Every finding on record at Copper Ridge Nursing and Assisted Living Center

Based on observations, interviews, review of facility investigations and medical record review, it was determined that the facility failed to adequately supervise Resident #34 from behaviors that subjected him/her to the risk of serious injuries. This was found to be evident for 1 (Resident #34) of 3 residents reviewed for behaviors. The Maryland Office of Health Care Quality (OHCQ) determined that the concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 2 PM on 6/17/26. The findings include:On 6/17/26 at 8:30 AM, the surveyor reviewed the Facility Reported Incident (FRI) #2686663 pertaining to an injury of unknown origin noted on Resident #34. The incident was reported to OHCQ on 12/05/25. On review of the progress notes from the date of the discovery of the injury of unknown origin, 11/30/25, it was noted that Resident #34, remains alert with episodes of confusion. Was seen walking around the unit in circles. Was put to bed x2, was not effective. Around 7:40 pm, the resident was seen with a hematoma to the forehead and a laceration to the bridge of the nose. The investigation concluded that Resident #34's injury probably resulted from the resident's bumping into a wall or door when ambulating independently and history of unwitnessed falls. Next, the surveyor reviewed the unwitnessed injury care plan created on 11/30/25. One of the interventions stated to ensure the environment was safe, and another was to implement increased rounding/observation as needed. No additional detail was given as to how and when this should be done. On further review of Resident #34's medical record, a note written on 12/10/25 by Registered Nurse (RN) #5 and documented at 11:04 AM, Resident # 34 was seen on the floor after hearing a loud crash. It was also noted that Resident #34 was observed walking in the hallway 5 minutes prior to fall. This was the second fall in 10 days. A note written on 12/14/25, shortly after the fall was reviewed. The note was written by Registered Nurse (RN) #26 and documented Resident #34 demonstrated limited ability to understand communication and was intermittently able to be understood. It further stated that Resident #34 did not follow simple commands, was not redirectable, was observed wandering in the unit without awareness of environmental hazards, and that memory impairment and confusion were noted. Additionally, RN #26 documented that Resident 34's gait was unsteady with imbalance and noted Resident #34 was at increased risk for falls and would be monitored closely for safety. Resident #34's insomnia, Urinary Tract Infection (UTI), pain and increased anxiety were addressed with an order to monitor behavior every shift for the presence of agitation, anxiety, depressed, hallucinations, restlessness, refusal of care and other, however, no additional orders or care plan updates were made, to indicate how Resident #34 would be monitored closely for safety for wandering or unsteady gait. The surveyor reviewed a progress note written by Registered Nurse (RN) #5 on 2/8/2026 at 10:24 AM. The progress note documented that Resident #34 was observed leaning against the wall close to the dining room, lost consciousness for a few seconds, and fell backwards and hit his/her head on the floor. The actual fall care plan was reviewed and an update was done on 2/9/26 and stated, witnessed fall in dining room, resident transferred to the Emergency Department (ED) for evaluation of hematoma and returned within 24 hours. However, no new interventions were added. Resident #34's activities of daily living care interventions last updated on 4/16/25 indicated that Resident #34 walked on the unit independently but also needed hands-on guidance at times for appropriate movement on the unit. An additional intervention stated, to provide increased assistance if gait is unsteady. Resident #34's gait was documented unstable from the previous fall and the interventions were not updated. The surveyor reviewed a progress note written after a history and physical on 4/24/26 by Physician #27 that documented Resident #34's gait was unstable and that Resident #34 had a history of falls and was a fall risk. The note stated ambulatory wandering was addressed with the use of environmental supervision and fall prevention included safe footwear and continued staff-supervised ambulation. Next the surveyor reviewed a note written by the Social Work Director (SWD) #8 written on 4/10/26 at 8:33 AM. The note stated that Resident #34 needed 24/7 care, required supervision and had recently been put on a Wander Guard system to prevent risk of wandering off the unit. The note also noted that Resident #34 was able to feed his/herself but will also try to consume non food items if not monitored or will eat food off of other's plates. It further stated that Resident #34 was non verbal, no longer able to communicate, was a fall risk and wandered the unit often. Next the surveyor reviewed the care plan for Resident #34 that stated, he/she had behavioral problems of taking food from peers during meal times, wandering into others' rooms uninvited, eating and drinking foods not intended for him/her, will take items from the medication cart and consume them and will eat hand sanitizer if applied to hands. One of the interventions initiated on 4/8/24 was to complete environmental monitoring every shift for hazards to resident and monitor if ingested. No intervention was added for additional monitoring to prevent ingestion. The surveyor further reviewed the medical record to identify hazards Resident #34 was ingesting and found a note written on 2/12/25 that stated, another resident reported to staff the Resident #34 may have ingested the urine that was in his/her bedside urinal. The note stated staff were educated to look for ways to reduce incidents of unwanted ingestion while in residents' rooms. Next the surveyor reviewed a progress note written on 5/15/2026 by Licensed Practical Nurse (LPN) #28 in Resident #34's medical record. The note documented, During wound rounds at approximately 11:00 AM, the treatment cart was left in the hallway while wound care was being provided to another resident. A bottle of povidone-iodine solution that had been placed on top of the cart was taken by another resident [Resident #34]. The resident was observed opening the bottle and attempting to drink the solution. The bottle was immediately retrieved from the resident, and no ingestion of the povidone-iodine solution occurred. The resident was redirected without incident. No adjustments to monitoring were noted. On Review of the May Treatment Administration Record (TAR) Resident #34 had no behavior checked. The surveyor reviewed a progress note written on 5/30/26 by LPN #29 that documented Resident #34 was observed wandering in an unsecured area (Baltimore unit, the upstairs unit) at approximately 5:45 PM during dinner time. It was discovered that the resident had removed the wandering device. The resident was safely redirected to the common area, and a new wandering device was applied to his/her right ankle. Staff will continue to closely monitor the resident for safety and well-being. On Review of the May TAR again no behavior had been checked. While on the initial tour of the Baltimore unit on 6/15/26 at about 7 AM- two medication carts and one treatment cart were observed unlocked and unattended on the Baltimore unit.On 6/15/26 at approximately 8:40 AM and again at 11:17 AM, the surveyor observed Resident #34 alone in the room resting in bed with the covers pulled over his/her head. The door was closed on both observations. While making an observation on the Eastern Shore Unit in a common area next to the nurses' station, on 6/16/26 at 8:15 AM, Resident #34 walked up to and swung his/her arm, hitting the surveyor's computer, causing the work screen to close down, and then walked away. On 6/17/26 at 10:15 AM, the surveyor conducted an interview with the Director of Nursing (DON). The surveyor reviewed the concerns regarding Resident #34's level of supervision. The DON stated that Resident # 34 was stopped before ingestion and that she was not even sure if Resident #34 removed his/her own wander guard monitor. However, Resident #34 was assessed as needing close monitoring but continued to experience multiple falls and demonstrated an unstable gait requiring ambulation support. The resident also sustained an injury of unknown origin, attempted to drink from a treatment cart, had known wandering behavior, and successfully left a locked unit without detection. On 6/17/26 at 2 PM, Immediate Jeopardy was determined to exist related to failure to provide adequate supervision to a resident with known safety risks, such as an injury of unknown origin, multiple falls, near-miss ingestion of non-food items, and elopement, which was cited under F689. The immediacy removal plan was accepted on 6/17/26 at 4:16 PM after the initial plan was submitted at 3:46 PM. The plan included placing Resident #34 on a 1:1 supervision, identifying any additional residents with the same need, and educating staff that residents with a 1:1 need to have that intervention in their care plan. Further random observation rounds would be completed to validate that 1:1 interventions were provided for appropriate residents weekly x4 then monthly for three months.The removal plan was verified on 6/18/26 at 11am and immediately was abated as of 6/17/26. After the immediacy was removed, the noncompliance was determined to continue with a scope and severity of D.

Based on observation and interview, it was determined that the facility failed to maintain food service equipment and food storage practices in a manner that ensured sanitary food service operations. This was evident during the initial kitchen tour upon entry into the facility and follow-up observations of the kitchen and unit refrigerators.The findings include: On 6/15/2026 at 7:20 AM, surveyors and Staff #6 conducted the initial kitchen tour upon entry into the facility and observed brown standing water on the floor in the dish room. Staff #6 stated that the standing water resulted from mopping the previous night and that staff used too much water. Surveyors also observed standing water in the dry storage area. Surveyors noted that the walk-in refrigerator area temperature measured 42 degrees Fahrenheit and had a foul odor. Staff #6 stated that staff had not been tracking refrigerator temperatures. Staff #6 further stated that they would report the concern and discard all food if the equipment was not working properly. Staff #6 also stated that the temperature logs had not been kept up to date since the manager left the previous Friday.On 6/15/2026 at 7:24 AM, surveyors observed standing water on the kitchen floor in additional areas, including the dishwashing area and food preparation area.On 6/15/2026 at 7:25 AM, surveyors observed a dirty kitchen scrub sponge at the handwashing station.On 6/15/2026 at 7:27 AM, surveyors observed 2 plastic bags of meat patties open to air in the walk-in refrigerator.On 6/15/2026 at 7:29 AM, surveyors observed a bag of lemons labeled as opened on 3/23/2026.On 6/15/2026 at 7:30 AM, surveyors observed a bottle of ReaLemon lemon juice labeled use by 4/14 and opened 3/15. Surveyors also observed a plastic bag of bacon open to air. In addition, surveyors observed at least 24 fruit cups that were not labeled or dated.On 6/15/2026 at 8:48 AM, surveyors observed the East Unit refrigerator and noted multiple unlabeled and undated items, including juice pitchers, dessert cups, juice cups covered with plastic wrap, a tray of meat, and cheese and crackers.On 6/15/2026 at 10:05 AM, surveyors observed the Baltimore Unit refrigerator and noted multiple unlabeled and undated items, including a drink cup with the lid ajar, a plate of yellow substance covered with plastic wrap, drink containers, food containers, a pitcher of red juice, and a drink cup. Surveyors also observed an unopened milk carton dated 6/10/2026.On 6/17/2026 at 9:36 AM, surveyors reviewed the findings from 6/15/2026 with the Regional Director for Contracted Dining Services and observed unlabeled applesauce and uncovered cookies in a walk-in refrigerator in the kitchen.On 6/18/2026 at 12:36 PM, the surveyor reviewed the concerns regarding food storage and sanitary food service operations with the Administrator.On 6/22/2026 at 9:09 AM, the Administrator stated the facility is conducting tray audits for accuracy and temperature and looking at the full picture to address resident concerns with the food.

Based on observation and interview, it was determined that the facility failed to ensure staff followed residents' meal tickets. This was evident for 2 out of 2 meal time observations during the annual survey.The findings include: On 6/17/2026 at 11:47 AM, surveyors observed the kitchen tray line during lunch preparation and noted that the meal tickets listed beets. However, staff did not place beets on the meal trays. Staff #6 stated that the facility did not have beets available, so staff changed the menu and the dietitian approved the change.On 6/17/2026 at 12:28 PM, the surveyors observed that Residents #49, #47, and #33 had meal tickets that indicated tri-colored pasta. However, staff served regular white elbow pasta on their lunch trays. Staff did not correct or update the meal tickets to reflect on the food served. While walking around the dining room, surveyors observed that staff served all residents regular pasta instead of tri-colored pasta. Residents commented about the incorrect food items they received.On 6/18/2026 at 12:36 PM, the surveyor reviewed the concern regarding the menu change with the Administrator.On 6/18/2026 at 12:46 PM, during a dining room walk-through, surveyors observed that staff served dinner rolls to residents without margarine, although the meal tickets listed margarine. Surveyors observed that no residents received margarine with their dinner rolls.On 6/22/2026 at 9:09 AM, the Administrator stated the facility is conducting tray audits for accuracy and temperature and looking at the full picture to address resident concerns with the food.

Based on observation, record review, and interviews it was determined that the facility failed to provide treatment to prevent further decreased range of motion for a Resident. This was found evident of 1 (Resident #6) out of 2 residents reviewed for mobility. The findings include: On 6/15/26 at 11:47 AM, the surveyor observed Resident #6 participating in activities and noted the resident had left-sided weaknesses. No splints or supportive devices were noted. On 6/15/26 at 2:48 PM, the surveyor reviewed Resident #6's care plan and noted a care plan that state Resident #6 has osteoarthritis, contraction to the left hand/wrist initiated on 7/7/22. On 6/16/26 at 9:53 AM, the surveyor conducted an interview with the Director of Rehab (DOR) #9. During the interview DOR #9 confirmed that Resident was last seen by Occupational Therapy (OT) on June of 2026 and OT recommended that Resident #6 have a restorative plan which included passive range of motion and application of a palm guard. The recommendations were written on a restorative nursing instruction form. Next the surveyor reviewed Resident #6's Treatment Administration Record (TAR). The review revealed an order was placed for staff to perform left wrist flexion/extension and left digit flexion and extension. (2 Sets of 10 daily 2 times per week for 15mins on Tuesday and Thursday). However, there was no order for a palm guard. On 6/16/26 at 11:11 AM, the surveyor conducted an interview with Unit Manager #10. During the interview UM #10 reviewed the restorative nursing instruction form and stated that she had overlooked the palm guard while entering in restorative orders and would enter the order.

Based on observations, staff interviews, and record review, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was evident for 6 (Resident #3, #75, #48, #43, #59 and #31) of 42 residents reviewed during the annual survey.The findings include:Enhanced Barrier precaution (EBP) are targeted infection control measures used in nursing homes and skilled nursing facilities to prevent the transmission of multidrug resistant organisms (MDRO's). They are required for residents who have one or more medical devices such as urinary catheter, feeding tubes, central lines, tracheostomy, chronic or open wounds or pressure ulcers. Staff are required to put on Personal Protective Equipment (PPE) such as a clean gown and gloves before engaging to care for these devices or when performing wound care. 1. On 06/15/26 at 7:39 AM, the surveyor observed PPE stationed outside of a shared room. The surveyor did not observe transmission-based precautions signage inside or outside of the room to indicate if the precaution was for Resident #3 or his/her roommate. On 06/15/26 at 8:17AM, the surveyor interviewed the Unit Manager. The Unit Manager stated that there was PPE on the door because Resident #3 is on enhanced barrier precautions for two reasons: 1) A foley catheter and 2) Right lateral diabetic foot wound. The Unit Manager also stated that in shared rooms, transmission-based precautions signage should be placed by the resident it is indicated for. On 06/16/26 at 8:20 AM, the surveyor performed a record review. The surveyor confirmed that Resident #3 had orders for 1) maintaining enhanced barrier precautions every shift for infection prevention and control, 2) a foley catheter, and 3) treatment for his/her right lateral foot open wound. On 06/16/26 at 8:30 AM, the Director of Nursing acknowledged the concern. 2. On 6/16/2026 at 9:30 AM, review of the facilities matrix indicated that resident # 75 has a peripheral inserted central line (PICC) for intravenous (IV) antibiotics infusion. Review of the resident's physician's order dated 6/12/26 reads: IV-PICC (all types) monitor site Q shift for signs/symptoms of infection and/or infiltration. There was no order for enhanced barrier precaution. Observation of the resident revealed the presence of a PICC line to the Right upper arm. Continuous review of the Matrix on 6/16/26 also reveal that resident #48 has a wound to the right hip. The Physician's order on 6/10/26 reads: Wound to distal R hip: cleanse with NSS, pat dry, apply calcium alginate. Cover with gauze and border foam every shift for Wound care. There was no order for enhanced barrier precaution. Further review of the facility matrix on 6/16/26 revealed that resident #43 has an indwelling foley catheter. Review of the doctor's order written on 5/19/26 reads: Maintain Foley catheter: size 14F balloon size 10 cc diagnosis Obstructive Uropathy every shift for Monitoring and on 5/20/26, the order reads: Maintain enhanced barrier precautions every shift for Infection Prevention. Observation of the three residents' rooms on 6/15/26, 6/16/26 and 6/17/26 did not reveal any signage on their doors to indicate that they were on Enhanced barrier precaution and no PPE outside all three resident's doors/room to help with infection control. On 6/17/26 at 2:37PM the unit manager/infection preventionist #16 was asked if residents on EBP precautions should have EBP signage on their doors and PPEs outside their rooms and she said they should. She was made aware that there were no signs on the residents' door to alert staff or visitors that these residents were on any sort of isolation precaution. She validated that there were none and that this was a concern. On 6/18/26 at 8:56 AM the Director of Nursing (DON) was made aware of the concerns, and she said she talked with the unit manager, and it has been corrected. 3. On 6/18/26 at 7:26 AM, the surveyor observed Registered Nurse (RN) #5 remove the portable blood pressure (BP) machine from Resident #59's room. RN #5 stated she had just taken the Resident #59's blood pressure and was ready to administer his/her medications. On 6/18/26 at 7:34 AM, the surveyor observed RN #5 prepare medications for Resident #31. RN #5 stated that she would put Resident 31's one blood pressure pill aside, take the resident's blood pressure, and then determine if the medication should be given. After preparation RN #5 used the same portable blood pressure machine and cuff utilized with Resident #59 to take Resident #31's blood pressure. On 6/18/26 at 7:53 AM, the surveyor conducted an interview post medication administration. The surveyor asked RN #5 if she had sanitized the shared portable blood pressure machine/cuff between the two residents. RN #5 stated she had forgotten to and the expectation was to disinfect equipment that is shared between residents. On 6/18/26 at 8:36 AM, the surveyor informed the Nursing Home Administrator of the observation.

Based on observation and interview, it was determined that the facility failed to ensure a clean homelike environment. This was evident for 2 (Resident #14 and 52) out of 15 residents reviewed during the initial tour of the recertification survey. The findings include:On 06/15/26 at 8:00 AM, the surveyor observed that Resident #14's room was in disarray. The floor was cluttered with debris, including sugar packets, a cup, and napkins. Further inspection revealed visible pink and gray stains on the carpet and a detached wall panel by Resident #14's bed.On 06/15/26 at 8:04 AM, the surveyor observed Resident #52's side table was visibly soiled, and dried food particles were scattered across the floor. On 06/16/26 at 12:55 PM, the Administrator acknowledged the concern.

Based on record review and staff interviews, it was determined that the facility failed to send a copy of the notice of transfer and discharges to the ombudsman. This was evident for all transfer /discharges in the facility from November 2025 to July 2026 reviewed during the annual survey. The findings include: On 06/15/2026 at 2:53 PM a review of Resident #5's medical records revealed that resident was sent out to the hospital on 6/14/26 for a medical condition. Further review revealed that notification of transfer was given to families but not to the ombudsman. On 6/16/26 at 11:35 AM, the facility ombudsman stopped by to chat with the surveyors and was asked if the facility sent her a list or notification of their hospital transfers and discharges, she said they did not. Review of the facility policy on transfer and discharge documented that the facility would maintain evidence that the notice was sent to the Ombudsman, In an interview with the Director of Nursing (DON) on 06/16/2026 at 4:52 AM she was asked if the facility sends a list of all their transfers and discharges to the ombudsmen or sends any form of notification to the ombudsman for all hospital transfers and discharges. She stated that their facility has not been notifying the ombudsman, that the resident's family and the doctors are the only ones notified when a resident is transferred to the hospital or discharged . She explained that the ombudsman is notified only if it's a reportable event. She was made aware that this was a concern, she said she would follow up.

Based on record review, and interviews, it was determined that the facility failed to accurately document a Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 1 (Resident #11) of 1 residents reviewed for hospice during the survey. The findings include: On 6/15/26 at 2:24 PM, the surveyor reviewed Resident #11's medical record. The review revealed a care plan that stated Resident #11 was admitted to Hospice on 1/18/26 with the goal that Resident #11 would remain comfortable. On 6/16/26 at 12:44 PM, the surveyor reviewed the most recent Hospice provider documentation and noted that Resident #11's Hospice care plan was active and updated on 3/10/26 and again on 6/2/26 with a nurse's visit on 4/29/26 related to a fall. Next the surveyor reviewed Resident #11's Minimum Data Set (MDS) assessment with the Assessment Reference Date (ARD) of 6/10/26 and noted in Section O it was coded No for Hospice care. On 6/16/26 at 2:55 PM, the surveyor conducted an interview with the MDS coordinator. During the interview the MDS coordinator confirmed that the assessment was coded incorrectly and that she would correct that error.

Based on record review and interview, it was determined that facility staff failed to ensure that a positive PASARR (Preadmission Screening and Resident Review) screening that determined a level 2 evaluation was needed was completed. This finding was evident for 1 (Resident #6) out of 1 resident reviewed for PASARR. The findings include: Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions. Adult Evaluation and Review Services (AERS)- is a Maryland program based in local health departments that provides assistance to frail, aged, and disabled adults and children who are at risk of institutionalization. On 6/15/26 at 12:21 PM, the surveyor reviewed Resident #6's medical record and was unable to locate Resident #6's PASARR screening. On 6/15/26 at 3:02 PM, the Director of Social Work (DSW) #8 provided the PASARR screening for Resident #6 from 2021. In section C of the screening it was determined the Resident #6 had a Serious Mental Illness by having all three questions answered yes. The instructions ask that section D be completed if a serious Mental Illness is determined. Resident #6's section D indicated no to all screening questions. The instructions state, if all answers in Part D are No, the individual must be referred to AERS for a Level II evaluation. The area on the form where the local AERS Office was contacted was left blank. The surveyor asked DSW#8 if AERS was contacted for Resident #6. She stated she was not the social worker during this time but would look into it and follow up. On 6/16/26 at 8:13 AM, the surveyor conducted a follow-up interview with DSW #8. During the interview DSW #8 stated she was unable to find documentation that the level 2 was referred to AERS and would peruse the correct steps for evaluation.

Based on observation, interview and record reviews, it was determined that the facility failed to to provide necessary services to maintain good personal hygiene for dependent Residents timely. This was evident for 2 (Resident #74 & #68) of 5 residents reviewed for activities of daily living during the annual survey.The findings include:Activities of daily living (ADL) are tasks we do to stay alive and well, and include eating, going to the bathroom, bathing, transferring etc.1) On 06/16/2026 at approximately 8:20 AM the surveyor observed that Resident #74 call light was on. LPN #20 was in the hallway passing medication. The surveyor waited 20 minutes to see if anyone would respond to the call light, but no one did. The surveyor went into the resident's room to see if they were ok. Resident #74 said it's been 24 minutes since she put on their call light and no one had shown up and s/he wanted to go to the bathroom and be cleaned up. The surveyor told the resident that she would go look for their aide. The surveyor approached LPN #20 and told her the resident needed help and asked if the aide was available, she said the aide was in another resident's room providing care. The MDS Coordinator-#12 was seen going into Resident #74's room. She told the resident she would get someone to help them. The surveyor went back to check on the resident 30 minutes later and asked if help had been provided. The resident told the surveyor that it took 40 minutes before someone came to provide care. In an interview with the unit manager #16 on 06/16/2026 at 3:26 PM, she was asked about call bell response time. She said call lights are to be responded to immediately to see if the resident needed immediate attention. She was made aware that the surveyor observed the call light for 20 minutes without anyone responding even though the LPN #20 was in the hallway passing medications. She said the LPN should have popped in to see what the resident needed and to make sure they were not in distress. She said she will follow up. On 06/16/2026 at 4:22 PM the unit manager told the surveyor that she went to see the resident and resident confirmed that she waited 45 minutes before help could be provided. The unit manager said she will put a concern form in and provide education and in-services to staff regarding call bell response time and will follow up with LPN #20. On 06/18/2026 at 9:19 AM The Director of Nursing (DON) was made aware of the above concern. 2) On 6/22/26 at 7:19 AM, the surveyor reviewed complaint #2728155. The complaint alleged that Resident #68 sat in urine saturated diapers for hours. Next the surveyor reviewed Resident #68's care plan. A care plan for Activity of Daily Living (ADL) selfcare performance deficit was created on 1/27/26. One of the interventions was to have a toilet schedule at least every 2 hours. Additionally, a care plan was created stating Resident #68 had bladder incontinence. The surveyor reviewed Resident #68's admission Minimum Data Set (MDS) assessment. The review revealed that Resident #68 was coded dependent or toileting hygiene. On 6/22/26 at 9:46 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor requested documentation that toileting/incontinent care was provided to Resident #68 every 2 hours as identified as needed in his/her care plan. On 6/22/26 at 10:55 AM, the surveyor conducted a follow-up interview with the DON. The DON provided a TASK flowsheets for January 2026 and February 2025. Staff documented every shift (except on day shift on 2/24/26 & 2/25/26) that Resident #68 was incontinent, however there was no indication as to how many times in the shift Resident #68 was provided incontinent cares. The surveyor reviewed the concern that there was no documentation to indicate Resident #68 was provided with incontinent care every 2 hours per his/her assessed need in the care plan.

Based on record review, observation and interviews, it was determined that the facility failed to carry out a physician's order related to ace wrap. This was evident for 1(Resident #75) of 2 residents reviewed for quality of care during the annual survey. The findings include: On 06/16/2026 at 10:00 AM, review of Resident #75 physicians order revealed an order written on 6/12/26 that reads; Apply ACE wraps to bilateral lower legs in morning and remove at bedtime every morning and at bedtime for bilateral lower extremity edema. An observation of the resident on 6/15/2026 at 10:03 AM reveal bilateral lower extremities swelling, the ace wrap was not on resident's bilateral lower extremities as ordered by the physician. A second observation on 6/16/2026 at 9:42 AM showed the ace wrap was not placed on the resident's bilateral lower extremities. In an interview with the resident on 6/16/26 at 10:05 AM s/he was asked if staff were applying the ace wrap and s/he said no one has applied it since they were admitted . Resident #75 stated they were not aware that it was ordered for their leg edema. On 6/16/26 at 10:06 AM, a review of the June 2026 Treatment Administration Record revealed that nursing staff have been signing off the order since 6/12/26 even though they were not applying it. In an interview with the Resident #75's nurse on 6/16/2026 at 2:53 PM, the License Practical Nurse (LPN) #20 was asked about the ace wrap and the process for documenting intervention. She stated that it should be documented after the intervention was completed. LPN #20 was made aware that she documented that Resident #75 had their ace wrap on when they did not. She stated that resident was in therapy and she will address it when resident returns. She confirmed that the expectation was to put it on before signing off that it was done. On 6/16/2026 at 3:26 PM the unit manager #16 on Baltimore unit was made aware of the concern. She stated that signing it off means it was done. She validated the concern that staff have been signing off and intervention without performing it and will investigate further. On 06/18/2026 at 9:20 AM The Director of Nursing (DON) was made aware of the concern, she said she will also follow up.

Based on record reviews and interviews, it was determined that the facility failed to provide treatments to ensure proper care was provided for a Resident with suprapubic catheter. This was found evident in 1 (Resident #2) of 1 resident reviewed for suprapubic catheter and Urinary Tract Infection (UTI) during the survey. A suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin in the abdomen used to drain urine through a tube from the bladder to a collection bag in individuals with obstruction of normal urinary flow. The findings include: On 6/15/26 at 8:50 AM, the surveyor observed Resident #2 had his/her catheter bag at waist level while in bed. Resident #2 reported that he/she had just transferred back to bed and was getting settled. Next the surveyor reviewed Resident #2's care plan and noted a care plan was in place for an indwelling suprapubic catheter initiated on 4/29/25. Additionally, there was a care plan related to educating Resident #2 on activities and possible infection control concerns initiated on 5/15/25. On 6/16/26 at 8:02 AM, the surveyor reviewed Resident #2's orders. The review revealed that orders for Resident #2's suprapubic catheter care were discontinued on 5/1/26 and included:-Change urinary catheter collection bag every 7 days, as needed in the evening every Sunday for infection control.-Empty urine bag. Dignity cover in place every shift for monitoring. -Maintain securement device to urinary catheter every shift.-Maintain suprapubic catheter: 20 FR, 10ml. Clean around the catheter every shift. Apply split gauze as needed every shift.-Suprapubic catheter: send to Urology center per order for routine in-office catheter exchanges approximately every 30 days as needed.-Flush catheter with 60ml normal saline as needed. Initiated on 2/26/26.There were no active orders to care for Resident#2's suprapubic catheter. On 6/16/26 at 8:35 AM, the surveyor reviewed the urology consult note written on 4/23/26. The note stated that Resident #2 had his/her 4-week suprapubic catheter exchange and was treated for a urinary tract infection last month. The note further stated that the urologist previously provided orders for the facility to flush Resident #2's catheter once daily with 60 cc of normal saline to prevent obstruction and to follow up in 4 weeks for the next exchange. On 6/16/26 at 10:07 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concerns that Resident #2 did not have any suprapubic catheter order until today, 6/16/26, when it was brought to the facility's attention and suprapubic cares were not documented as provided after they were discontinued. Also noted the urologist flush recommendation for a scheduled daily flush was not updated after the April visit.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to administer medications according to procedures that ensure accurate dispensing and ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #31) out 4 residents observed for medication administration and 1 (Resident #68) out of 2 complaints related to medication administration. The findings include: 1) On 6/18/26 at 7:34 AM, the surveyor observed RN #5 prepare medications for Resident #31. RN #5 asked Resident # 31 if he/she was having pain before administering the medications. Resident #31 acknowledged he/she was having pain and RN #5 informed Resident #31 that she would give him/her pain medication. Next RN #5 obtained Resident #31's as needed tramadol(pain medication) from the locked controlled substance box and signed the medication out on the controlled log book. RN #5 added the medication to Resident #31's morning medication and administered them to the resident. On 6/18/26 at 9:37 AM, the surveyor conducted a medication reconciliation to Resident #31's medication orders. The surveyor reviewed what was scheduled to be given, signed out as given, to what was observed given. On review of the tramadol order, no medication was signed off on Resident #31's Medication Administration Record (MAR) even though it was observed given. On 6/18/26 at 10:24 AM, the surveyor conducted an interview with RN #5. During the interview the surveyor reviewed that the MAR did not show that the tramadol was given. RN #5 stated that it was omitted in error and that she must have not hit save on the administration charting. RN #5 confirmed that it is the expectation to sign out controlled substances in the controlled log book as well as the resident's MAR. 2)On 6/22/26 at 7:19 AM, the surveyor reviewed complaint #2728155. The complaint alleged that Resident #68 missed two doses of his/her antibiotic during his/her stay at the facility. Next the surveyor reviewed Resident #68's Medication Administration Records (MAR). Resident #68 had an order for an antibiotic to be given every 4 hours scheduled at 2AM, 6AM, 10AM, 2PM, 6PM and 10PM. On the January MAR on 1/23/26 the 2AM dose was coded 5- Hold/See progress notes. On review of the progress note written by Registered Nurse (RN) #30 on 1/23/26 it stated, medication not available. On review of the February MAR on 2/9/26 the 6AM, dose was coded 9-Other/See Progress notes. On review of the progress note written by Registered Nurse (RN) #31 on 2/9/26 it stated; Medication not available. On-coming nursing and supervisor made aware. On 6/22/26 at 9:42 AM, the surveyor conducted an interview with the Director of Nursing (DON). The surveyor reviewed the missed doses of Resident #68's antibiotic. The DON confirmed the expectation was to have the medication available and administer medications as they are ordered.

Based on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident of 2 medication carts and 1 treatment cart on 1 out of 5 days observed during the survey. The findings include: On 6/15/26 at 7:03 AM, on the initial tour of the survey, the surveyor observed a medication cart unlocked and unattended on the Baltimore unit. On 7:04 AM, the surveyor conducted an interview with Certified Nursing Assistant (CNA) #4. The surveyor asked where the nurse responsible for the medication cart was located. CNA #4 stated that she must have been on the other side of the unit. On 6/1/5/26 7:07 AM, the surveyor walked over to the other side of the unit and noted the medication cart and treatment cart both unlocked next to each other in front of the nurses' station. Two staff were behind the nurses' station. When asked who was responsible for the medication and treatment cart Registered Nurse (RN) #3 stated that she worked night and had handed the key to the day nurse RN #5, who was also sitting behind the nurses' station. RN #5 stated that she was in close proximity to the cart but confirmed that when she walked away from the carts they should have been locked. RN #3 confirmed that the medication cart on the other side of the unit should have been locked before walking away. She stated she was responsible for that medication cart because she had not signed it out to the day nurse yet. At the time of the entrance conference the Nursing Home Administrator and the Director of Nursing (DON) were made aware of the observations.

Based on observation and interview, it was determined that the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature. This was evident for 1 out of 1 observation of the kitchen tray line and test trays.The findings include:On 6/17/2026 at 11:47 AM, the surveyors observed the kitchen tray line during lunch preparation and requested regular and pureed test trays at the end of tray preparation.On 6/17/2026 at 12:28 PM, the surveyors interviewed residents in the dining room. Resident #47 stated that the food was lukewarm. Resident #33 stated that the chicken was very dry.On 6/17/2026 at 12:43 PM, a surveyor tasted the entree and side items on both the regular and pureed test trays. The surveyor noted that the chicken, carrots, and plain white noodles on both trays did not appear appetizing. The chicken was dry and poorly seasoned. The remaining food items also lacked seasoning.On 6/17/2026 at 12:44 PM, another surveyor tasted the entree and side items and found that the food was barely warm and not served at a palatable temperature. Another surveyor tasted the carrots on the regular diet tray and stated that the carrots tasted like water.On 6/18/2026 at 12:36 PM, the surveyor reviewed the concerns regarding food temperature, texture, color, and palatability with the Administrator.On 6/22/2026 at 9:09 AM, the Administrator stated the facility is conducting tray audits for accuracy and temperature and looking at the full picture to address resident concerns with the food.

Based on review of facility and medical records and interview with staff it was determined the facility staff failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This was evident for 1 (#7) of 2 residents reviewed for accidents.The findings include:Review of Resident #7's medical record on 12/4/25 at 1:38 PM revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to mild neurocognitive disorder due to known physiological condition with behavioral disturbance, cognitive communication deficit and other sequelae of cerebral infarction. Resident #7 ambulated independently and without the use of assistive devices. The resident had 2 physician certificates indicating s/he lacked capacity to make medical decisions due to Cognitive Impairment. An initial elopement risk assessment dated [DATE] indicated s/he was not an elopement risk. A Brief Interview for Mental Status (BIMS) assessment is a tool used to identify a resident's cognitive function levels, a score of 8-12 indicates moderate impairment in thinking and memory; 0-7 indicates severe impairment.A BIMS assessment was conducted on 8/13/25 at 9:37 AM by Therapy. The assessment indicated Resident #7's BIMS score was 11/15. Another BIMS assessment was conducted later the same day, at 5:25 PM by Social Service. Resident #7's score at that time was 7/15. Nursing progress notes from 8/13/25 12:31 PM - 8/16/25 included that Resident #7 did not obey commands, had behaviors such as refusing care and medications, agitation, wandering at night and identified safety concerns including exit seeking, fall risk and wandering. However, no measures were put in place to address these behaviors. An SBAR summary note dated 8/17/25 09:00 identified the Situation: patient eloped. It described that the resident woke up around 7:00 AM, was fully dressed with bags packed and attempted to leave to go home. S/he was redirected, reoriented to place. The oncoming supervisor was notified. The note indicated that at 7:30 AM Resident #7 attempted to break a window to elope, was agitated and cursed at staff. A GNA was asked to watch the resident. The GNA alerted the nursing supervisor that the resident was attempting to elope. Around 8:55 AM the nurse was alerted that staff could not find Resident #7.Facility reported incident #2592377 was reviewed on 12/4/25 at 11:34 AM. The report revealed that Resident #7 eloped from the facility on 8/17/25 at approximately 8:50 AM. The facility staff began their search protocol, and the police were notified. The police located the resident at 9:39 AM at a gas station approximately 3.5 miles away. S/he was positively identified by the facility and taken to the hospital for an evaluation. S/he returned, unharmed and at his/her baseline, to the facility at 10:00 PM on 8/17/25.The facility investigated and determined through interviews and review of video footage that Resident #7 walked to the elevator with 2 tote bags and rode the elevator to the lower level with a laundry aide. Once on the lower level, Resident #7 went to the kitchen where a dietary aide assumed s/he was a visitor trying to get to his/her car parked behind the building and the dietary aide escorted Resident #7 out a building exit door. From their investigation of the incident the facility concluded that facility staff (laundry and dietary) failed to verify the identity of an exit seeking resident, mistook him/her as a visitor and let him/her out of the building. In an interview on 12/9/25 at 11:07 AM, Staff #1 confirmed she was the nursing supervisor working on the morning of 8/17/25. She indicated it was the beginning of the day shift and she was in the process of getting everything organized for the day. Resident #7 spoke to her. Staff #1 stated S/he didn't tell me s/he wanted to leave, just that s/he wanted to go. S/he was calm. Another nurse reported to her that Resident #7 did something to the window so I watched him/her for a little while and s/he was calm. She indicated that she went around to all the staff to give them a heads-up regarding Resident #7's behavior. She asked the nurse to call the on-call provider to inform them of Resident #7's behavior. She indicated she wanted to make sure the receptionist knew what the resident looked like, so they went together to look at the resident and discovered s/he was gone. She indicated that it transpired very fast and that when staff went outside to search, a gentleman across the street reported he was outside and witnessed someone resembling Resident #7's description getting into a truck. The police were immediately notified. Staff #1 indicated that Resident #7 was very put together and could have been easily mistaken for a visitor. On 12/9/25 at 11:32 AM Staff #5, a staffing agency Geriatric Nursing Assistant (GNA), revealed that when she started her shift on the morning of 8/17/25 Resident #7 was just walking around, went to the doors several times and started saying s/he wanted to go out. The supervisor was notified. Staff #5 indicated that she sat with Resident #7 in the dayroom for about 30-45 minutes to keep an eye on him/her. She indicated that Resident #7 calmed down, wasn't talking about going out and remained calm. Other staff were around. She indicated that she updated the nurse on Resident #7's behavior and that she was going to start her assignment. When asked if she was asked to sit 1 to 1 with Resident #7 she stated, I had an assignment, so I wasn't assigned to be a sitter or anything like that. She indicated that she didn't really know what time staff realized Resident #7 was gone. She also indicated that the supervisor was notifying staff of the resident's behavior and was attempting to point him/her out to the receptionist.Staff #4 a cook was interviewed on 12/9/25 at 10:30 AM. She confirmed that on the morning of 8/17/25 Resident #7 walked into the kitchen twice. We said, can I help you? Resident #7 just said, I need to go out and one of the dietary aides let him/her out. Afterward they said s/he was a resident, it never occurred to us, s/he didn't look like a resident, and the residents don't have any way of getting onto the elevator or to the kitchen by themselves. When asked which door the dietary aide opened for the resident she pointed to a lower level hallway and indicated it was the building exit door at the end of the hall. The facility's failure to provide adequate supervision to prevent a cognitively impaired resident with exit seeking behaviors puts them at risk for serious harm or death by allowing them access to unsafe environments and situations including but not limited to nearby busy highways, falls and the ill intention of others. The facility implemented the following corrective measures with a completion date of 10/8/25, resulting in a finding of past non-compliance. Upon return from the hospital on 8/17/25, Resident #7's Plan of Care was updated, s/he was placed on 1:1 GNA sitter care, a Psychiatric behavioral health evaluation was completed, and s/he was assessed by the physician. On 8/17/25 after Resident #7's elopement, the facility implemented a visitor name tag system. An email was sent to staff and residents' families regarding the new system. Families without an email on file were notified by phone. Signs were posted at the front lobby desk and on the nursing units requiring visitor badges and badge protocol. On 8/17/25 the facility conducted in-service training with staff. However, on 10/3/25 the Administrator identified that 100% education was not done. The facility conducted additional training for: Location of an Elopement Binder at the Front Desk; Code Pink, Signs & Symptoms of Elopement, interacting with all visitors as possible residents, and never letting anyone out a coded locked door without a nurse's approval, which was completed on 10/8/25. Elopement drills were conducted with staff. Quality Assurance audits were conducted to monitor effectiveness of the corrective measures.

Based on review of facility files and interview with staff it was determined the facility staff failed to ensure all staff received mandatory training on the elements and goals of the Quality Assurance Performance Improvement (QAPI) program.This was evident for 4 (#8, #10, #3 and #4) of 6 staff reviewed for Training Requirements during the extended survey.The findings include:Six employee files were reviewed for education and training on 12/11/25 at 9:30 AM. The files for Staff #8 and #10 Geriatric Nursing Assistants (GNA's), Staff #3 a Dietary Aide and Staff #4 a [NAME] failed to reveal they received the mandatory training on the elements and goals of the facility's QAPI program.Staff #12, the Human Resources (HR) Director, was made aware of the above findings on 12/11/25 at approximately 11:30 AM. Despite several attempts she was unable to produce evidence that the training was provided as required. Staff #6 the Corporate Nurse was made aware of these findings at 11:57 AM on 12/11/25. She spoke with Staff #12 and attempted to locate the education records. However, she informed the surveyor that the education records were not systematically maintained, and she was unable to determine if and when the education was provided.

Based on review of facility files and interview with staff it was determined the facility staff failed to ensure all direct care staff received mandatory training for Effective Communication.This was evident for 4 (#8, #9, #10, and #11) of 4 direct care staff reviewed for Training Requirements during the extended survey.The findings include:Six employee files were reviewed for education and training on 12/11/25 at 9:30 AM. The files for Geriatric Nursing Assistants (GNA) Staff #8, #9 and #10 and Staff #11 a Registered Nurse (RN) failed to reveal that they received mandatory training for Effective Communication.On 12/11/25 at approximately 11:30 AM, Staff #12 Human Resources (HR) Director was made aware of the above findings. Despite several attempts she was unable to produce evidence that Effective Communication education was provided to the above staff members as required.On 12/11/25 at 11:57 AM, Staff #6 the Corporate Nurse was made aware of these findings. After attempting to obtain the records and speaking with Staff #12, she informed the surveyor that the education records were not systematically maintained, and she was unable to determine if and when the education was provided.

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility failed to conduct yearly performance reviews at least every 12 months. This was found to be evident for 4 (#8, #13, #14, #15) of 4 GNA employee files reviewed.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. During a complaint survey, a review of Geriatric Nursing Assistant personnel files failed to reveal evidence of yearly evaluations. On 12/11/25 at 1:18 PM the surveyor requested the yearly performance reviews for 4 GNAs (#8, #13, #14, #15).On 12/11/25 at 2:20 PM, Staff #12, Human Resources reported to surveyor that s/he was unable to find any GNA performance reviews.On 12/11/25 at approximately 6:00 PM, the above concerns were discussed with Staff #6, Corporate Registered Nurse (RN). The Corporate RN acknowledged the concerns at that time and confirmed there was no evidence to indicate annual performance reviews of the GNAs had been conducted.

Based on review of facility documents and staff interview it was determined the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. This was evident for 2 (#3, #1) of 3 residents reviewed for an injury of unknown source and 1 (#2) of 1 residents reviewed for misappropriation of resident property.The findings include:On 12/4/25 at approximately 12:15 PM, a review of facility reported incident, 263516, documented that on 10/5/25 at 6:15 AM, Resident #3 was observed to have bruising and swelling of his/her left eye that was an injury of unknown origin.The facility's investigation documented that staff became aware of the incident on 10/5/25 at 6:15 AM. Further review of the facility's documentation revealed an email confirmation that documented the facility's initial self-report was sent to the State Agency on 10/5/25 at 11:51 AM.The facility failed to report the injury of unknown source immediately, but not later than 2 hours after the becoming aware of injury.The concerns with late reporting an injury of unknown source was discussed with the Nursing Home Administrator (NHA) and Staff #17, Registered Nurse (RN) Unit Manger (UM). The NHA acknowledged the concerns and offered no further comments at that time.2) On 12/8/25 at 1:33 PM, a review of facility reported incident, 2594806 documented that on 8/19/25, around 8:30 AM, the nurse observed Resident #1 with a bruise on his/her right forehead that was an injury of unknown source.The facility's investigation documented that staff became aware of the incident on 8/19/25 at 8:30 AM. Further review of the facility's documentation revealed an email confirmation that documented the facility's initial self-report was sent to the State Agency on 8/19/25 at 11:31 AM.The facility failed to report an injury of unknown source immediately, but not later than 2 hours after the allegation was made.3) On 12/10/25 at , a review of facility reported incident, 2583979, documented that on 8/6/25 at 4:00 PM, a discrepancy between Resident #2's Medication Administration Record (MAR), the narcotic log sheet and the number of pills administered alleging misappropriation of Resident #1's narcotic medication.The facility's investigation documented that staff became aware of the alleged misappropriation of a resident's narcotics on 8/6/25 at 4:00 PM. Further review of the facility's documentation revealed an email confirmation that documented the facility's initial self-report was sent to the State Agency on 8/7/25 at 3:59 PM.The facility failed to report an allegation of misappropriation of a resident's medication immediately, but not later than 2 hours after the allegation was made.The concerns with the failing to ensure that the alleged violations involving injuries of unknown source and misappropriation of resident property were reported timely were discussed with the NHA on 12/10/25 at 3:00 PM. The NHA acknowledged the concerns with late reporting and no further comments were offered at that time.

Based on complaint allegations, medical record review, and interviews of staff, it was determined that the facility failed to, 1) ensure wounds were accurately assessed with weekly wound evaluation and 2) failed to provide appropriate treatment and services to promote healing of pressure ulcers and prevent new ulcers from developing. Failure to provide appropriate treatment and services to promote healing of a stage 1 pressure ulcer resulted in the development of a stage 4 pressure ulcer causing harm to a resident. This was evident for 1 (#10) of 4 residents reviewed for pressure ulcers. The Findings Include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). Review of complaints #MD00174291 and #MD00181602 revealed allegations that the facility staff failed to prevent and treat pressure wounds for resident #10. Resident #10 ' s closed medical record was reviewed on 11/15/22. Resident #10 was admitted to the facility from a hospital on 10/12/21. The Peak Admission/Readmission Evaluation dated and signed on 10/12/21 revealed the resident was assessed to have 2 pressure ulcers. Section C Skin Integrity documented Sacrum Type =Pressure length 5 by width 6 [cm], wound stage 1, left buttock pressure 0.8 by 0.5 depth 0.2, wound stage = unstageable, and Other Type = Skin Tear 1.5 by 1.0 stage = N/A. Review of the October 2021 physician orders revealed orders for wound care that were prescribed on the day of admission. The orders stated, left buttock wound-cleanse with normal saline apply Medi-honey and cover with dry dressing daily, and Left elbow skin tear cleanse with saline, apply bacitracin cover with dry dressing daily. Review of the resident ' s entire medical record revealed that the resident was seen one time by the attending physician on 10/15/21. Review of the physician ' s History and Physical dated 10/15/21 and uploaded to the electronic medical record on 11/1/21, did not reveal documentation related to an evaluation/and or assessment of the resident ' s skin status. Cross-reference to F711 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the Minimum Data set 5-day compressive assessment completed on 10/30/21 revealed that staff documented the resident did not have any pressure ulcers or skin tears. Cross reference to F636 Review of Resident #10's care plans revealed a skin integrity care plan with the focus, Resident at risk for skin breakdown related to disease process. The goal was written as the resident will maintain or develop clean and intact skin by the review date, and the resident will be free from injury through the review date. Interventions were written generically as avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, and incontinence care every 2 hours and as needed. The documented interventions did not include the instructions needed to provide effective and person-centered care of the resident that met professional standards for care and treatment of pressure ulcers. The skin integrity care plan did not address Resident #10's pressure ulcers and skin tear he/she had on admission to the facility. The goals were not resident centered as resident #10 was admitted with injuries to the skin. There were not any revisions made to the care plan. Cross-reference to F656. Review of the treatment administration record (TAR) for October 2021 indicated staff signed off on the prescribed skin care. Review of the Peak Skin Check Weekly assessments did not reveal accurate assessments, and there was not any documentation of wound measurements after 10-12-21 until 11/9/21. A skin check dated 10/19/21 indicated the resident ' s skin was intact. (no documented skin concerns) A skin check dated 10/26/21 and signed on 11/4/21 indicated the resident ' s skin was not intact and the area was not new. An additional comment previously identified sacral wound and right heel DTI (deep tissue injury). There was not any measurements or further description of the wounds. A 10/27/21 nursing progress note documented that resident #10 was transferred to the hospital via EMS at 2:50 PM for a separate medical condition. A readmission nursing progress note documented on 10/30/21, resident #10 was readmitted with a left heel necrotic wound. A wound consultation was ordered by the resident ' s attending physician. The note documented, sacral wound present, bilateral toes are dry and rash like [her/his] back shows presence of molted skin with brown discoloration, right heel blanchable to touch. There was not any documentation of wound measurements upon the resident ' s readmission to the facility. A skin check dated 10/30/21and signed on 11/6/21 indicated the resident ' s skin was not intact and the skin condition was not a new area, with documentation sacral wound (pressure ulcer) Additional comments included Upon assessment. Large bruise noted to left breast, IV sites to bilateral forearm, bilateral ankle bruises, bilateral below the knee edema of the bilateral upper forearm. This assessment documented 16 skin alterations to include 5 areas on the resident ' s back and shoulders described as moulted (sic) like area on the back (brownish discoloration), inner part of right and left elbow bruise at IV site, edema on the legs, right toe = dry rash like, left toe = Dry rash like. The coccyx indicated open area and left heal = necrotic area noted, skin is not opened. (Necrotic tissue is dead tissue) There was not any documentation of wound measurements. The 10/30/21 treatment orders were documented as, WOUND CONSULT secondary to sacral wound and left heel necrotic, and NECROTIC LEFT HEEL cleanse necrotic area with NSS, pat dry apply Skin Prep BID until seen by wound doctor. Two times a day for Skin Integrity. Review of a 2nd Medicare 5-day MDS assessment dated [DATE] revealed the facility failed to accurately assess and document Resident #10 ' s wounds. Review of section M Skin Conditions M0210 Unhealed Pressure Ulcers/Injuries, coded no. An interview with the MDS Coordinator (staff #17) was conducted on 11/16/22 at 12:50 PM. She reviewed the Peak Admission/Readmission Evaluation related to resident #10's wound assessments and reviewed the admission MDS assessment with confirmation that the original assessment was not completed timely (greater than 14 days after admission) and pressure ulcers were not documented in the initial Medicare 5-day assessment. Additionally, a review of a second Medicare 5-day assessment dated [DATE], assessed by the MDS Coordinator was shown to not code the resident's pressure ulcer. Review of section M Skin Conditions M0210 Unhealed Pressure Ulcers/Injuries, coded no. A skin check dated 11/6/21 indicated skin was not intact with sacral wound tx (treatment) in progress. There was not any additional evaluation or measurements of the wound condition. Resident #10 was seen by a contracted nurse practitioner wound consultant on 11/9/21. A review of the uploaded consultant ' s wound evaluation revealed an assessment of the resident ' s Left buttock/sacrum. The wound consultant documented the wound was new, unstageable, and acquired in the facility. The wound measurements = Length 2.22 cm (centimeters) x Width 2.57 cm depth 0.00 cm. Further description of a scant amount of serosanguinous drainage with no odor was observed. Wound care was identified as Cleanse with normal saline with Medihoney and bordered gauze dressing. The consultant documented ensure compliance with turning and positioning. There was not any evidence of an evaluation of the necrotic left heel. A weekly skin check dated 11/13/21 indicated skin intact without any further documentation. Review of all the Peak PDPM/Skilled nursing evaluation[s] documented in November of 2021 revealed that resident #10 ' s skin assessments documented that there were not any changes in the resident ' s skin integrity. Section I Skin -Are there changes in resident ' s Skin Integrity? were answered no on 11/1/21, 11/2/21, 11/3/21, 11/4/21, 11/6/21, 11/7/21, 11/9/21, 11/11/21 at 14:26 and 11/11/21 at 22:38, and 11/15/21. The resident was seen by the contract wound consultant on 11/16/22. The uploaded wound evaluation for the left buttock/sacrum indicated a worsening unstageable pressure ulcer with a moderate amount of malodorous serosanguinous drainage. The measurements were greater than the previous week, as Length = 6.29 cm, Width = 9.64 cm L x W = 60.64 cm squared, and a depth of 1.00 cm. A wound evaluation of the necrotic left heel unstageable pressure ulcer indicated the wound was new and facility-acquired. The wound measurements were documented as Length 4.11 cm, Width 2.65 cm, L x W 10.89 cm squared, and Depth 0.00. A corresponding wound consultant progress note date 11/16/21 at 8:42 AM indicated she performed a comprehensive skin and wound evaluation for Left buttock/sacrum pressure ulcer, left and right great toe, left and right heel. The note documents See Tissue Analytics Documentation for full wound description and recommended nursing plan of care. (Tissue Analytics is the name of the wound consultation company). There was not any uploaded Tissue Analytics documentation for the wounds of the left and great toe or the right heel. The wound consultant nurse ' s note further documented, Wound rounds completed and reconciled with the wound nurse today. All questions and concerns answered for staff and patient as applicable The last progress note in resident #10's medical record was time stamped for 11/16/21 at 14:15 (2:15 PM) The note was a change of condition and the text was blank. Review of the corresponding Peak Healthcare Change in Condition/Concurrent Review under the Evaluations tab in the electronic health record revealed resident #10 was noted with a change in mental status and running a low-grade fever. Tylenol was given to lower the resident fever and the resident was subsequently ordered to be transferred to the hospital. Review of the November treatment administration record showed staff signed off daily as completing the cleansing and dressing change to the left buttock, cleansing and dressing change to a skin tear on the resident left elbow, and cleansing and applying skin prep to the residents necrotic heel for both day shift and evening shift (at 9 PM) including the day he/she was transferred out of the facility. The progress notes by the certified registered nurse practitioner (staff #19) who works with the attending physician were reviewed on 11/18/22. She documented visits with resident #10 on the following dates: 10/13/21 10/14/21 10/18/21 10/26/21 11/1/21 Review of all her progress notes did not reveal any documentation related to assessment and/or evaluations of the residents ' skin conditions. On 11/16/22 at 3:10 PM the nursing home administrator (NHA) and director of nursing (DON) were involved in a group discussion; they could not answer questions related to the care of resident #10 as they were not here during resident #10 ' s admission. Concerns related to resident #10 ' s admission to the facility with 2 pressure wounds that were not coded/assessed on the admission MDS ' s and a skin integrity care plan indicating the resident was at risk for developing wounds were shared. The DON confirmed the documentation of the wounds on admission as she made a copy of the Peak admission assessment, the initial 5-day Medicare assessment, and a copy of resident #10 ' s care plans that did not document interventions for the care and treatment of pressure ulcers. Upon request, the NHA provided a phone number for the consultant wound nurse. The NHA revealed that resident #10's attending physician was not available as she was on a vacation out of the country. A phone interview was conducted with the Tissue Analytics nurse practitioner wound consultant on 11/17/22 at 11:47 AM. She indicated that she started coming to the facility approximately 1 year prior (November 2021?). She indicated not being able to remember resident #10 in question. When asked if the facility had a wound nurse, she responded she did not always have a staff person to follow her for wound rounds. She indicated that there were to be wound communication books (1 book for upstairs and 1 book for the downstairs unit) and the facility staff was to document resident wound concerns. She indicated that the wound communication book was not always available as there were times when the books were misplaced. She repeated several times that her electronic system and the facility ' s electronic medical record (Point Click Care [PCC]) did not match up and she did not have access to information in PCC. There is no way for her to know who has wounds if there are no communication books. She indicated there is never consistency of staff to round with her and many times there was not anybody to follow her for wound rounds. She further revealed issues with administrative staff and a shortage of nursing staff. The consultant wound nurse was asked about her note that indicated she had reconciled with the wound nurse today, and she acknowledged that parts of her progress notes are pre-populated. A phone interview was conducted with the CRNP staff #19 on 11/23/22 at 9:05 AM. She was asked if she reviews resident ' s wounds. She did not answer the question and indicated that she will call back. She called back at 11:15 AM. Resident #10 was reviewed, and information was shared related to the documentation not found in the resident ' s medical record to show evaluations of the pressure wounds and other skin conditions. Her notes were discussed, CRNP (staff #19) was informed that there were 5 notes in the electronic medical record and documentation was not seen related to evaluations of the resident ' s skin conditions. CRNP #19 indicated that she evaluated the resident and directed that the resident be transferred to the hospital. CRNP #19 indicated that she failed to upload one of her notes and indicated that she would upload it. Review of resident #10 ' s electronic medical record on 11/23/22 at 12:15 PM revealed additional uploaded documents on 11/21/22 and 11/23/22. The contract wound consultant nurse had uploaded Tissue Analytics wound documentation dated 11/16/21 related to wound evaluations of resident #10 ' s Left great toe, right great toe and right heel. Review of the documentation for the right heel indicated the wound was a pressure ulcer staged as a suspected deep tissue injury. The wound was new and acquired at the facility with measurements of Length 1.85 cm, Width 1.96cm, depth 0.00 cm. Both wound evaluations for the right great toe and left great toe indicated the wounds were identified as Arterial and acquired in the facility with measurements. Review of the CRNP ' s (staff #19) note dated 11/16/21, electronically signed on 11/30/21 and uploaded to the electronic medical record one year later 11/23/22 revealed the resident was seen for altered mental status and fever. SKIN: sacral wound is deep with tunneling and moderate amount of foul-smelling discharge. Pressure ulcer of sacral region, stage 4 modified 11/30/21. CRNP #19 documented resident #10 required emergent transfer to the Emergency Department. 911 notified. EMS arrived and this writer provided a report. Nurse provided necessary paperwork. The facility failed to show basic skin care such as offloading the wounds and providing consistent turning and repositioning as a plan of care was not developed. Upon implementation of wound treatments, the facility failed to show evidence of wound monitoring and/or modification of interventions to attempt to stabilize, reduce or remove underlying risk factors to aid pressure ulcer healing and the development of additional pressure ulcers. Resident #10 was transferred out of the facility when a stage 1 ulcer deteriorated and/or merged with the unstageable wound (left buttack/sacrum) and was evaluated as a stage 4 ulcer. The concerns with additional findings were reviewed with the NHA on 11/23/22 at 2:30 PM