resident #8's care plan review revealed Resident is on Hospice care related to: Cardiovascular disease and end of life. On 04/30/2026 at 8:44 AM during an interview, the Director of Nursing (DON) stated the facility is contracted with Hospice of Chesapeake and follows this process: an order for a hospice consult is obtained, the hospice agency is contacted, and a meeting is held with the resident and family. Once the resident is admitted to hospice services, the facility collaborates with hospice staff. Hospice personnel conduct visits, document care, and communicate any changes to facility staff. The facility updates the care plan and follows the hospice plan of care. When asked whether the resident is currently receiving hospice services, the DON stated that the Resident #8 was admitted to hospice on 04/19/2025 and disenrolled from hospice services on 02/11/2026. On 04/30/2026 at 9:10 AM the DON confirmed that the resident's care plan continues to indicate hospice services and Matrix report does not reflect resident's plan of care. On O4/30/2026 at 9:30 AM review of Resident #8's chart revealed no documentation in the medical records indicating resident was formally disenrolled or discharged from hospice services. On 04/30/2026 at 11:23 AM interview with Staff #14 stated that a significant change assessment is required when a resident is admitted to or disenrolled from hospice and must be completed within 14 days of the determination date, including following hospice disenrollment. Staff # 14 further stated that the MDS department was not aware of Resident #8's hospice disenrollment until 03/11/2026 at 12:01PM, when the Business Office Manager notified the department via email of a change in level of care. Staff #14 further stated that the census line was not updated until 03/30/2026. As a result of the delayed notification and failure to update the census timely, the required assessment was not initiated to reflect the resident's level of care. On 05/01/2026 at 11:48 AM interview with Business Office Manager (BOM), she stated that hospice is supposed to send a notification letter confirming a resident's disenrollment; however, this process was not followed this time. The BOM further indicated that the facility relies on receipt of this notification to initiate follow-up actions, including notifying the Interdisciplinary Team (IDT). Interview conducted on 05/04/2026 at 7:28 AM with the DON she confirmed that she is the facility designee for hospice coordination and stated that hospice normally coordinates and communicates any changes with the nursing staff, Unit Managers, and herself.The DON confirmed that hospice verbally notified the facility of the resident's disenrollment. The facility was awaiting the required documentation from hospice; however, no follow-up was conducted by the facility to obtain the supporting paperwork.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents were free of any significant medication errors. This was identified during the Medication Administration facility task completed during the annual/complaint survey. This was evident for 1 resident (Resident #50) out of 7 residents reviewed for medication administration.The findings include:Insulin is a medication used to help control blood sugar levels in individuals with diabetes. Because insulin directly affects blood glucose levels, incorrect dosing may place a resident at risk for adverse effects such as hypoglycemia (low blood sugar levels) which could be life-threatening. On 04/30/2026 at 9:14 AM, this surveyor observed LPN (Licensed Practical Nurse) #7 administer medications to Resident #50. LPN #7 reported that she was administering 21 units of insulin to the resident and was observed administering 21 units into the resident's right arm. After the medication pass, this surveyor reviewed the physician order in the MAR (Medication Administration Record) with LPN #7. The MAR directed staff to administer 18 units of insulin one time daily at 0800 for diabetes mellitus. LPN #7 reported that the MD (Medical Director) had verbally instructed her the previous day to increase the insulin dose from 18 units to 21 units but acknowledged that the physician order in the MAR had not yet been updated. It was explained that administration of insulin that did not match the active MAR order constituted a medication error.On 04/30/2026 at approximately 1:00 PM, a record review of the facility's Medication Administration policy revealed the following compliance guidelines for medication administration: Compare medication source (bubble pack, vial, etc.) with the MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time.On 04/30/2026 at approximately 1:15 PM, a record review of the facility's Verbal/Telephone Orders policy revealed the following: prescribed orders are to be repeated back to the physician or healthcare provider for clarification to avoid misunderstandings; orders are to be entered into the medical record manually or electronically; and verbal or telephone orders are to include the date, time, resident name, complete order, and signatures of the physician or healthcare provider and nurse, or be electronically signed in accordance with the facility's software system guidelines. The policy further stated that the physician is to sign the order at the next facility visit or within the timeframe required by the facility. On 05/01/2026 at approximately 11:00 AM, this surveyor conducted an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) regarding the medication administration observations. It was explained that the observation of LPN #7 administering a different amount of insulin than what was listed in the active order (21 units instead of 18 units) was considered a significant medication error. The DON acknowledged understanding and confirmed that verbal insulin orders should not be administered until the MAR and physician orders are updated and verified.

Based on record reviews and interviews it was determined that the facility failed to ensure that Pharmacy Recommendations were implemented. This was found to be evident for 3 (Resident # 3, Resident #14 & #15) out of 6 Residents reviewed for Pharmacy Medication Regimen Review (MRR) during the recertification and complaint survey. The findings include: 1)The Minimum Data Set (MDS) is a standardized assessment tool used in nursing homes to evaluate a resident's clinical condition, functional status, and care needs. Antipsychotic medications are drugs used to treat certain mental health conditions and behaviors, and because these medications can have significant side effects, facilities are expected to routinely evaluate their ongoing need. A Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Psychotropic drug is defined in the regulations as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. On 04/29/2026 at 10:48 AM, this surveyor conducted a record review of Resident #3's MDS assessment dated [DATE]. The MDS documented that Resident #3 received antipsychotic medications on a routine basis. The assessment further documented that a GDR (Gradual Dose Reduction) had not been attempted and that the physician had not documented that a GDR was clinically contraindicated. A continued record review on 04/29/2026 at 11:00 AM revealed an active physician order for Rexulti Oral Tablet 2 MG (Brexpiprazole), Give 2 mg by mouth in the morning for Depression, with an original order date of 04/22/2025 and revision date of 01/25/2026. Pharmacy Medication Regimen Review (MRR) or Drug Regimen Review (DRR) is a comprehensive, systematic evaluation of a patient's medication list by a pharmacist to identify, prevent, and resolve medication-related problems, such as drug interactions, adverse effects, or inappropriate dosing. It involves reviewing medical records and collaborating with the healthcare team to optimize therapeutic outcomes and ensure safety, particularly in post-acute care. A Pharmacy Medication Regimen Review (MRR) Recommendation is a pharmacist-led, systematic, and documented evaluation of a patient's medication list against their medical record to identify and resolve issues like unnecessary drugs, interactions, or safety concerns. It involves proactive clinical interventions to improve outcomes and reduce risks, particularly in long-term care. On 04/29/2026 at 12:20 PM, this surveyor reviewed Resident #3's Medication Regimen Reviews (MRRs). A pharmacy recommendation dated 04/23/2025 stated: Trazodone 50 mg - Give 50 mg by mouth every 24 hours as needed for Depression, Insomnia nightly as needed. Please consider discontinuing this (thus far) unused PRN order. If it remains active, please have STOP DATE of 14 days at which time further need may be assessed and documented. The document was signed OK on 04/23/2025; however, the Agree, Disagree, and Other sections were left blank. On 04/29/2026 at 12:39 PM, continued review of the MRRs revealed another pharmacy recommendation dated 06/17/2025 regarding the same medication. The pharmacist documented: Psychotropic medications should not be extended beyond 14 days without thorough documentation regarding continued need. Resident has orders for the following PRN medications which have not been used in greater than 60 days. Please consider discontinuing due to non-use: Trazodone HCL Oral Tablet 50 mg Give 50 mg by mouth every 24 hours as needed for Depression, insomnia nightly as needed. This was the second recommendation made by the pharmacist for discontinuation of the medication. The physician signed Agree on 06/19/2025. On 04/29/2026 at 12:40 PM, continued record review confirmed that the Trazodone order, originally dated 04/22/2025, was not discontinued until 06/19/2025, approximately two months after the initial pharmacy recommendation on 04/23/2025. On 04/29/2026 at 1:58 PM, continued review of Resident #3's MRR dated 08/13/2025 revealed another pharmacy recommendation regarding Citalopram Hydrobromide Oral Tablet 10 mg. Give 10 mg by mouth one time a day for Depression. The pharmacist documented: During the first year in which a resident is admitted on a psycho-pharmacological medication or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters. Please consider a GDR at this time. State reason if contraindicated at this time and state date if past GDR attempt was a FAIL. The physician response section for Agree, Disagree, and Other was left incomplete, and handwritten documentation stated cont some. The form was signed on 08/14/2025. Continued record review revealed that the Citalopram medication was later discontinued on 10/30/2025. On 04/30/2026 at approximately 10:00 AM, this surveyor reviewed the facility's Medication Regimen Review policy, which stated: Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities within 30 days. On 05/01/2026 at 10:17 AM, this surveyor conducted an interview with the DON (Director of Nursing). It was explained that the pharmacy recommendation dated 04/23/2025 was not acted upon until 06/19/2025, after a second recommendation had been issued, which exceeded the facility's policy requirement to address MRR irregularities within 30 days. Concerns were also discussed regarding the incomplete physician response sections on the MRR forms and the lack of clear rationale regarding the GDR recommendation for Citalopram. The DON acknowledged the concerns and reported that the facility had recently identified issues with physicians not properly completing the Agree, Disagree, and Other sections and had begun correcting the process in recent months. On 05/01/2026 at 1:53 PM, this surveyor conducted an interview with the Medical Director regarding Resident #3's psychotropic medications and GDR process. The physician reported that Resident #3 had originally been admitted for rehabilitation with plans to return home but later transitioned to long-term care. The physician stated that if residents are admitted already taking psychiatric medications prescribed by outpatient providers, she generally does not make changes unless clinically indicated. Regarding Rexulti, the physician reported that the resident's outpatient nurse practitioner had originally prescribed the medication for major depression. The physician stated that she had discussed tapering the medication with the resident on multiple occasions, but the resident declined dose reductions. The physician stated, I cannot do a GDR on someone who does not want the meds to be touched, and reported that she attempts to evaluate these medications quarterly. When asked what specific guidelines she follows regarding GDR practices, the physician reported, No, I just know them after 15 years. 2) During a review of Resident #14's Pharmacy Medication Regimen Review (MRR) conducted on 04/30/2026 at 10:08 AM it was discovered that the Pharmacy made a recommendation on 08/17/2025. The Pharmacy recommended making Loratadine 10 milligram (mg) PRN (as needed) because the medication had not been routinely administered. The Physician agreed and signed on 09/12/2025. On 03/13/2026 the Pharmacy made the same recommendation again. During a review of Resident #14's Medication Administered Record (MAR) conducted on 04/30/2026 at 10:17 AM it was discovered that the Pharmacy recommendation was not implemented until 3/16/2026. During a review of Resident #15's Pharmacy Medication Regimen Review (MRR) conducted on 04/30/2026 at 11:00 AM it was discovered that the Pharmacy made a recommendation on 10/20/2025. The Pharmacy stated that Lidoderm patch is recommended for up to 12 hours ON with period of 12 hours OFF. Please review this resident's order and reconcile. Staff should document removal in eMAR [electronic medication administration record]. The Physician agreed and signed the recommendation on 10/27/2025. On 11/09/2025 the Pharmacy made a second recommendation that stated Lidocaine patches (two orders) are STILL being left on for almost 24 hours. Please discuss with staff and reconcile. The Physician agreed, signed the recommendation and wrote on lower back and on right rib on 11/14/2025. On 02/13/2026 the Pharmacy made a third recommendation that stated patches, according to documentation in eMAR are being left on 24 hours. Lidoderm patch is recommended for up to 12 hours on with period of 12 hours off. Please review this resident's order and reconcile. The Physician agreed and signed the recommendation. The word done was written on the recommendation on 02/20/2026. On 04/17/2026 the Pharmacy made a fourth recommendation that stated Lidoderm patch is recommended for up to 12 hours on with period of 12 hours off. Please review this resident's order and reconcile. The Physician agreed and signed the recommendation on 04/20/2026. The word corrected was written on the recommendation. During a review of Resident #15's MAR conducted on 04/30/2026 at 1:00 PM it was discovered that recommendation was implemented on 04/19/2026. During an interview conducted on 05/01/2026 at 8:33 AM, the Surveyor expressed concern for the delay in implementing the Pharmacy recommendations with the Director of Nursing (DON). The DON reported that she would investigate and return. The DON returned and confirmed the delay in the implementation of the Pharmacy recommendation for Resident #14 & #15.

Based on medical record review and interviews with resident and facility staff, it was determined that the facility failed to invite residents to their care plan meetings. This was evident for 2 (Resident #8 and #6) out of 2 residents reviewed during recertification survey.The findings include: Residents have the right to be informed of and participate in the development and review of their care plan. The facility must invite the resident and/or representative to care plan meetings, allow participation in person or by phone, and document attendance or refusal. This supports person-centered care and ensures resident involvement in decisions about their care. 1). On 04/28/2026 at 9:22 AM during interview Resident#8 reported that he/she has never attended a care plan meeting and does not know the Social Worker.On 04/30/2026 at 6:50 AM, record review revealed that Resident #8 was admitted to the facility on [DATE]. Further review of the medical record revealed no documentation indicating the resident was invited to or attended care plan meetings.On 04/30/2026 at 9:25 AM interview conducted with Staff #17 stated that care plan meeting notifications are provided through written letters for long-term care residents and in-person communication for short-term residents, with responsible parties notified if the resident is unable to participate. She stated residents are informed verbally and encouraged to attend if alert and oriented.She further stated that documentation of invitations is maintained through copies of letters and that meeting attendance is recorded on a signed attendance sheet. If residents or responsible parties are unable to attend, a copy of the care plan is provided via email or directly to the residents. Staff #17 stated care plan meetings are conducted annually, quarterly and as needed.On 04/30/2026 at 10:31 AM the surveyor and Staff #17 reviewed Resident #8's medical record and confirmed there was no documentation indicating the resident was invited to or attended care plan meetings.On 05/01/2026 at 12:10 PM Staff #16 submitted care plan signature sheets for Resident #8 dated 10/15/2025 and 01/21/2026; both documents indicated no evidence of the resident #8's attendance or invitation to the care plan meetings.2). On 04/28/2026 at 9:41 AM, Resident #6 reported, I have not had any meeting here. I have been here on and off for about four and a half years.On 04/30/2026 at 10:54 AM review of Resident #6's medical record revealed re-admission [DATE]. BIMS 15.On 04/30/2026 at 11:09 AM, review of Social Worker's notes revealed the following: On 11/14/2023 at 11:40, documentation indicated the resident was unable to attend the care plan meeting due to a COVID outbreak on the unit. On 01/03/2024 at 15:20, documentation indicated the resident was present at the care plan meeting. On 10/01/2024 at 15:42, documentation indicated the resident was invited but did not attend the care plan meeting. Additionally, only one care plan signature sheet was identified in the resident's medical record during record review.On 04/30/2026 at 1:03 PM record review with Staff #17 revealed a care plan meeting signature sheet dated 11/14/2023. Documentation indicated the resident's brother was in attendance.Further review of Resident #6's medical record revealed that the resident serves as his/her own responsible party (RP); however, there was no documentation indicating that the resident was invited or attended the care plan meeting dated 11/14/2023.On 04/30/2026 at 1:11 PM Staff #17 stated that care plan meetings for Resident #6 are conducted at the bedside due to the resident being bedbound. Staff #17 confirmed that the resident is able to participate and sign the care plan signature sheet.On 04/30/2026 at 2:23 PM Staff #17 provided one care plan meeting signature sheet dated 05/28/2025, which contained no signature from the resident or responsible party (RP), and one care plan invitation dated 01/29/2025. Staff #17 confirmed there was no documentation indicating that the resident or RP attended care plan meetings.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were offered written information regarding advance directives. This was evident for 1 (Resident#120) out of 3 residents reviewed for advance directives during the recertification survey process.The findings include:An advance directive is a written instruction, such as a living will or durable power of attorney for healthcare, that is completed by a resident to outline their preferences for medical care in the event they are unable to make decisions for themselves.In a long-term care facility, an advance directive guides staff and providers in honoring the resident's choices regarding treatment, life-sustaining measures, and designation of a representative to make healthcare decisions on their behalf, in accordance with the resident's rights.On 04/28/2026 at 1:47 PM review of Resident #120's medical record revealed no documentation in the electronic health record (EHR) to indicate that the facility offered an advance directive or provided education regarding advance directives to the resident and/or the resident's Responsible Party (RP).On 04/30/2026 at 2:30 PM an interview was conducted with Staff #16, who stated that the facility's process for advance directives includes inquiring upon admission whether the resident has an advance directive. If the resident does not have one, the facility provides a Maryland Advance Directive packet for completion.Staff #16 further stated that the Social Services admission assessment is completed within one week of admission and includes providing education regarding advance directives to the resident and/or the resident's Responsible Party (RP).During an interview on 04/30/2026 at 2:54 PM, Staff #16 stated that the expectation is for the facility to offer advance directives and complete the Social Services assessment within seven (7) days of admission.On 04/30/2026 at 3:00 PM surveyor review of the Social Services Assessment with Staff #16 confirmed that the assessment was not completed. Staff #16 further stated, I am not sure why the assessment was not completed.On 05/04/2026 at 10:30 AM the facility Administrator submitted documentation of an AD HOC meeting held on 04/30/2026 at 4:00 PM, which addressed the facility's noncompliance with advance directive requirements.

Based on observations and interviews, it was determined that the facility failed to ensure that the environment was in good repair. This was found to be evident for 2 (Resident #10 & #15) out of 7 Resident rooms observed during the recertification and complaint survey. The findings include: During an interview conducted on 04/27/26 at 8:44 AM it was observed that Resident #10 had an oval shaped area where the paint had peeled from the wall behind the bed. The Surveyor also observed the wall in front of the resident's bed with 2 large white patches from a wall repair. During an interview conducted on 04/27/26 at 9:39 AM, the Surveyor observed peeling paint behind the resident's bed and on the wall facing the resident #15's bed. The Surveyor also observed the top right side of the nightstand covering had peeled off. 05/04/2026 9:27 AM during an interview the Director of Nursing (DON) reported that the Maintenance Director was recently no longer employed at the facility. The Surveyor, DON and Assistant Director of Nursing (ADON) toured the facility. The Surveyor pointed out the observations and the DON took notes. The DON reported that she would have maintenance make the necessary repairs.

Based on record review and interview it was determined that the facility failed to ensure a resident was free of a chemical restraint. This was found to be evident for 1 (Resident #15) out of 5 Residents reviewed for unnecessary medications during the recertification and complaint survey. The findings include: A chemical restraint is a medication used to intentionally control behavior, restrict movement, or sedate a person, rather than to treat a specific, diagnosed medical or psychiatric condition. These drugs-commonly antipsychotics, sedatives, or mood stabilizers-are used for staff convenience or discipline, often in nursing homes or emergency care, and are not required for standard, direct treatmentA non-pharmaceutical approach (or non-pharmacological intervention, NPI) refers to evidence-based, non-invasive methods used to prevent, manage, or treat health conditions without medication. These approaches include lifestyle changes, physical therapies, and psychological strategies aimed at improving quality of life, such as exercise, diet, mindfulness, and, in public health, measures like masks or social distancing. During a review of Resident #15's Medication Administration Record (MAR) conducted on 04/29/2026 at 11:00 AM revealed an order for an antianxiety, antidepressant, and opioid medication. Further review of the MAR and Treatment Administration Record (TAR) did not show an order for a nonpharmacological approach. According to the Centers for Medicare & Medicaid Services (CMS), a care plan is a structured, person-centered document that outlines individualized medical and support services to address a patient's health conditions and goals. It includes medication management, provider coordination, and community services, developed with the patient and their representatives.A review of Resident #15's medical records conducted on 04/29/2026 at 11:07 AM did not reveal a care plan for a non-pharmacological approach for the antianxiety, antidepressant, and opioid medications. During an interview conducted on 05/01/2026 at approximately 8:30 AM, the Surveyor discussed the concern that Resident #15 had received ordered antianxiety, antidepressant, opioid medications. However, the facility had not implemented alternative interventions such as a nonpharmacological approach. The Director of Nursing (DON) reported that she would investigate and return. The DON returned and confirmed that no alternative interventions had been attempted.

Based on medical record review, staff interviews, and review of the facility's discharge practices, it was determined that the facility failed to notify the resident and/or resident's representative with written notification of the bed-hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #131) of 1 resident reviewed for hospitalization during the annual survey process.The findings include:On 04/29/2026 at 11:02 AM record review revealed that Resident #131 was transferred to the hospital following a fall. Review of the Nurse Manager's notes dated 04/04/2026 at 13:45 confirmed the resident was admitted to Maryland University [NAME] Regional Center.Further review of the resident's medical record revealed no documentation that the facility provided written information regarding the bed-hold policy to the resident and/or the resident's Responsible Party at the time of transfer.On 04/29/2026 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the discharge process. The DON stated that during hospital transfers, the physician is notified and appropriate orders are obtained, and the family or Resident Responsible Party (RP) is notified of the transfer. The DON further stated that the bed-hold policy is provided to the resident if they are capable; if not, it is mailed to the resident's RP via certified mail. Additionally, the DON stated that the admission Assistant follows up with the family or RP.On 04/29/2026 at 2:45 PM an interview was conducted with the admission Assistant who stated that when a resident is transferred to the hospital, the bed-hold policy is mailed to the resident's family/RP if the resident is unable to sign or receive the information, and a copy is maintained in a binder.On 04/29/2026 at 2:55 PM review of Resident #131's medical record with the DON and admission Assistant revealed no signature or documentation indicating that the resident or RP received the bed-hold policy at the time of transfer.On 04/29/2026 at 3:06 PM further review of Resident #131's record with the DON and admission Assistant revealed that the bed-hold policy was mailed to the resident's home address while the resident was hospitalized . There was no documentation indicating that the resident was unable to sign at the time of transfer, and no documentation that the resident's emergency contact or RP was provided with the bed-hold policy.On 04/29/2026 at 3:15 PM the admission Assistant confirmed that there was no documentation in the electronic medical record (PCC) indicating that the resident or RP was offered or provided with the bed-hold policy.

Based on observation, record review, and interview, it was determined that facility staff failed to identify and evaluate factors contributing to a resident's falls and ensure appropriate interventions were implemented to prevent future occurrences. This deficient practice resulted in actual harm to Resident #1. This was evident for 1 (#6) of 1 resident reviewed for accidents/hazards.The findings include:Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.On 1/2/26 the state agency (SA) received a complaint 2708089 regarding Resident #6 alleging that the resident had multiple falls. The allegation stated that the resident had broken their right hip in 1/2025 and then broke the left hip on 12/31/25.A medical record review for Resident #6 on 1/7/26 at 12:31 PM revealed a care plan focus on the resident's high risk for falls related to dementia, poor gait/balance, poor safety comprehension, incontinence, and a history of falls that was initiated on 5/24/24. The goal was to keep the resident free of falls during the review period. The interventions included but were not limited to the following: ensure the resident's environment was decluttered and well lighted, initiated on 5/24/24; ensure resident was wearing appropriate footwear, initiated on 7/3/24; staff to place fall mats on the floor while the resident was in bed, initiated on 7/3/24. Staff noted a fall that occurred on 1/28/25 resulting in a right hip fracture. On 1/30/25 the following interventions were initiated: implement a toileting program to prevent falls and to review each fall for the root cause and remove the cause. However, the care plan failed to reveal an intervention addressing the level of supervision Resident #6 needed to prevent future falls. A review of the Change in Condition (CIC) forms dated 6/1/25 to current revealed the resident had a fall on 6/16/25. Further review revealed this fall was not listed on the care plan and there were no new interventions implemented. There was no evidence that staff reviewed the fall to determine the cause as stated in the care plan. A CIC form dated 7/1/25 revealed the resident had a fall and further review revealed the care plan was not updated with the fall, and no new interventions were added. There was no evidence that staff reviewed the fall to determine the cause. A review of the physician's orders, medication administration record (MAR), and treatment administration record (TAR) for 2/1/25 - 12/31/25 revealed the toileting program to prevent falls had not been implemented.The quarterly Minimum Data Set (MDS) with the assessment reference date of 11/14/25 was reviewed. The document revealed the resident had severe cognitive impairment. A review of section GG revealed that the resident was able to go from a lying to a sitting position independently but required moderate assistance to transfer from the bed to the wheelchair. Once in the wheelchair the resident was able to move about the room and nursing unit independently. A review of Section H revealed the resident was frequently incontinent which indicated that at times the resident was able to use the bathroom. Review of a CIC form dated 12/23/25 revealed the resident had a fall and further review revealed this fall was documented on the care plan. There was one new intervention added on 12/24/25 which was to ensure the bed was locked and in a low position. There was no evidence of the fall review to determine the cause. A CIC form dated 12/31/25 revealed the resident had a fall and was complaining of left hip pain. Further review revealed that the resident was sent to the hospital and diagnosed with a broken left hip as a result of this fall.A review of the resident's discharge summary from the acute care hospital dated 1/7/26 revealed the resident had a fractured left hip requiring surgical intervention and was to be discharged back to the facility.An interview with Licensed Practical Nurse (LPN) #6 on 1/7/26 at 3:03 PM revealed he was frequently assigned to Resident #6. He reported that the resident was mostly confused due to the diagnosis of dementia and would frequently get out of bed or chair without assistance. He stated the resident was able to move about the room by holding onto things and in the hallway s/he would use the wheelchair to ambulate. He reported that staff would leave the resident's wheelchair beside the bed in hopes that the resident would get into the chair when s/he tried to get up unassisted. When asked why he thought the resident would get up unassisted he stated that at times the resident wanted to rummage through things and to go to the bathroom. He reported the resident would wander into other resident's rooms. When asked if the resident was on a toileting program, he stated s/he was not.LPN #6 reported that on 12/31/25 the resident fell while staff were passing lunch trays and he was administering medications to other residents. Staff were alerted by the roommate screaming for help. He stated that he found the resident lying inside the doorway of the room near the bathroom. The resident was unable to verbalize what had happened.A subsequent medical record review on 1/8/26 at 10:00 AM revealed the resident had returned to the facility and was admitted to a different room. The care plan for falls had been updated with 1 intervention to place the wheelchair beside the resident bed while the resident was in bed. However, per the interview with LPN #6, staff were doing this intervention. Further review revealed no evidence that the fall was reviewed for the root cause and no intervention to include the level of supervision the resident needed to prevent falls.An observation of Resident #6 in their new room on 1/8/26 at 10:32 AM revealed the resident was in the bed closest to the window and the curtain was closed so staff were unable to see what the resident was doing. There were no fall mats on the floor. The roommate's bed was pushed close to the dividing curtain to accommodate the roommate's things. The roommate's light was off, making his/her side of the room low lighting. At the end of the roommate's bed was a dresser with a TV on it and a fan that was partially hanging off. Situated beside the dresser was a metal stand that was filled with food, snacks, drinks, and miscellaneous items. On the floor next to the stand were 2 six packs of a bottled drink sticking out into the walkway between the bed and the dresser. On 1/8/26 at 12:11 PM an interview with the Director of Nursing (DON) revealed the resident was impulsive with poor safety awareness and frequently attempted to get up and walk without assistance. The DON reported that the resident had been placed in a room closest to the nurses' station prior to the fall on 12/31/25. However, due to some concerns with the interactions between the family and the Unit Manager they did not want the resident on the same unit, so when the resident was readmitted to the facility, they were unable to find a bed closest to the nurses' station on the new unit. Upon review of the concern regarding the failure to implement a toileting program for the resident, she confirmed that the toilet program would have been documented on the resident's MAR or TAR. She was unable to provide a rationale as to why it had not been implemented. She stated she would look into the concern and report back to the surveyor. She failed to report back by the end of the survey. During this interview the DON and surveyor made a subsequent observation of Resident #6's current room. She acknowledged the room was furthest from the nurses' station, however failed to implement safety measures to mitigate this concern. She acknowledged the resident's roommate's side of the room was cluttered and had low lighting increasing the resident's risk for another fall. She stated that staff were supposed to check on the resident as they came by the room and acknowledged that with the curtain closed, they could not see what the resident was doing. In addition, the DON had to lower the bed during the observation because it was too high, there were no floor mats beside the bed, and the resident's wheelchair was not positioned beside the bed. There was no room to put the resident's wheelchair next to the bed because the roommate's bed was pushed against the curtain that was hanging to separate the room. While leaving the room the DON reported that she would take care of these concerns to keep the resident safe.The Nursing Home Administrator (NHA) was made aware of the concerns via a phone call on 1/16/26 at 11:58 AM.

Based on record reviews and interviews with facility staff, it was determined that the facility failed to protect residents from accidents and hazards. This was found to be evident for 1 (Resident #22) out of 1 Resident reviewed for accidents. This deficient practice resulted in actual harm cited as past noncompliance. The findings include: On 03/20/25, at 8:00AM, during a medical record review, it was found that Resident #22 sustained second degree burns on the right fourth and fifth digits, abdomen, and thigh from hot coffee on 02/23/25. As a result, the resident was admitted to the hospital for burn treatment. During an interview conducted on 03/20/25 at 8:05 AM, the Surveyors were unable to communicate with Resident #22 because he/she was non verbal. During an interview conducted on 03/20/25 at 8:12 AM, the Kitchen Manager stated that at the time of the incident coffee was served at 150 degrees Fahrenheit. He further stated that the appropriate serving temperature for hot beverages was 135 degrees Fahrenheit. During an interview conducted on 03/20/25 at 8:13 AM, the District Certified Dietary Manager (CDM) confirmed that the kitchen staff received education on proper beverage temperatures. She also advised that a process was implemented to check hot beverage temperatures before leaving the kitchen. At 8:15AM on 03/20/25, the Surveyors reviewed the facility ' s hot liquid safety policy, which stated that if a beverage temperature is greater than 145 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature. At 8:20AM on 03/20/25 the Surveyors interviewed the Director of Nursing (DON), who confirmed that Resident #22 sustained burns from hot coffee. The DON advised that hot coffee was served to the Resident during dinner set up. She stated that the Resident moved the tray table, and the hot coffee spilled onto the Resident causing the second-degree burns. The DON acknowledged that the coffee temperature was a concern, stating that it was too hot. The DON further advised that since then the nursing staff had been educated on serving hot beverages, safe temperatures for hot beverages, and safe temperatures for reheating food. During an interview conducted on 03/20/25 at 8:30 AM, the District CDM confirmed that the facility had implemented a hot beverage temperature monitoring on 02/24/25 following the incident. She stated that the Kitchen staff are required to check all hot beverage temperatures before they leave the kitchen, ensuring they do not exceed 135 Fahrenheit. Beverage temperatures are recorded in a daily log, which is reviewed by the Kitchen Manager or a designated supervisor. The District CDM further stated that both the kitchen and nursing staff were provided with education on safe beverage temperatures and the monitoring procedures. A review of the hot beverage temperature log conducted on 03/20/25 at 8:32 AM confirmed the hot beverage temperatures were documented for each daily serving and the temperatures were no greater than 135 Degrees Fahrenheit since 02/24/25. A review of the in-service education for the kitchen and nursing staff was conducted on 03/20/25 at 8:54 AM. The in-service provided education on the hot beverage temperature safety and safe temperatures for reheating food. The facility implemented corrective measures on 02/24/25 to monitor and document all hot beverage temperatures served from the kitchen. The kitchen staff were educated on the new process to monitor, document and serve all hot beverages with a temperature of no greater than 135 degrees Fahrenheit. On 02/24/25 the nursing staff were educated on hot beverage safety and safe temperatures for reheating food.

Based on medical record review, interview of facility staff and observation it was determined that the facility staff failed to utilize the proper sling size when transferring residents with the mechanical lift. This was evident for 2 of 22 sampled residents selected for review. The findings include: 1) Resident #12 is a [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 4/19/2013. Review of the Lift-Transfer-Repositioning Evaluation dated 3/30/2013 revealed that the resident requires a total lift to be transferred in and out of bed. Based on the assessment, the facility staff determined that the resident requires the use of a large, full body sling with the mechanical lift for transfers. Observation of the resident on 4/19/2013 at 11:30 a.m. revealed that the resident was out of bed in a geri-chair. The sling that was used with the mechanical lift to transfer the resident was underneath the resident. The border of the sling was purple. Interview of the assistant director of nursing, Staff #1, revealed that sling size is identified by the color of the border. The selection of sling size is based on a resident's weight. The purple border indicates a medium size sling. The facility staff failed to utilize the correct size sling for Resident #12's weight. 2) Resident #4 is a [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 4/19/2013. Review of the Lift-Transfer-Repositioning Evaluation dated 4/16/13 revealed that the resident requires a total lift to be transferred in and out of bed. Based on the assessment, the facility staff determined that the resident requires the use of an extra large, full body sling with the mechanical lift for transfers. Observation of the resident on 4/19/2013 at 2:30 p.m. revealed that the resident was out of bed in a geri-chair. The sling that was used with the mechanical lift to transfer the resident was underneath the resident. The border of the sling was green. Interview of the assistant director of nursing, Staff #1, revealed that sling size is identified by the color of the border. The selection of sling size is based on a resident's weight. The green border indicates a large size sling. The facility staff failed to utilize the correct size sling for Resident #4's weight.

Resident #1 is a [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 3/5/13. review of the resident's medical record revealed [REDACTED]. The evaluation revealed that the resident is unable to safely ambulate and transfer independently or with supervision only, cannot safely ambulate with assistance and perform greater than or 50% of lift/transfer with stand pivot assist and is unable to bear weight on at least one leg. Based on the evaluation, the facility staff determined that the resident required the use of the total lift for transfers. Additionally, the resident requires the assistance of two (2) staff members for transfers. Review of the nursing progress note dated 12/11/12 at 11:11 p.m. revealed that while the resident was being transferred from the geri-chair to the bed by the geriatric nursing assistant (GNA), the resident's " left knee hit the edge of the bed or knee was twisted. " The nurse further documented that the resident complained of severe pain. The nurse notified the resident's attending physician and an x-ray of the resident's left knee was ordered. Review of the facility's investigation of the resident's injury revealed that the GNA transferred the resident from the geri-recliner to the bed. The GNA failed to use the mechanical lift and the assistance of a second staff member to transfer the resident from the geri-chair to the bed. The results of the x-ray revealed that the resident had sustained an acute fracture of the distal femur. The resident's physician was notified of the x-ray results and the physician gave an order to transfer the resident to the hospital. The resident was subsequently admitted to the hospital on [DATE] and underwent surgical repair of femur fracture.

Based on medical record review it was determined the physician failed to appropriately and promptly intervene when a resident experienced signs and symptoms of complications related to the placement of a gastrostomy tube. This was evident for 1 of 2 sampled residents selected for review. The findings include: Resident #1 is an [AGE] year old with [DIAGNOSES REDACTED]. The resident has a gastrostomy tube due to inadequate oral intake and a history of [MEDICAL CONDITION]. A gastrostomy is a surgical procedure in which an opening for a tube is made through the wall of the stomach and joined to an opening in the adjacent abdominal wall. This allows food, fluids and medications to be placed directly into the stomach via a tube, referred to as a gastrostomy tube. Review of the resident's medical record on 1/26/12 revealed that on 12/13/11 the nurse documented in the progress note that the resident's gastrostomy tube appeared to be leaking. The resident's physician was notified and ordered replacement of the gastrostomy secondary to leakage of the existing gastrostomy tube. The resident was scheduled for the gastrostomy tube replacement on 12/14/11. The resident was transferred on 12/14/11 to the [MEDICATION NAME] for replacement of the gastrostomy tube and returned to the facility on the same day. On 12/18/11 the nurse documented in the progress note that while incontinent care was being provided, the geriatric nursing assistant noticed that the resident's stool looked like undigested tube feeding and the resident had a small amount of light green emesis. The nurse assessed the resident and documented that the resident had a copious amount of diarrhea. The physician was notified on 12/18/11 and gave an order to hold the resident's tube feeding for 4 hours, then restart. The physician also ordered laboratory blood work which included a complete blood count and a comprehensive metabolic panel. The physician did not order an x-ray to confirm placement of the gastrostomy tube. On 12/19/11 the nurse documented in the progress note that the resident's stool was "GT (gastrostomy tube) feeding colored." The physician was notified and in response, the physician ordered a PT/INR which is a blood test that assesses coagulation. The physician did not give an order to hold the tube feeding and the physician did not order an x-ray to confirm placement of the gastrostomy tube. On 12/20/11 the nurse documented in the progress note that the resident continued to have abnormal colored stools which appeared to be the color of the gastrostomy tube feeding. On 12/21/11 the nurse documented in the progress note that the resident's respirations were labored. The resident also had an elevated temperature and pulse. The physician was notified of the resident's change in condition and in response at 10:07 a.m. the physician ordered a chest x-ray secondary to coughing and fever, [MEDICATION NAME], an antibiotic medication, oxygen for shortness of breath and [MEDICATION NAME] nebulizer treatments 3 times per day. At 1:20 p.m. the physician ordered that the resident be transferred to the hospital for further evaluation. The resident was subsequently admitted to the hospital on [DATE]. Review of the hospital medical record revealed that the resident was diagnosed with [REDACTED]. The resident was intubated and placed on mechanical ventilation. Additionally, after receiving two tube feedings in the hospital, it was noted that "tube feeds were coming directly into the colon and the rectum." As a result, a CT scan was performed and revealed that the resident's gastrostomy tube was misplaced in the sigmoid colon. The resident underwent [REDACTED]. The gastrostomy tube was removed from the sigmoid colon and a new gastrostomy tube was placed. Despite evidence that the resident's gastrostomy tube, which was replaced on 12/14/11, was not in his stomach, but rather in the colon as evidenced by multiple reports of stools that looked like gastrostomy tube feeding by nursing between 12/18/11 and 12/20/11, the physician failed to respond and intervene appropriately. The standard of practice is to hold the tube feedings and confirm placement of the gastrostomy tube. Because the resident was being malnourished 12/14/11 through 12/21/11 as the result of a misplaced gastrostomy tube, this contributed to the resident's overwhelming infection as no nutrients were being absorbed.