Every finding on record at Complete Care at Severna Park LLC

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure the proper infection prevention and control practices related to 1) the availability and use of personal protection equipment (PPE), 2) handling and processing of soiled laundry, and 3) the cleaning and storage of reusable medical equipment. This was evident in 3 of 3 facility areas observed during the annual survey.The findings include:1) On 06/08/2026 at 7:27 AM, the surveyor observed that there was no isolation carts placed in the A-wing hallway.On 06/08/2026 at 1:30 PM, a record review revealed that Resident #66 was on Enhanced Barrier Precautions (EBP) with care planning initiated on 4/1/2026.On 06/08/2026 at 1:45 PM, the surveyor revisited the A-wing hallway and observed two isolation carts located near residents' doors with EBP signage. On 06/10/2026 at 10:00 AM, the surveyor toured the facility with the Infection Preventionist (IP). During the interview, the IP confirmed that no isolation carts had been placed in the A-wing hallway during the morning of Monday, 06/08/2026. The IP stated that the weekend night-shift may have removed the isolation carts while cleaning the hallway. The IP further explained that the facility may implement an alternative process to ensure PPE remained readily accessible for residents on EBP in order to minimize the risk of infection transmission.2) On 06/08/2026 at10:44 AM, the surveyor observed a bedside commode obstructing access to the handwashing sink in the soiled laundry room. The surveyor requested that the Maintenance Director turn on the hot and cold water from the faucet. However, no water dispensed in the sink. In addition, the handwashing sink was not supplied with soap and paper towels.Further observation revealed that the plastic air curtain installed between the clean and soiled laundry rooms as a physical barrier swayed back and forth, leaving the separation partially open. The Nursing Home Administrator and the Maintenance Director acknowledged that the plastic air curtain was insufficient to maintain proper separation between the soiled and clean laundry rooms. On 06/10/2026 at 9:21 AM, the surveyor revisited the soiled laundry room and observed Staff #25 sorting soiled laundry without proper PPE, including a gown and gloves. During an interview, Staff #25 retrieved a plastic gown from the clean laundry room. However, he was unable to perform wash hygiene because the handwashing sink remained nonfunctional and did not provide hot running water.At 10:20 AM, the surveyor toured the laundry room with the IP and discussed the issues listed above. The IP acknowledged that the staff would require additional education regarding proper donning and doffing of PPE, and that repairs or replacement of the handwashing sink would be necessary to ensure hand hygiene practices could be performed appropriately.3) On 06/10/2026 at 10:30 AM, the surveyor toured the central supply room with the IP and observed four oxygen concentrators and six IV poles stored in the room. The IP confirmed that the equipment stored in the central supply room should be clean and sanitized before storage and availability for resident use. However, upon inspection, several oxygen concentrators contained visible dust accumulation, and height adjustable IV poles had tape wrapped around portions of the equipment, preventing verification that the equipment had been appropriately cleaned and sanitized.During an interview, the IP acknowledged that the oxygen concentrators appeared unclean and stated that the IV poles with tape should have been discarded.

Based on administrative record review and interview with facility staff, it was determined that the facility failed to ensure nurse aides received a minimum of 12 hours of annual in-service training. This was evident in 3 of 3 certified nurse aide/ geriatric nurse aide (CNA/GNA) employee files reviewed during the annual survey.The findings include:On 06/10/2026 at 5:00 PM, the surveyor reviewed employee files for three GNAs. Record review revealed that Staff #20, Staff #22, and Staff #27 did not have documentation of the required 12 hours annual in-service training.At 6:00 PM, an interview with the Director of Nursing (DON) confirmed that the facility did not currently have an in-service training program in place to ensure GNAs completed the 12 hours of annual in-service training. The DON acknowledged that Staff #20, Staff #22 and Staff #27 had not received the required annual in-service education hours.

Based on observation, and interview with facility staff, it was determined that the facility failed to maintain a pest-free environment. This was evident in the kitchen, 2 (Rooms A-6, and D-9) of 4 rooms, and 2 (Station 1 Single, and Station 2) of 3 shower rooms reviewed during the annual survey.The findings include:On 06/08/2026 at 7:40 AM, the surveyor conducted an initial kitchen tour with the Dietary Manager and observed multiple gnats flying near the front kitchen entrance door. Additional gnats were observed in the area of the cookline handwashing sink area, and within the food storage room. During an interview, the Dietary Manager stated that he was unaware of the source of gnats.At 8:00 AM, the surveyor observed a rodent glue trap placed on top of the dish machine. The trap was visible within the kitchen equipment and contained several dead insects. At 9:30 AM, the surveyor conducted a follow-up kitchen tour with the Nursing Home Administrator (NHA), Maintenance Director, and the Dietary Manager and showed them the improper placement of rodent glue trap on the dish machine. The NHA immediately removed the glue trap and discarded it in the trash can. The NHA confirmed that the glue traps should not be placed on top of food service equipment.On 06/09/2026 at 10:25 AM, the surveyor observed multiple gnats flying throughout residents' room, A-6. During an interview, Staff #22 confirmed the presence of gnats the resident room.At 10:32 AM, while touring the shower rooms with Staff #5, the surveyor observed gnats flying around in the Station 1 Single Shower Room.At 10:41 AM, the surveyor observed additional gnats flying in the Station 2 Shower Room. During an interview, Staff #5 acknowledged that gnats have been an ongoing issue within the shower rooms.At 10:53 AM, the surveyor observed a rodent glue trap on a windowsill in residents' room, D-9. The glue trap contained several dead insects and was accessible within the resident environment. During an interview, the Director of Nursing (DON) confirmed that the glue trap would be removed from the windowsill. The DON further stated that the damaged windowsill, and torn baseboard in the room would be repaired and/or replaced to prevent possible pest harborage and future infestations.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure to provide proper airflow local exhaust ventilation systems. This was evident for 3 out of 3 shower rooms, 1 of 2 used linen rooms, soiled laundry room, and a chemical storage room reviewed during the annual survey.The findings include:Airborne transmission occurs when pathogens are so small that they can be easily spread in the air, and because of this, there is a risk of transmitting the disease through inhalation. These small particles containing infectious agents may be spread over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individuals. According to the Centers for Disease Control and Prevention (CDC), preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems.On 06/08/2026 at 9:30 AM, the surveyor revisited the kitchen with the Nursing Home Administrator (NHA) and the Maintenance Director. During an interview, the Maintenance Director confirmed that the exhaust ventilation system serving the chemical storage room located within the kitchen was not functional.At 10:30 AM, the surveyor observed that the Station 1 Shower Room was humid and lacked noticeable airflow. The Maintenance Director turned on the switch for the exhaust ventilation and a loud grinding noise emitted from the unit. The Maintenance Director acknowledged that the exhaust ventilation system required further assessment and repair. At 10:40 AM, a review of the Station 2 Used Linen Room and observed three bins filled with soiled laundry. A strong foul odor was present throughout the room. During an interview, the Maintenance Director stated that the exhaust system may require readjustment to properly remove odors and provide adequate air exchange within the room.At 11:00 AM, the surveyor observed that the mechanical exhaust ventilation was absent in the soiled laundry room, exhaust fan cover was missing, and noted that the room window was open. During an interview, the Maintenance Director confirmed that the mechanical ventilation system serving the soiled laundry room was nonfunctional and stated that repairs would be completed promptly. On 06/09/2026 at 10:32 AM, the surveyor observed that the Single Shower Room by the Nurse's Station 1 remained humid and lacked adequate airflow. During an interview, Staff #5 acknowledged that the room was humid, and confirmed that no airflow could be felt from the exhaust ventilation system.At 10:41 AM, the surveyor observed Station 2 Shower Room was also humid and had a musty odor. In addition, the bottom portion of the door jamb showed rust and deterioration consistent with prolong moisture exposure. During an interview, Staff #5 confirmed that the Maintenance Director would be notified of the ventilation concerns and associated repairs.

Based on observation, record review, policy review and staff interview, it was determined that the facility failed to ensure respiratory equipment was maintained, stored, and labeled in accordance with physician orders, facility policy, and infection prevention and control standards. These deficient practices had the potential to affect residents receiving oxygen therapy, nebulizer treatments, and tracheostomy. This was evident for five (Residents #1, #4, #9, #15, and #45) of six residents reviewed for respiratory care during the recertification survey. The findings include: On 6/08/2026 at 8:13 AM, Resident #45 was observed receiving oxygen via nasal cannula; however, the oxygen tank connected to the resident was empty. The oxygen tubing was not labeled with the required date and staff initials. A nebulizer machine and face mask were also observed unlabeled, and the nebulizer face mask was not stored in a manner that prevented contamination. On 6/08/2026 at 8:15 AM, observation of Resident #15 revealed a nebulizer machine on the bedside table with unlabeled tubing and an uncovered nebulizer mask. On 6/08/2026 at 9:33 AM, observation of Resident #9 revealed oxygen tubing connected to the oxygen concentrator that was not labeled with the required date and staff initials. On 6/08/2026 at 9:42 AM, observation of Resident #4 revealed oxygen tubing and nasal cannula lying on the floor. At 9:47 AM, Licensed Practical Nurse (LPN) #12 entered the room, picked up the nasal cannula from the floor, wiped it with an alcohol wipe, and reapplied it to the resident. On 6/09/2026 at 7:45 AM, review of medical records revealed the following: -Resident #15 had diagnoses that included Chronic Obstructive Disease (COPD). Physician orders directed oxygen at 2 liters per minute via nasal cannula continuously and required staff to change oxygen humidifier bottle and tubing weekly and label each component with the date and initials. -Resident #9 had physician orders for oxygen at 3 liters per minute via nasal cannula and weekly replacement of the oxygen humidifier bottle and tubing, with instructions to label each component with the date and initials. -Resident #4 had a diagnosis of COPD and physician orders for continuous oxygen at 3 liters per minute via nasal cannula. The resident also had an order requiring weekly replacement of oxygen humidifier bottle and tubing, with each component labeled with date and initials. On 6/09/2026 at 9:04 AM, during an interview, Registered Nurse (RN) #6 stated oxygen tubing should be changed every seven days and labeled with the date and staff initials. RN #6 further stated that nebulizer masks should be rinsed after each use and stored in a bag to prevent contamination. When asked what action should be taken if a nasal cannula was found on the floor, RN #6 stated it should be replaced immediately because staff would not know how long it had been on the floor. RN #6 further stated that staff should not wipe the cannula with alcohol and reapply it to the resident. On 6/09/2026 at 10:57 AM, the Assistant Director of Nursing (ADON) was notified of the findings and acknowledged the concerns. On 6/10/2026 at 2:08 PM, a review of the facility's Oxygen Therapy Policy revealed that disposable oxygen equipment was to be changed weekly, or in accordance with the facility's infection prevention and control guidelines. During the initial tour on 6/08/26 at 9:05 AM, the surveyor observed that Resident #1 had an active tracheostomy with oxygen infusing. The oxygen flow meter was set to 4 L/min (liters per minute), and the oxygen tubing was lying directly on the floor. During a second observation on 6/12/26 at 8:37 AM, Resident #1's oxygen tubing was again observed lying on the floor. The oxygen flow meter remained set at 4 L/min, and the oxygen humidifier bottle was not labeled with a change date or initials. A review of Resident #1's medical record on 6/12/26 at 8:50 AM revealed active physician orders stating: change the oxygen humidifier bottle and tubing weekly, label each component with the date and initials, maintain a 6.5 mm Shiley tracheostomy tube and an Ambu bag at the bedside, maintain an 8.0 mm Shiley tracheostomy tube and an Ambu bag at the bedside, and administer oxygen at 5 L/min via the tracheostomy. At 9:02 AM on 6/12/26, the surveyor observed Resident #1's room alongside Unit Manager #5. Unit Manager #5 verified that the oxygen tubing was lying on the floor, the oxygen was set incorrectly at 4 L/min, the humidifier bottle was unlabeled, and there were no back-up tracheostomy tubes (neither the 6.5 mm nor the 8.0 mm Shiley) or emergency Ambu bags present in the room. On 6/12/26 at 9:15 AM, the surveyor reviewed Resident #1's care plan. The review revealed that a comprehensive tracheostomy care plan had not been initiated since the resident's admission on [DATE]. During an interview with the Director of Nursing (DON) on 6/12/26 at 9:20 AM, the surveyor reviewed the aforementioned findings. The DON validated the findings and confirmed that the facility staff failed to implement the ordered respiratory services and emergency safety equipment.

Based on observation, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tours of the annual survey. The findings include:A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 06/08/2026 at 7:36 AM, the surveyor conducted a tour of the kitchen alongside the Dietary Manager and identified the following deficient practices:-All three handwashing sinks in the kitchen were not properly stocked with soap and paper towels. One handwashing sink located in the cooking area, next to the two-door reach-in refrigerator, had a nonfunctional hot water faucet handle and could not dispense hot water necessary to perform proper hand hygiene practices. -The chemical storage room was inadequately illuminated. No lightbulbs were installed in the room, requiring the door to remain propped open to view and access chemical products stored in the room.-The deli slicer was damaged. The slicer handlebar was missing, and staff were using a rusted metal lever to manually push and pull the food tray back and forth across the spinning blade. -The walk-in cooler fan covers, and conduit lines were unclean and showed excessive buildup of dust, dirt, debris, and mold-like substances.-A pan of sliced deli meat and multiple opened packages of deli meat wrapped in plastic and stored in the walk-in cooler without labels indicating the preparation date and/or date opened. Deli meats are considered ready to eat foods, and if held beyond recommended timeframe, may support the grow of pathogens such as Listeria monocytogenes. Unlabeled food items were discarded onsite. -The rear kitchen entrance door was in disrepair. The door surfaces were chipped, pitted, cracked, and rusted, with multiple holes that could allow the entry of outside elements, and pests.-The low-temperature Ecolab dish machine was unclean. The outside surfaces of the machine were soiled, a rodent glue trap was placed on top of the machine next to the temperature gauges, the dishwasher curtains were warped, and the vertical vent stack damper venting holes were covered in dust, debris, and mold-like substances.On 06/08/2026 at 9:00 AM, the surveyor revisited the kitchen with the Nursing Home Administrator (NHA) and the Maintenance Director to review the observations listed above.On 06/09/2026 at 11:30 AM, the surveyor observed the trayline food service operations and noted that all plastic food trays and most of the plastic dome covers showed signs of wet nesting. In addition, several plastic plate dome covers were heavily damaged, which chipped surfaces creating potential for contamination and preventing effective cleaning and sanitization. During an interview, the Dietary Manager confirmed that trays and plate covers could not be completely air-dried between meal services when utilizing the low-temperature dish machine. The Dietary Manager further confirmed that the damaged plastic plate dome covers would be replaced.On 06/10/2026 at 6:15 PM, the surveyor conducted a preliminary exit conference with the facility leadership team. The NHA confirmed that the kitchen equipment such as the rear entrance door and dish machine will be replaced and/or repaired within the next several weeks.

Based on record review, complaint #3008206 and interviews, it was determined that the facility failed to: 1) obtain hospice orders as required to ensure that the hospice services meet professional standards which was evident for 4 (Resident #32, #112, #115 and #142) of 4 residents record review for hospice orders during the annual survey process; and 2) provide services in the facility, and to the timeliness of the services which was evident for 1 (Resident #142) of 6 resident records review for complaint during the annual survey process. Findings Included:1) On 06/11/2026 at 1:42 PM, in a Director of Nursing (DON) interview she was asked about Resident #115's hospice order and she reported that there was no hospice order in the Resident's chart. The DON confirmed that there should have been an order placed for hospice. She reported that the facility was made aware of the Resident being placed on hospice based on hospice communication log documentation on 12/10/2026.On 06/12/2026 8:28 AM, in an interview with Licensed Practical Nurse (LPN)#18 agency nurse, she was asked to explain how the facility communicate to nursing that a resident was admitted to hospice and she reported that they get the communication from the previous nurse in hand off report. She reported that hospice documentation can be found at the resident's bedside and the same information would be in the resident's physical chart as well as in the electronical chart. On 06/12/2026 at approximately 09:00 AM, the surveyor observed three hospice Resident rooms (resident #32, #112 and #115) for hospice documentation at the bedside; however, there was none found.On 06/12/2026 9:05 AM, in an interview with the memory care director (Staff 47), she was asked to explain how the facility notify staff when a resident switches to hospice care and she explained we have the information on our plan of care, we have a form at the nurse cart with new changes including hospice, we also provide the information in hand off report and then when someone goes off hospice that would also be communicated. On 06/12/2026 at 9:45 AM, a review of Resident #32, #112 and #115's record revealed that the facility failed to obtain admission to hospice orders at the time of the residents' hospice admission. A review of Resident #32's record revealed that on 5/5/2026 the resident was placed on hospice; a review of Resident #112's record revealed that on 1/3/2025 the resident was placed on hospice; and a review of Resident #115 record revealed that on 12/10/2025 the resident was placed on hospice; however, there was no documentation to suggest that the facility obtained orders to admit the resident to hospice at the time of the hospice admission. After surveyor's intervention hospice orders were obtained on 06/11/2026 and placed in each Resident's chart.On 06/12/2026 at 9:33 AM, in an interview with LPN#51, she was asked if a resident was admitted to hospice, should the resident's chart have orders for hospice at the time of admission and she stated yes. She was notified that the above-mentioned residents did not have written order for hospice care until 6/11/2026 and it was a concern that the facility failed to have a cohesive method to identify the residents who are on hospice. She verbalized understanding.2) On 06/12/2026 at approximately 1:20 PM, a review of complaint #3008206 revealed allegations that Resident #142 had hospice physician's order for comfort measures medication that was not fulfilled for 24 hours on April 15, 2026. The complaint alleged that the resident was writhing in pain for 24 hours, NEGLECTED.On 06/15/2026 at approximately 11:00 AM, a review of Resident #142's admission profile revealed that the resident was admitted to hospice on 04/15/2026; however, there was no documented evidence that the facility obtained an order to admit resident to hospice services on 04/15/2026 to ensure that all staff members were aware of the Resident's hospice admission and could meet the resident's hospice needs. There was also no documentation from nursing to indicate the time the resident was admitted to hospice and/or when the resident's healthcare practitioner was notified that the hospice admission was completed.On 6/15/2026 at approximately 11:15 AM, a review of the resident hospice agency admission documentation revealed that the resident was admitted to hospice on 4/15/2026 between 3PM and 5 PM. At the time of admission, the admitting hospice nurse wrote management recommendations for morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution Notes: Indication: pain/ shortness of breath 5MG Oral Every Four around the clock. Lorazepam 0.5mg, 1 tablet every 4 hours as needed for anxiety and agitation.A review of Resident #142's electronic Medication Administration Record (MAR) revealed that on 4/16/2026 at 12:19 AM, the order was initiated for Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours for pain, Shortness of Breath (SOB), agitation Administer 0.25 mL (5mg) every 4 hour around the clock and Lorazepam Oral Tablet 0.5 MG (Lorazepam)Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation/SOB for 14 Days.On 06/15/2026 at approximately 11:20 AM, a review of Resident #142's hospice nurse's notes revealed that on 04/16/2026 the resident was having pain/restlessness, and the pharmacy had not delivered morphine as ordered to manage resident's comfort. As a result, the resident was transferred to an in-patient hospice facility for unmanaged pain.On 06/15/2026 at approximately 11:30 AM, a review of a medication administration note written on 4/16/2026 at 1:45 PM revealed that the pharmacy delivered the morphine on 4/16/2026 at 12:50 PM.A review of Resident#142's discharge summary revealed that on 4/16/2026 the medical practitioner wrote: Assessment & Plan: End of life care patient actively transitioning, admitted to hospice on 4/15 pain not well controlled, discharging to inpatient hospice house.On 06/15/2026 at 1200 PM, in an interview with the Director of Nursing (DON) she was asked about how the facility monitors residents for pain and she report the use the numeric pain scale and if they cannot speak but were cognitively intact, we would use the communication board to indicate their pain level. Residents who cannot speak the nurse's observe for non-verbal cues such as grimacing, crying, withdrawing, guarding would be used to assess pain. She reported that they would also be care planned for pain management.On 06/15/2026 at approximately 12:15 PM a review of Resident #142's notes revealed 04/16/2026 13:47 Medication Administration Note stated patient is now hospice, couldn't verbalize pain level.On 06/15/2026 at 1250 PM, in an interview with hospice Staff #50, the staff member was asked to explain the admission process and he/she explained that after the referral for hospice was obtained that the hospice admission nurse would be sent out to meet the resident and the resident representative at a specified location where hospice nurse would assess the resident and admit if appropriate. Once the resident is admitted the nurse would obtain recommendation from the hospice physician and would provide the written recommendations to the nursing staff in a long-term care setting. They reported that the facility's medical practitioner would make the final decision if they agreed or not, with the recommendation of the hospice physician. After the hospice nurse notified facility of the admission, the facility becomes responsible for obtaining the orders and sending them off to their pharmacy. The surveyor requested hospice care documentation, and it was obtained from the hospice agency.On 06/15/2026 at approximately 1:30 PM, a review of the hospice care agency documentation revealed that on 04/16/2026 12:00 PM, Resident#142 was restless in pain, hospice facility recommended morphine 5 mg every 4 hours. However, the pharmacy did not deliver medication to the facility and facility does not have the medication in the pyxis system. The resident has not received ordered morphine. Oxycodone 5mg crushed and given at 11:45 AM.On 06/15/2026 at 01:38 PM, in an interview with Staff #5 (unit manager), she was asked to explain the hospice process, and she reported that the facility would receive an order from the resident's healthcare practitioner for the hospice admission on the date that the hospice was initiated. The hospice recommendations would be given from the hospice nurse but the order have to be cleared by our attending Physician, Physician Assistant or Nurse Practitioner. Staff #5 explained that usually the hospice nurse would communicate with the facility staff and the written order were typically given to the nurse because the hospice nurse cannot enter the order in the electronic chart. After the orders are obtained from the healthcare practitioner, we would put it in the electronic medical record which would communicate to the pharmacy that new orders were obtained. If the medication is a controlled substance, the pharmacy requires a prescription to be faxed before the pharmacy can deliver the controlled drugs to the facility. The surveyor was unable to obtained clarification from the staff about if and when Resident #142's prescription was sent to the pharmacy.She was asked if the hospice admission should be documented in the resident chart in a progress note and she explained that hospice admission notes are not always written but she admitted that a hospice admission note should be in the resident's chart.The surveyor shared with Staff #5 that the facility failed to obtain an order for hospice, failed to document the resident's chart about the resident's condition when they were admitted to hospice and failed to indicate when the physician was notified about the hospice admission. She was asked if a change of condition form was required at the time of the hospice admission and she reported that it was typical for the change of condition form to be completed before the actual hospice admission because it would be done to capture when the resident status initially changed requiring hospice care.Staff#5 was informed that the resident had a recommendation for morphine 5mg every 4 hours around the clock for shortness of breath and pain by the hospice nurse at approximately 5PM on 04/15/2026 due to the resident being symptomatic; however, the facility failed to ensure proper symptom management as the resident did not receive morphine as ordered to ensure the resident was comfortable throughout the night. There was also no documentation to suggest that the facility staff made any effort to obtain alternate pain measures or contact hospice if the comfort medications were not available. She was asked if it was reasonable that the resident should wait and extended period of time for pain medication from (4/15/2026 at approximately 5p to 4/16/26 at 1250 PM and she confirmed that the wait was too long and agreed that other intervention should be taken. Concerns were communicated to the unit manager at this time.

Based on a review of medical records and staff interviews, it was determined that the facility failed to provide necessary care and follow required clinical protocols for a resident with an indwelling urinary (Foley) catheter. This failure was identified in one resident (Resident #122) out of two residents reviewed for Foley catheter care during the annual survey.The findings include:On 6/08/26 at 1:03 PM, the surveyor investigated a complaint received from an outside source. The review revealed that Resident #122 did not receive appropriate Foley catheter care from the facility staff.A review of Resident #122's medical records on 6/09/26 at 11:27 AM revealed that the resident was evaluated by Urology on 1/23/26. The consultation note from the urologist stated, Remove catheter and have him/her changed every 4 hours. and consult one of our MDs for suprapubic catheter placement. However, there was no subsequent follow-up appointment documented in the facility's system.During an interview with Unit Secretary #8 on 6/09/26 at 12:33 PM, she verified that the most recent urology consultation occurred on 1/23/26. When the surveyor asked whether Resident #122 had any follow-up appointments scheduled after the January 2026 visit, Unit Secretary #8 confirmed that no further follow-up had been arranged, stating, I just talked to the resident, he/she did not like [the] suprapubic catheter.Further review of Resident #122's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the resident's Foley catheter was documented as changed on 3/20/26, 3/22/26, and 6/02/26. However, progress notes indicated additional catheter changes occurred on 5/14/26 and 6/01/26 without being documented on the MAR or TAR with various sizes of catheter.During an interview with the Director of Nursing (DON) on 6/11/26 at 12:29 PM, the surveyor shared the aforementioned concerns. The DON stated that Resident #122 had frequent issues regarding Foley catheter care, including refusing care, complaining of discomfort, and expressing false beliefs that the catheter was damaged, leaking, or contaminated. The DON stated, I agree all of those episodes should be documented in his/her chart.

Based on observations, medical record reviews, and interviews with facility staff, it was determined that the facility failed to ensure residents remained free from accidents and hazards. Specifically, the facility failed to: 1) thoroughly assess residents who smoke to ensure their safety, and 2) implement timely interventions for residents experiencing ongoing altercations with peers. This deficient practice affected 2 out of 5 residents reviewed for smoking (Residents #108 and #122), and 2 out of 2 residents reviewed for resident-to-resident altercations (Residents #56 and #81) during this annual survey.The findings include:1) Failure to Assess and Ensure Smoking SafetyDuring the entrance conference on 6/08/26 at 8:20 AM, the Assistant Director of Nursing (ADON) stated, This is a smoke-free building. However, alert and oriented residents can go outside of the facility's property after signing in and out on the Leave of Absence (LOA) form.On 6/09/26 at 1:36 PM, facility staff provided a list of five current smokers. A review of these residents' medical records revealed the following:-Resident #108: The resident's Brief Interview for Mental Status (BIMS) score on 5/15/26 was recorded as 00 (indicating severe cognitive impairment). The resident's previous BIMS scores consistently ranged between 12 and 13 out of 15 (indicating mild to no impairment). There was no follow-up documentation regarding this significant cognitive decline.-Additionally, Resident #108's medical record showed that the most recent smoking assessment was conducted over a year prior, on 4/15/25. There was no current documentation addressing how the facility assessed the resident's ability to smoke safely.On 6/09/26 at 1:40 PM, Resident #108 and Resident #122 were observed smoking outdoors behind a designated line marking the facility's property boundary. During an interview at that time, Resident #108 stated that there were no rules or limitations regarding smoking, adding, I can be here anytime I want to smoke. I have not signed the form recently.On 6/09/26 at 1:54 PM, Receptionist #7 stated during an interview that smokers are required to sign the LOA form before going outside to smoke. A review of the sign-out sheet, titled Release of Responsibility for Leave of Absence (for the week of 6/07/26 to 6/13/26), revealed columns for date, departure time/signature, destination, phone number, return date/time, and return signature. The log contained only seven signatures-all from the same individual, whose name was illegible-and lacked any of the other required tracking information.On 6/09/26 at 2:00 PM, Resident #108 was observed lying in bed while receiving oxygen via a nasal cannula. The resident confirmed keeping a cigarette lighter and cigarettes inside the room.On 6/09/26 at 1:45 PM, a medical record review for Resident #122 revealed that their most recent smoking assessment was also dated 4/15/25. Resident #122 confirmed that they had not filled out the LOA log recently for smoking.During an interview on 6/12/26 at 8:18 AM, the Director of Nursing (DON) stated that because the facility is smoke-free, they do not maintain a specific smoking policy or procedure. However, the DON agreed that the facility must track and evaluate a smoker's cognitive level to ensure they are safe to go outside to smoke independently. The DON reviewed the medical records for Residents #108 and #122 and verified that both residents required updated assessments to clear them for independent smoking.2) Failure to Implement Interventions for Resident AltercationsDuring a review of self-reported incident #3019517 on 6/11/26 at 1:00 PM, record review revealed that Resident #81 reported to the Administrator that his/her roommate had allegedly hit [them] on the right hand and in the stomach on 5/20/26 at 10:00 AM. The facility's internal investigation noted that the resident had visible bruising on the right hand and stomach.A review of Resident #81's medical record revealed that the resident had reported several conflict episodes with his/her roommate prior to the injuries noted on 5/20/26:-On 4/29/26: Resident #81 reported that his/her roommate (Resident #56) used the phone all night, causing severe disruption.-On 5/01/26: A progress note recorded another verbal/physical conflict, including claims that Resident #56 blocked the pathway to the restroom and spoke loudly while Resident #81 was trying to sleep.-On 5/07/26: Another conflict occurred between Resident #56 and Resident #81 regarding light and noise levels in the room.-On 5/14/26 at approximately 2:00 PM: Resident #81 was observed throwing him/herself out of a wheelchair, resulting in a transfer to the hospital for an emergency evaluation. While at the hospital, Resident #81 insisted that the roommate and [they] have been having difficulties getting along for a while, and stated that the roommate may have pushed [them] to the ground.A review of Resident #81's psychology notes dated 5/13/26 revealed documentation stating the provider encouraged a room move to a safe room and encouraged [the resident] to inform staff of future roommate issues. Despite this recommendation and the ongoing history, no interventions were implemented by the facility to protect Resident #81 until after the physical assault and resulting injuries were reported on 5/20/26.During an interview with the DON on 6/11/26 at 3:12 PM, the surveyor reviewed the medical and administrative records of Resident #81 and Resident #56 with her. When asked what interventions had been provided to ensure resident safety during these ongoing disputes, the DON stated that both residents had been offered room changes but had refused them. However, a comprehensive review of both residents' medical records revealed zero documentation showing that room changes were ever officially offered or refused.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure that residents received medications and care in a timely manner. This deficient practice affected 1 resident (Resident #122) out of 21 residents reviewed for care provision during the annual survey.The findings include:During the investigation of complaint #3036801 on 6/12/26 at 2:44 PM, a record review revealed that the complainant expressed severe concerns regarding Resident #122's care on 6/08/26, specifically alleging that the resident received delayed care.On 6/15/26 at 8:20 AM, the surveyor reviewed Resident #122's Medication Administration Record (MAR) and Treatment Administration Record (TAR). The review revealed that on 6/07/26, scheduled morning medications (ordered for administration between 7:00 AM and 9:00 AM)-which included a diuretic, Parkinson's medication, and blood pressure medications, some of which were scheduled for twice-daily administration-were not administered until 4:20 PM. There was no documentation within the medical record explaining why the medication administration was delayed by approximately eight hours.During an interview on 6/15/26 at 7:35 AM, Unit Manager #5 was asked whether Resident #122 had experienced any issues regarding delayed care. She stated that she was completely unaware of any issues regarding care delays for this resident.During an interview on 6/15/26 at 8:50 AM, the Director of Nursing (DON) stated that facility staff are required to administer medications within a standard two-hour window (one hour before or one hour after the scheduled time). The DON further explained that nurses are required to document the exact administration time in the MAR immediately after giving the medications. The surveyor reviewed Resident #122's MAR alongside the DON and shared the finding that the morning medications were administered more than eight hours late. The DON validated the surveyor's concern and verified the non-compliance.

Based on medical record reviews and interviews with facility staff, it was determined that the facility staff failed to provide nursing care within professional standards of practice regarding safe medication administration. This deficient practice affected 1 resident (Resident #122) out of 6 residents reviewed for medication administration during the annual survey.The findings include:A review of Resident #122's medical records on 6/12/26 at 2:44 PM revealed that on 6/07/26, the resident's scheduled morning medications (ordered for administration between 7:00 AM and 9:00 AM) were significantly delayed and not administered until 4:16 PM.The delayed administration included a scheduled 9:00 AM dose of Tylenol (acetaminophen) 650 mg. A further review of the Medication Administration Record (MAR) showed that a second scheduled dose of Tylenol 650 mg (ordered for 1:00 PM) was documented as administered just three minutes later, at 4:19 PM. The records indicate that Resident #122 received a combined total of 1,300 mg of Tylenol within a three-minute interval, exceeding the maximum safe single dose of 1,000 mg for adults and posing a severe potential risk for medication toxicity.During an interview on 6/15/26 at 8:50 AM, the Director of Nursing (DON) stated that all medication administrations must be documented immediately after they are given to the resident. The surveyor reviewed Resident #122's MAR alongside the DON and pointed out that the two separate doses were administered concurrently, resulting in an unsafe single dose exceeding 1,000 mg. The DON validated the surveyor's concern and verified that the resident received an excessive single dose of acetaminophen at 4:19 PM.

Based on medical record review and staff interviews, it was determined that the facility failed to 1) revise the residents care plan after each fall and 2) ensure a care plan meeting was held. This is evident for two (Resident #27 and #7) of 24 resident care plans reviewed during the recertification survey process. The findings included: A care plan is a tool used to summarize the resident's healthcare needs, treatments, care goals and the staff responsible for the completion of treatment/task. This tool is to be developed within 7 days after completion of the comprehensive assessment and prepared by an interdisciplinary team. The Minimum Data Set (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 for based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 06/08/2026 at 10:14 AM, in an interview with Resident #27's representative they explained that the resident had multiple falls that resulted in various injuries. On 06/09/2026 at 9:01 AM, in an interview with License Practical Nurse (LPN) #46, the LPN was asked if she knew the resident and she explain that she was unfamiliar with Resident #27 because she worked for an outside agency and it was her first day at the facility. On 06/09/2026 at 09:05 AM, in an interview with Staff #47 (memory care director), she was asked who was responsible for care plan development and revision and she explained that care team which could include nurses, social work, rehab, activities, memory director, etc. were responsible for the care plan after an Interdisciplinary Team (IDT) meeting, each IDT member complete their section of the care plan which is typically done every 90 days and as needed due to change of the resident's status. She also reported that upon admission a care plan meeting would be completed with the resident, family and/or representative and the care plan was usually initiated immediately after the care plan meeting. On 06/09/2026 at 9:14 AM, a review of Resident #27's care plan revealed that the facility initiated a high risk for fall care plan on 04/24/2022 and it was revised on 04/15/2026 indicating that the resident: will have no falls with major injury through the next review date. The care plan also revealed that Resident #27 has had an actual fall with injury. This care plan was Initiated on 05/11/2022 and revised on 04/15/2026; however, there was no documentation to support that the facility revised the care plan after each fall to indicate additional interventions that were established to prevent future falls. On 06/09/2026 at 10:28 AM, a review of Resident #27 record revealed falls on 6/25/2025 6/5/2026, 3/13/2026, 4/14/2026. On 06/09/2026 at approximately 2:30 PM, a review of the facility's incident report revealed that on 06/25/2025 at approximately 06: 52 PM the resident was observed sitting on the floor facing their wheelchair and was noted to have bleeding on the back of the head. The resident was sent to the emergency room for evaluation. On 06/09/2026 at 2:38 PM, a review of the facility's incident report revealed that on 03/13/2026 at 04:35 AM Geriatric Nurse Assistant (GNA) reported that she found the resident face down on the floor and upon staff assessment a laceration to the resident's chin and head trauma was observed and as a result the resident was sent to the emergency room for suture and evaluation. On 06/09/2026 at 2:46 PM, a review of the facility's incident report revealed on 04/14/2026 at 1040 AM resident slid out of wheelchair to the floor sideways hitting the right lower leg on the wheelchair causing a 5cm scratch. The resident was not sent to the hospital. On 06/09/2026 at 2:55 PM, a review of the facility's incident report revealed on 06/5/2026 at12:10 PM resident was standing next to the bed when the resident fell back and hit their head on the floor. Bleeding was noted from the back of his/her head and the resident was transferred to hospital. 06/10/2026 8:38 AM, in an interview with LPN#45 she explained that the resident was alert and oriented to self and even though the resident was physically able to press the call light the resident never uses the call light due to confusion. On 06/10/2026 at 9:02 AM, in an interview with the memory care director (Staff #47), she was asked about the resident status related to the multiple falls sustained and the interventions that were put in place to prevent future falls. Staff #47 reported that they added a mirror in the hallway that the staff can observe the resident's living room. They also changed the location of the GNA table so that they were closer to the resident's room and had a better visual point for the resident. Resident #27 was encouraged to attend and participated in most activities. She explained that there was also a foam helmet that the staff encouraged the resident to wear when he/she was out of bed. However, the care plan was not revised to indicate above-mentioned interventions the facility implemented for this resident. On 06/10/2026 at 10:36 AM, in an interview with Staff #4, she reported that the GNA documented every shift: fall observation, helmet and hipster foam brief. She reported that the actual fall care plan was updated on 4/15/2026 and was documented in the progress notes. Staff #4 did not answer when asked if care plans should be updated after each fall to reflect resident status changes and additional injury-prevention interventions. She was asked how often the care plan should be updated and she reported every 90 days and with any changes in the resident's status. On 06/11/2026 8:50 AM, in an interview with the Director of Nursing (DON), the DON was notified that Resident #27 was identified as a high fall risk resident who had 4 falls (6/25/2025, 3/13/2026, 4/14/2026 and 6/5/2026) and 3 of the 4 falls the resident sustained injuries. However, the facility failed to have documentation to support that the care plan was revised/updated after each actual fall to prevent future falls with injury. The DON acknowledged the above-mentioned findings. 2) A review of Resident #7's clinical record on 6/11/26 at 10:48 AM revealed that the facility completed quarterly MDS's on 3/2/26 and 4/17/26. Further review revealed the most recent sign-in sheet was for a care plan meeting on 3/24/26. The social worker (Staff #16) was interviewed on 6/12/26 at 11:07 AM. This surveyor showed her the care plan sign in sheet dated 3/24/26 and asked if it was held as a result of the 3/2/26 MDS or in preparation for the next MDS which would later be completed on 4/17/26. She said she did not know. The Surveyor pointed out that if it referred to the 3/2/26 MDS then the meeting was held late and then there was no care plan meeting held as a result of the 4/17/26 MDS. The Surveyor then said if the care plan meeting was for the 4/17/26 MDS then it was too early and they failed to have a meeting after the 3/2/26 MDS was completed. Staff #16 was interviewed on 6/12/26 at 12:10 PM. This surveyor asked if she had an update in regard to the care plan meetings. She replied, we did miss one. This surveyor asked which one and she replied, the April one.

Based on record review and interviews, it was determined that the facility failed to develop a care plan as required. This is evident for 1 (Resident #27) of 24 resident care plans reviewed during the recertification survey process. Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, care goals and the responsible parties. This tool is to be developed within 7 days after completion of the comprehensive assessment (MDS) and prepared by an interdisciplinary team.On 06/08/2026 at 10:32 AM, in an interview with resident representatives reported that Resident #27 had a colostomy and had concerns about the colostomy care provided to the resident. On 06/09/2026 at 9:21 AM, a review of Resident #27's care plan revealed that there was no documented evidence to support that the facility developed a colostomy care plan to indicate who would be responsible to perform care, the type of care to be performed and how often care would be performed.On 06/09/2026 at 09:26 AM, a review of Resident #27's orders revealed that an order was written for colostomy care every shift and as needed on 05/05/2023.On 06/09/2026 at 09:32 AM, in an interview with Geriatric Nursing Assistant (GNA)#44, she confirmed that the resident had a colostomy bag and colostomy care was provided to the resident as needed by the GNAs.On 06/10/2026 8:59 AM, in an interview with License Practical Nurse (LPN)#43, she stated that the GNAs were responsible for changing the Colostomy once on day shift but stated she was not sure how often colostomy care was required.On 06/10/2026 at 09:55 AM, a review of Resident #27's Treatment Administration Record (TAR) revealed that the colostomy care was signed off every shift by the nurses. However, the administration record does not specify the type of colostomy care that was provided and it did not make clear that the colostomy care was delegated to the GNAs.On 06/10/2026 at 10:15 AM, a review of the facility's ostomy care policy revealed Ostomy care will be provided by License nurses under the orders of the attending physician. The frequency of pouch changes and the product required for changing ostomy will be noted in the resident specific care plan. On 06/10/2026 at 11:24 AM, an observation of Resident care with GNA #27 revealed that the GNA conducted a complete change of the colostomy appliance without any concern. When asked about the frequency of colostomy care she explained that after each bowel movement the GNAs are required to change the colostomy pouch/bag because it was not reusable.On 06/11/2026 at 2:27 PM, in an interview with the DON, the surveyor informed the Director of Nursing (DON) that the facility's policies indicated that ostomy care would be provided by a nurse; however, the GNAs provided colostomy care and the nurses were signing off the colostomy care on the TAR without indicating that the care was delegated to the GNAs. Also, the facility failed to develop a colostomy care plan to indicate the treatment and intervention for the colostomy. The DON verbalized understanding of the above-mentioned findings.

Based on a review of facility investigative materials, medical records, and staff interviews, it was determined that the facility failed to thoroughly investigate a self-reported incident. This was evident for one (incident report #3003592) of 21 reports reviewed during this annual survey.The findings include:On 6/10/26 at 2:08 PM, the surveyor reviewed self-reported incident #3003592. The review revealed that Resident #122 reported to the unit manager on 5/04/26 that his/her nurses had allegedly used inappropriate language.In an interview with Resident #122 on 6/08/26 at approximately 1:00 PM, the surveyor noted that the resident was alert and oriented. The resident's most recent Brief Interview for Mental Status (BIMS)-a short, standardized cognitive screening tool used primarily in long-term care settings to check memory, attention, and orientation-was conducted in April 2026, with a score of 15 out of 15, indicating intact cognitive function.Further review of the facility's investigation packet revealed that it contained no statement from Resident #122. Additionally, the facility identified that two nursing staff members were involved in this incident (Licensed Practical Nurse #48 and LPN #49). LPN #48's most recent abuse training was on 4/02/25, and LPN #49's most recent abuse training was on 1/10/24. However, there was no documentation indicating that LPN #48 and LPN #49 received corrective abuse training after this incident to prevent similar occurrences.In an interview with the Director of Nursing (DON) on 6/11/26 at 12:19 PM, the surveyor reviewed the facility's investigation documentation with her. She verified that there was no statement from Resident #122, who had reported the verbal abuse to the facility. The DON stated, The abuse training should be conducted right after the incident. She validated that there were no subsequent training records for LPN #48 and LPN #49.

Based on record review and staff interviews, it was determined that the facility failed to protect a resident's right to be free from misappropriation of property specifically involving the diversion of narcotic medication. This was evident for 2 (Resident #136 and Resident #137) of 2 resident Facility Reported Incidents reviewed for missing narcotic medications during the recertification/complaint survey.The findings include:1. On 6/09/2026 at 9:08 AM, the surveyor investigated the facility's self-report intake #2784380 which indicated that Resident #136 had 3 pills of a Narcotic medication (Oxycodone: medication prescribed for severe pain) missing on 2/18/2026. The investigation surmised that Staff #41 was asked to go to the Unit Manager's office because the Nursing Supervisor noted that he/she was repeating words during a conversation and had pin pointed pupils. While Staff #41 had gone to the office, Staff #42 and Staff #43 counted the narcotics in the cart that Staff #41 was assigned to throughout the shift. During the narcotic count it was noted that the Narcotic sign off sheet was last dated 2/18/2026 at 11:00 AM indicated 19 pills remaining, but the actual narcotic pill bubble pack had 16 pills present. This was immediately brought to the attention of Staff #41 and the DON. Staff #41 went to the cart and stated and wrote on the narcotic count sheet that she administered 1 pill at 3:00 PM and 1 pill at 6:00 PM but could not account for the other (1) missing pill. The Nursing Supervisor (Staff #43) interviewed Resident #136 who stated that her last pain medication was administered by the previous nurse, Staff #38 at 11:00 AM. The resident also stated that Staff #41 came in the room to say Hi, but did not administer any pain medication. Staff #41 could not account for the missing pill. A review of the Resident's medical record on 6/09/2026 at 10:32 AM revealed that Resident #136 was admitted to the facility on [DATE] and discharged on 2/21/2026. The resident had a Brief Interview for Mental Status (BIMS) score of 15. The resident had an order for Oxycodone oral tablet 15 MG, give 1 tablet by mouth every 4 hours as needed for pain rated 6-10/10 and the Medication Administration Record (MAR) did not have any documentation of Oxycodone tablets administered to Resident #136 by Staff #41.On 6/9/2026 at 12:04 PM, during an interview with Staff #6, the surveyor asked about the procedure for narcotic count on the shifts. Staff #6 stated that the narcotic count is done at the beginning and ending of the shift between the oncoming and off going nurse. The count starts with the number of physical narcotic cards on hand and compared to the number on the narcotic shift count sheet, then proceed to the individual cards with the resident's name and the number of pills remaining in each card. If there is a discrepancy, there is a recount, and if the count is not correct, notify the Unit Manager, the Nursing Supervisor, or the DON if necessary. When asked about narcotic administration, Staff #6 stated the nurse should document on the narcotic count sheet and the MAR when the medication is given and not at the end of the shift.2. A review of the Facility Reported Incident (FRI) # 2794677 indicated that Resident #137 had a total of two packets of Oxycodone 5 mg tablets bubble packs missing on 3/2/2026.1 pack had a total of 19 tablets remaining with the last dose given on 2/16/2026 at 6:30 PM.1 pack had a total of 22 tablets remaining on 2/20/2026 with the last dose given at 08:00 AM.Staff #37 reported in a written statement that on 3/2/2026 at approximately 11:05 PM that a handoff and narcotic count was done at the beginning of the shift with Staff #36, who worked a double shift 7AM-3PM and 3PM -11PM. During the count Staff #36 and Staff #37 confirmed that number of cards of Narcotics was 6. Staff #37 reported in her statement that during her rounds on the unit, no resident was discharged or transferred, therefore the number of cards of narcotics should have been 7. Staff #37 immediately notified the Nursing Supervisor who reviewed the medication log book and found the Narcotic sheet with 22 tablets of Oxycodone 5mg tab for Resident #137 lined through without an explanation or signature for destruction. Staff #36 had already exited the building, and the Nursing Supervisor reached out to the nursing agency and obtained the number to call Staff #36, who did not answer the phone. The DON stated in the investigation document that Staff #36 denied removing any medications outside of what was administered to the resident.On 6/11/2026 at 11:00 AM, a review of the medical record for Resident #137 revealed that the resident was admitted on [DATE] and discharged on 3/10/2026. The resident had a BIMS score of 15. The resident had an order for Oxycodone 5 MG tablets, give 1 tablet by mouth in the morning for pain, order date 02/16/2026 and discontinue date 02/20/2026. The surveyor noted that a medication sheet indicating 26 tablets were received on 2/17/2026 at 8:00 PM and the last date the medication was administered was 2/20/2026 at 8:00 AM with a remaining 22 tablets. There was a diagonal line drawn through the sheet. There were no signatures or initials on the sheet to indicate destruction of the medications. There was another order written to give oxycodone tablet 5 mg by mouth every 4 hours as needed for pain 6/10-10/10, order date 02/12/2026 and discontinue date 02/21/2026.On 6/11/2026 at 11:25 AM, in a review of Resident #137's MAR, there was no documentation of Oxycodone given for pain as needed for 02/12/2026 to 02/21/2026. However, the Narcotic count sheet indicated that 30 tablets were received from the pharmacy on 2/12/2026 at 8:00 AM. 1 tablet was administered on 2/12/2026 at 5:00 PM and 11:00 PM; on 2/13/2026 1 tablet was administered at 4:00 PM and 10:10 PM; on 2/14/2026 1 tablet was administered at 2:00 AM, 4:00 PM, and 11:00 PM; on 2/16/2026 1 tablet was administered at 2:00 AM, 11:00 AM, and 6:30 PM. The sheet had a diagonal line drawn through it and indicated at the bottom that 19 pills were destroyed with 2 different initials as witnesses.During further review on 6/11/2026 at 11:30 AM of the facility's investigation, the surveyor noted that the facility conducted an audit of the narcotic books and found that on the dates and shifts that Staff #36 worked from 2/27/2026 to 3/1/2026 that there were narcotic cards deducted from the shift count sheet. In addition, the narcotic administration count sheets had signatures and initials that did not match any staff members.On 6/11/2026 at 11:50 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA), the Assistant Director of Nursing (ADON), and the Unit Manager, Staff #5, who stated that they believed that drug diversion occurred based on their investigation of both incidents. The surveyor informed them that the incidents are a concern for misappropriation of property because the medication was prescribed and delivered to the Residents and could not be accounted for. The leadership team agreed, and stated that education was provided to the staff on the proper handling of controlled/double lock medications, and both nurses were reported to the Maryland Board of Nursing.

Based on review of facility-reported incident investigation, record review, policy review, and interview, it was determined that the facility failed to ensure that a resident remained free from abuse. This was evident for 1 (Resident #29) of 7 abuse investigations reviewed during the recertification and complaint survey.The findings include: On 6/11/26 at 10:47 AM, a review of facility-reported incident #2975907 revealed that on 4/6/2026, at approximately 3:20 AM, Resident # 29 allegedly sustained injuries during an interaction with Geriatric Nurse Assistant (GNA) #31.A review of Resident #29's medical record revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment.According to a telephone interview conducted by the facility with GNA #31, Resident #29 exited his/her room in a wheelchair and approached GNA #31 in the hallway. GNA #31 stated that the resident grabbed his/her hand and repeatedly asked, Where is my table? GNA #31 reported telling the resident that he/she did not have the table; however, the resident continued to hold onto the GNA's arm tightly. GNA #31 stated, I had to pry my arm from the resident's grip. GNA #31 further stated that he/she did not notice any injury or bleeding to the resident's arm during the encounter and reported the incident to the night supervisor.The facility also obtained a statement from the night supervisor, Licensed Practical Nurse (LPN) #32, who reported that approximately 3:30 AM, Resident #29 came to the nurses' station and stated, The aide did this to me. LPN #32 observed skin tears with active bleeding to the resident's left arm.On 4/6/2026, the facility interviewed 12 other residents who resided on the same assignment as GNA #31. Two residents reported that GNA #31 was a little rough while providing care. When asked to clarify, the residents stated that GNA #31's hands were not gentle during personal care.A review of the Nurse Practitioner's progress note dated 4/6/2026 at 3:56 PM confirmed bruising and skin tears to Resident #29's left arm.A review of GNA #31's personnel file revealed a documented disciplinary action dated 6/12/2025 for performance misconduct, which stated that the employee was heavy-handed with residents during care.Further review revealed that GNA #31's employment was terminated on 4/15/26. The documented reason for separation included rude, discourteous, condescending, unprofessional, or otherwise socially unacceptable behavior toward customers, residents, or anyone in contact with the Company.A review of the facility's Abuse Prevention Policy, implemented on 3/14/23 and revised on 9/12/24, stated: The facility strictly prohibits abuse, mistreatment, neglect, or exploitation of all residents, or misappropriation of resident property. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.On 6/12/26 at 8:38 AM, during an interview, LPN #18 stated that when caring for residents with dementia who exhibit behavioral symptoms, staff were expected to use interventions to calm the resident and maintain the resident's safety. LPN #18 further stated that if a resident became physically aggressive by pulling or hitting staff, staff were expected not to pull away forcefully or strike the resident, but instead seek assistance from other staff members.On 6/12/26 at 9:30 AM, during an interview, the Assistant Director of Nursing (ADON) stated that she was unable to provide additional details because she did not conduct the investigation. The ADON confirmed that GNA #31 left a handprint on Resident #29's arm and was subsequently terminated.On 6/12/26 at 10:07 AM, the Director of Nursing (DON) was informed of the findings and acknowledged that the incident met the facility's definition of abuse.

Based on observation and interview with the resident and facility staff, it was determined that the facility failed to ensure clean, safe, and comfortable environment. This was evident for 3 (rooms C-2, C-11, and D-9) of 3 rooms observed and 1 (Station 2) out of 3 shower rooms reviewed during the annual survey.The findings include:On 06/09/2026 at 10:32 AM, the surveyor toured the facility with Staff #5 and observed several vinyl floor panels missing beneath the bed wheels on the left side near the foot of the bed in Room C-2. The missing floor panels exposed the underlying subfloor surface and prevented the floor from being maintained in good repair and sanitation. At 10:41 AM, the surveyor observed a large hole in the wall of the Station 2 Shower Room. In addition, two shower stalls were missing privacy curtains. During an interview, Staff #5 stated that the Maintenance Director was aware of the issues and that repairs had been initiated.At 10:42 AM, the surveyor and Staff #5 observed several vinyl floor panels missing beneath the bed wheel on the left side near the foot of the bed in Room C-11. During an interview, Staff #5 stated that the damaged flooring may have been resulted from movement of the bed wheels. Staff #5 confirmed that the Maintenance Director would be notified for repairs promptly.At 10:53 AM, the surveyor observed damaged windowsill and torn baseboard underneath the wall mounted heating and air conditioning unit Room D-9. The windowsill was cracked, chipped and pitted. The baseboard was torn and showed excessive buildup of dust, dirt, and debris.At 10:59 AM, the surveyor revisited rooms C-2, C-11, and D-9 with the Director of Nursing (DON) to review the findings. The DON acknowledged that the identified concerns and stated that the Maintenance Director would be notified and repaired would be completed promptly.On 06/10/2026 at 9:30 AM, the surveyor conducted a follow-up observation of the Station 2 Shower Room with the Infection Preventionist (IP). Both the surveyor and IP observed that an approximately 8 inches by 11 inches panel had been placed over hole in the wall. However, the wall remained unrepaired, and the shower stalls lacked privacy curtains. The IP confirmed that the Maintenance Director was notified of the concerns and that repairs would be completed promptly.

Based on record review and interview, it was determined that the facility failed to ensure that residents and/or their resident representatives (RPs) were offered the opportunity to receive education regarding, formulate, and execute advance directives. This was evident for 3 (Residents #128, #9, and #15) of 4 residents reviewed for advanced directives during the recertification survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 6/08/2026 at 11:13 AM, a review of Resident #128's medical record revealed no evidence that the resident and /or RP had been offered information regarding advanced directives. Further review revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Additionally, a Social Services assessment dated [DATE] documented that an advance directive was not in place and confirmed that advance directive educational materials had not been provided and the resident had not been offered the opportunity to complete an advance directive. On 6/08/2026 at 12:32 PM, a review of Resident #9's medical record revealed no evidence that the resident representative had been offered information regarding advance directives or the opportunity to formulate an advance directive on behalf of the resident. Further review revealed a BIMS score of 10, indicating moderate cognitive impairment. Additionally, a Social Services assessment dated [DATE] documented that an advance directive was not in place and confirmed that advance directive education materials had not been provided and the resident and/or RP had not been offered the opportunity to complete an advance directive. On 6/08/2026 at 12:55 PM, a review of Resident #15's medical record revealed no evidence that the resident and/or RP had been offered information regarding advance directives or the opportunity to formulate an advance directive. Further review revealed a BIMS score of 15, indicating intact cognition. Additionally, a Social Services assessment dated [DATE] documented that an advance directive was not in place and confirmed that advance directive educational materials had not been provided and the resident and/or RP had not been offered the opportunity to complete an advance directive. On 6/11/2026 at 9:37 AM, during an interview, Social Services Assistant (SSA) #16 stated that upon admission, he/she interviewed residents and determined whether a Power of Attorney (POA) or advance directive was already in place. SSA #16 stated that if an advance directive existed, a copy would be requested and uploaded into the medical record. If an advance directive was not in place, the process would be explained to the resident and/or RP and the discussion would be documented in the medical record. The surveyor informed SSA #16 of the findings. He/she stated that he/she would review the records and provide additional information. On 6/11/2026 at 12:59 PM, SSA #16 provided the surveyor with copies of Social Services progress notes that were entered following surveyor inquiry, which included: - Resident #128: A Social Service Note dated 6/11/2026 at 12:24 PM documented that SSA #16 discussed advance directives with the resident and RP by telephone, provided education, and left blank advance directive materials in the resident's room for review.- Resident #15: A Social Services Note dated 6/11/2026 at 12;38 PM documented that SSA#16 provided a blank copy of advance directive forms and education to the resident's Healthcare POA, who stated that he/she would review the documents.- Resident #9: A Social Services Note dated 6/11/2026 at 12:40 PM documented that a blank copy of advance directive forms was emailed to the RP for educational purposes should the resident regain capacity. SSA #16 also provided documentation of advance directive education conducted by Regional Director of Social Services #17 on 6/11/26. The education included all capable residents should be provided with education and information on advance directives and offered the opportunity to complete one. If the resident is not capable, the information should be provided to the responsible party should they regain capacity. This must be documented in the electronic medical record.

Based on observation, resident interview, staff interviews, and record review, it was determined that the facility failed to maintain residents' dignity. Specifically, 1) a resident was not dressed according to their wishes, and 2) a dependent resident was not assisted out of bed until the afternoon. This affected two residents (Resident #5 and #41) out of seven reviewed for dignity during the annual survey. The findings include: 1) During the initial screening task of the survey process on 6/8/26 at 10:24 AM Resident #41 was observed to be in a hospital gown rather than street clothes. The resident was asked if they were okay with being dressed in a hospital gown or if they would have preferred to be dressed in street clothes. The resident stated that they would prefer to be dressed in street clothes. The resident's son, who was seated in the room at this time, added that he had requested multiple times that his parent be dressed in street clothes, but they keep dressing the parent in a hospital gown. A review of Resident #41's clinical record on 6/10/26 at 11:57 AM revealed that the resident's Minimum Data Set (MDS), which is a federally mandated assessment tool, was completed on 5/23/26. Section F Preferences for Customary Routine and Activities asked several questions to ascertain residents' preferences including: How important is it to choose the clothes you want to wear? The resident responded to this question by choosing Somewhat important. The resident was observed on 6/10/26 at 12:35 PM to be in bed wearing a hospital gown. The resident was observed on 6/11/26 at 1:25 PM to be out of bed but still wearing a hospital gown. The resident was observed on 6/12/26 at 12:30 PM and at 1:10 PM to be out of bed and wearing a hospital gown. Resident #41 was observed on 6/15/26 at 11:05 AM to be in bed and wearing a hospital gown. The resident was asked if they were comfortable and the resident replied yes. This surveyor then asked if he/she would like to be in street clothes and the resident replied yes, I would. This surveyor informed the resident that his/her request would be shared with the facility staff. This surveyor interviewed the Unit Manager (Staff #5) on 6/15/26 at 11:12 AM. This surveyor informed her of the resident's wishes as well as the son's wishes. She was also informed of the observations. Staff #5 replied so, the resident wishes to be in street clothes? I can take care of that right now. On 6/15/26 at 1:15 PM Staff #5 informed the survey team that the resident was now dressed and she said she had forwarded the resident's wishes to the nursing staff. 2) On 6/09/26 at 11:07 AM, a review of a facility self-reported incident (2976540) revealed that Resident #5's family members expressed concerns to administration regarding neglect. They noted that the dependent resident was not assisted out of bed until after 3:30 PM on 4/05/26. Further review of the investigation report, including staff statements, revealed that Geriatric Nurse Aide (GNA) #33, who was assigned to Resident #5 during the day shift (7:00 AM to 3:00 PM), stated she had not gotten the resident out of bed. GNA #34, who was also assigned to the resident during that shift, stated it was her first time working with Resident #5 and she did not know the resident was supposed to be out of bed. During an interview with the Director of Nursing (DON) on 6/11/26 at 12:11 PM, the DON was asked about facility expectations for dependent residents. She stated that residents should be assisted out of bed to start their day with staff help. When the surveyor shared the findings, the DON validated that Resident #5's dignity had not been maintained.

Based on record review, interview and Facility Reported Incident (FRI) #2980586, it was determined that the facility failed to ensure that pain management was provided to each resident with professional standards of practice. This was evident for 1 (Resident #139) of 3 residents reviewed for pain management during the survey process.Findings included:Non-pharmalogical interventions are identified as an alternative method of treatment for a medical concern without the use of medication. This could include physical, psychological, and lifestyle interventions designed to reduce pain and improve quality of life. The CDC's 2022 Clinical Practice Guideline for Prescribing Opioids emphasizes non-pharmacological, non-opioid therapies as the first line of treatment for subacute and chronic pain.On 06/12/2026 at approximately 9:00 AM, a review of FRI #2980586 revealed that on 04/07/2026 at approximately 3 PM Resident #139's family member reported that the resident appeared to be over-medicated.On 06/18/2026 at 09:44 AM, in an interview with Staff #5 (unit manager), she was asked about the resident's pain management and Staff #5 explained that Resident #139 reported pain and as a result the resident was treated for pain. Upon the family member's concern, the resident's pain medication was reviewed.On 06/15/2026 at 10:35 AM, in a follow-up interview with Staff #5, she reported that the resident's pain medication (oxycodone) was later decreased from 4 times per day to 2 times per day due to drowsiness.On 06/15/2026 at approximately 10:36 AM, a review of a pain assessment completed on 04/06/2026 03:17PM revealed a recommendation, new medications added: Oxycodone 5 mg PO four times per day Interventions: Patient reported inconsistent administration of Oxycodone. Order placed for routine Oxycodone will follow up.On 06/15/2026 at approximately 10:40 AM, a review of the resident's physician order and Medication Administration Record (MAR) revealed that the resident had the following pain medication order:-First, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe Pain -Order Date: 04/02/2026; pain medication administered as order on 04/3/2026, 04/4/2026, and 04/6/2026. -Then, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth four times a day for persistent pain -Order Date-04/06/2026 1555 -D/C Date- 04/07/2026 1701; pain medication administered as ordered (3 separate dose) and the 4th dose was held for drowsiness.-Final change, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth two times a day for persistent pain -Order Date- 04/07/2026 1701 -D/C Date-04/10/2026 1524; pain medication administered as ordered (4 doses).Non-Pharmacological Intervention(s) used before PRN (as needed) Pain Medication or before PRN anti-depressant, anti-anxiety, anti-psychotic or sedative/hypnotic medication Document by number:1 Reposition for comfort 2 massage 3 involve in activity/alt. activity to divert 4 provide quiet setting with reduced stimuli as needed 5 relaxation technique 6 music 7 remove from area 8 direction/distraction 9 toilet 10 ambulate 11 provide food/drink 12 educated 13 one: one 14 other -add to PN the description -Order Date04/01/2026.On 6/15/2026, a review of the medication administration record revealed that pain monitoring was completed at least once per shift and the documentation revealed that the resident was unable to communicate pain level most of the time.On 06/15/2026 in an interview with Staff #5, she was asked how pain level was assessed and she reported that pain assessment for non-verbal residents included signs such as grimacing during care and moaning. She reported that the pain assessment in the computer would indicate if the resident was communicative or non-communicative.On 06/15/2026 at approximately 10:41 AM, a review of Resident #139's progress notes written on 06/15/2026 at 4: 49 PM revealed: Resident is drowsy, opened eyes when called name. Also, a change of condition assessment for was completed on 06/15/2026 at 9:51 PM due to: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse).On 06/15/2026 10:44 AM. The Director of Nursing (DON) notified that the resident had orders for PRN non-pharmacological interventions prior to the administration of PRN pain medication. The resident received several oxycodone administrations for pain; however, there was no documentation to support that the facility implemented the non-pharmacological intervention as ordered to aid with pain management prior to administering narcotics.

Based on medical record review, interviews with facility staff, and review of Maryland Department of Health recommendations, it was determined that the facility failed to ensure that facility staff utilized effective infection control practices to prevent the spread of COVID-19 (Coronavirus 2019). This was evidenced by: 1. The facility staff failing to isolate 6 out of 8 COVID positive residents reviewed (Residents #4, #5, #8, #9, #10, & #11) and 2. Cohort staff for 8 of 8 COVID positive residents reviewed in a timely manner (Residents #4, #5, #8, #9, #10, #11, #13 & #14). These practices increased risk of harm and possible death to all residents, staff, and visitors during a declared health emergency. As a result of these findings, an Immediate Jeopardy (IJ) was declared on 9/3/20 at 1:05 PM. The facility submitted a plan of removal at 6:38 PM and it was accepted by the State Agency at 7:10 PM. After removal of the immediacy the deficiency practice remained for potential for more than minimal harm at a scope and severity of E. The findings include: On 4/5/2020, the Maryland Secretary of Health issued a Directive and Order Regarding Nursing Home Matters Pursuant to Executive Order No. 20-04-05-01 I The order stated: Staff Assignments: Nursing homes shall immediately implement, to the best of their ability, the following personnel practices: - Establish a cohort of staff who are assigned to care for known or suspected COVID-19 residents. - Designate a room, unit, or floor of the nursing home to care for residents with known or suspected COVID-19 On 6/18/20, the Maryland Department of Health issued guidance stating, Facility must continue to dedicate space for cohorting and managing care for residents with COVID-19 separate from the general population. 1.The facility staff failed to isolate COVID positive residents in a timely manner. The facility's Infection Control Preventionist (ICP) provided the surveyor a COVID-19 tracker for all residents on 8/31/20. Review of the facility's COVID-19 tracker revealed on 8/11/20, the facility conducted routine COVID testing. On 8/15/20 the facility received the results of the 8/11/20 COVID testing, five of those residents, all who resided on Unit B, (Residents #5, #8, #10, #13, and #14) had positive COVID results. Review of the facility's Daily Census for residents' room location from 8/15/20 until 8/20/20 revealed: a. Resident #5 remained in his/her room (B3) with Resident #9, who was tested on [DATE] and facility notified COVID negative on 8/15/20, until 8/16/20 when he/she was transferred to a COVID positive sister facility. Resident #9 later tested positive on 8/21/20. b. Resident #8 remained in his/her room (B2A) with Resident #4, who was tested on [DATE] and facility notified COVID negative on 8/15/20, until 8/16/20 when he/she was moved to Room B6B. c. Resident #10 remained in his/her room (B8B) with Resident #11, who was COVID negative, until recovered. Resident #11's 8/11/20 test results were not made available to the facility until 8/16/20. Although Resident #11's results were also positive, the facility was unaware of this and did not take action to protect Resident #11 from possibly acquiring COVID-19 when Resident #10 was known to be COVID positive. d. Resident #13 and #14 were roommates and remained in Room B5 until they were transferred on 8/20/20 to a COVID positive sister facility. On 9/1/20 at 12:10 PM the ICP provided a timeline for August 2020 of the facility's rooms dedicated for COVID positive residents. On August 1st the rooms C9, C10, C11 and C12 were designated COVID positive. Review of the Daily Census sheet for 8/15/20 revealed these rooms were empty. During interview with the DON on 9/1/20 at 1:16 PM, she stated the facility had rooms on C Unit that could be used to place COVID positive residents if the two sister facilities could not accept their residents. The DON was asked at that time why were the COVID positive residents were not placed on the C Unit on 8/15/20, the DON stated those rooms were closed for construction related to mold. During interview with the Administrator and Director of Nursing (DON) on 9/1/20 at 3:29 PM, the Administer and DON stated the facility's plan when residents tested COVID positive was to transfer those residents to two other sister facilities that were COVID positive, only. At that time, the DON stated it was her responsibility to get COVID results and make decisions on residents' disposition when diagnosed COVID positive. The surveyor asked the DON why the 5 positive residents were not moved to the two COVID positive sister facilities on 8/15/20. DON stated she had not made any calls to the two sister facilities on 8/15/20 and was waiting on the COVID results to come back for other residents on Unit B to get the whole picture. The DON was asked why the facility had not used the 3 available private rooms on the Observation unit for exposed residents. The DON stated since those residents had already been exposed, she did not want to put them on the Observation Unit. During interview with the Infection Control Preventionist (ICP) on 9/3/20 at 9:30 AM, she stated no attempts were made to reach out to the local health department on 8/15/20 or 8/16/20 to notify of the COVID positive residents or discuss room placement. The ICP stated she did not contact the local health department of the COVID positive residents until 8/17/20 by email. During interview on 9/2/20 at 9:08 AM with Local Health Department (LDH) Employee #1, she stated during a call with the facility and Maryland Department of Health on 8/19/20, the facility staff advised them the unit they were using for potential COVID positive residents had mold and that is why they were using rooms B5, 6 and 8 for COVID positive residents. LDH Employee #1 stated during the call on 8/19/20 was the first time she was advised the facility had an issue with mold. LDH Employee #1 stated during the 8/19/20 call, the Maryland Department of Health recommended to the facility that the COVID positive residents be separated from other residents by placing them at the end of a hall on the unit with a plastic barrier. 2. The facility staff failed to cohort staff for COVID positive residents in a timely manner. The DON stated on 9/1/20 at 3:29 PM the facility began cohorting staff for COVID positive residents on 8/16/20. Review of Unit A, B and C's staffing sheets for 8/15/20, 8/16/20 and 8/17/20 revealed the facility began to cohort staff for the COVID positive residents on 8/17/20 evening shift, 2 days after the first 5 residents on Unit B were diagnosed COVID positive. During interview with the DON on 9/3/20 at 9:30 AM, she could not state why staff was not cohorted prior to 8/17/20 but stated that staff were educated on precautions to take for COVID positive residents. Interview with Nurse #2 on 9/3/20 at 9:58 AM confirmed he/she was caring for both COVID positive and negative residents on 8/16/20. On 8/18/20 the facility staff conducted routine COVID screening, the results returned on 8/21/20 with 5 other residents on Unit B testing COVID positive (Residents #9, #15, #16, #17 and #18) and 1 resident on Unit A (Resident #19). On 8/25/20 the facility conducted routine COVID screening, the results revealed 2 other residents on Unit B to test COVID positive (Resident #2 and #7). As a result of these findings, a state of Immediate Jeopardy was declared on 9/3/20 at 1:05 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a plan at 6:38 PM and it was accepted by the state agency at 7:10 PM. The provisions of the plan to remove the immediacy had a completion date of 9/5/20 and included the following: For Part 1) 1.The Interdisciplinary Team reviewed the Line Listing and COVID-19 assessments of current residents to determine if any other residents had the potential to be affected. No other residents with discordant COVID status were identified. 2. COVID Positive residents will be isolated from non COVID Positive residents to minimize risk of transmission and exposure to other residents and healthcare workers. 3. The Director of Clinical Operations will educate the Interdisciplinary Team on proper process of cohorting presumptive/positive/naive residents to ensure proper isolation is maintained and to minimize risk of transmission. The Center Nurse Executive clarified with the Department of Health in(NAME)Arundel County Reporting requirements. The usual expectation during an outbreak is that Line Lists are sent daily seven days a week so that new cases can be reported. This was reviewed with the Infection Preventionist and she will follow it up with an email for documentation purposes. 4. Monitoring of cohorting practices including appropriate room placement between suspected or diagnosed positive residents and their symptomatic or asymptomatic roommates will be done daily including weekends and holidays and will be coordinated by Infection Preventionist. The Center Nurse Executive will ensure monitoring of the emails weekly for compliance in reporting line listings daily. Information gathered from daily reviews of line listings, bed board, Staffing Sheets, and COVID-19 assessments will be reviewed weekly throughout the outbreak and presented in Quality Assurance Performance Improvement Meetings for review and recommendations of analyzed patterns and trends. For Part 2) 1.The Staffing Sheets from 8/17/20 - present were reviewed. 2. COVID Positive residents will have dedicated staff designated on the Daily Staffing Sheets to minimize risk of transmission and exposure to other residents and healthcare workers. 3. Nurse Practice Educator/Infection Preventionist will re-educate current Nursing Staff on cohorting suspected cases of COVID-19 to reduce transmission risk between suspected or diagnosed positive residents and their symptomatic or asymptomatic roommates as well as dedicated staff with a designation on the daily staffing sheets of who is assigned to care for COVID positive residents. 4. Monitoring of Assignment sheets will be done daily including weekends and holidays to review that there are dedicated staff to care for COVID Positive residents designated on the Staffing Sheets and will be coordinated by the Center Nurse Executive. Information gathered from daily reviews of line listings, bed board, Staffing Sheets, and COVID-19 assessments will be reviewed weekly throughout the outbreak and presented in Quality Assurance Performance Improvement Meetings for review and recommendations of analyzed patterns and trends. The Immediate Jeopardy was removed on 9/8/2020 at 1:30 PM after on-site confirmation of the completion of the facility's plan of removal.