Every finding on record at Courtland, LLC

Based on record review, facility reported incident #2703327 and interviews, it was determined that the facility failed to report allegations of abuse to The office of Healthcare Quality (OHCQ) in a timely manner. This was evident for 1 of 1 Facility Reported Incident (FRI) reviewed during the survey process.Findings Included:On 07/09/2026 at 3:42 PM, a review of the FRI #2703327 initial report form revealed that on 12/24/2025 at 9:20 PM, the facility was notified by Resident #74 that he/she was assaulted by a relative; however, a review of the facility's internal incident report revealed that on 12/24/2025 at 7:50 PM staff heard loud yelling coming from Resident #74's room. As the nurse approached, the female relative was observed by staff exiting the room. The nurse then checked on the resident, who stated that he/she was struck in the head with a TV remote by the female relative.Further review of the initial report form submitted to OHCQ revealed that the allegation of abuse was submitted on 12/24/2025 at 11:45 PM.On 07/09/2026 at 3:50 PM a review of the facility's abuse policy and procedure (Last reviewed on 2/5/2025) revealed that the facility will report all cases of suspected or witnessed abuse, neglect, exploitation, mis- treatment, or crimes against residents, including injuries of unknown origin and misappropriation of resident property immediately. Staff who witness or suspect abuse, neglect, exploitation or mistreatment or who identify injuries of unknown origin or misappropriation of resident property should report the incident to their Unit Manager or Nursing Supervisor immediately. If the incident involves abuse or results in serious bodily injury, the incident will be immediately reported to the Director of Nursing and the Administrator. The Administrator or designee will notify law enforcement and The Office of Health Care Quality (OHCQ) within 2 hours (initial self-report).On 7/10/2026 at 8:25 AM, in an interview with the Director of Nursing (DON), he was asked about the abuse reporting process and he reported that if staff becomes aware of an abuse allegation it must be reported immediately to supervisor, then once notified of the alleged incident, the administration must be notified, then we decide if it was reportable. If the patient is cognitive, we can interview to find out details about the incident. If we find that the allegation was reportable after talking with the resident, then we will report it. If we cannot conclude if it is reportable then we have to report it. He explained that report to OHCQ must be done within a 2-hour time frame.On 7/10/2026 at 10:13 AM, the DON was notified that the facility failed to report the abuse allegation to OHCQ within 2-hours as required and the DON reported that it took some time for the staff to figure out what happened. The resident was aphasic and took time to express the concern. The staff wanted to ensure that the family member was out of the building before the issue was reported. He acknowledged that the facility failed to report to OHCQ first before attempting to conduct their investigation.

Based on observations, and interviews, it was determined that the facility failed to provide a safe sanitary environment related to sewage water backup. This was found on 1 of 8 days of the survey.The Maryland Office of Health Care Quality (OHCQ) determined that concern met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 3:25 PM on 7/15/25. The findings include:On 7/15/25 at 8:44 AM, at the entrance conference the Nursing Home Administrator (NHA) confirmed that the facility was having a problem with a drainage pipe and that they were dealing with a sewage issue.On 7/15/25 at 9:36 AM, the surveyor observed the kitchen. A pooling of sewer water was noted over a circular drain in the floor. Four other square drains throughout the kitchen were filled with liquid, 3 were noted with a brown color with a foul odor. One of the drains had a bleach smell as if it had just been cleaned.On 7/15/25 at 9:36 AM, the surveyor interviewed the kitchen manager. During the interview the Kitchen Manager stated that yesterday after lunch (7/14/25) the drain by the three-compartment sink started backing up and water started to accumulate in the kitchen. She further stated that the plan implemented was to continuously have the water evacuated by the floor cleaning machines. She stated that the backup was contained in this area and confirmed they continue to utilize the kitchen. On 7/15/25 at 10:32 AM, the surveyor observed the dishwashing area. The drain below the dishwasher was overflowing with discharged water from the dishwasher. The surveyor asked the kitchen staff if this was normal for the water not to drain. Kitchen staff #32 stated that sometimes when the drains are clogged the water accumulates but once the clog is removed it will drain again. The kitchen staff stated that the current blockage was affecting the draining of the discharged water from the dishwasher. The surveyor observed a portable rack to dry dishes parallel to the dishwasher and just behind the portable rack was another rack where clean dishes were placed to dry. The surveyor asked how the facility was ensuring that the backup and accumulated water from the drains were not contaminating clean surfaces used for food preparation. The kitchen manager stated that she now would be covering the clean dishes with plastic. The surveyor observed dishes on the lower rack were less than 6 inches off of the floor.The surveyor observed the utility hallway adjacent to the kitchen where it was noted that sewage was flowing from the drain. Fecal matter was next to the drain on the floor. The surveyor relayed the concern that sewage drainage was backing up from this drain and that a drain in the kitchen was also backing up, potentially containing the identified fecal matter.Also noted in the utility hallway were two mattresses on the floor in at least one inch of sewage water. A food storage room connected to the utility hallway was noted to have the carpet saturated by sewage water. All food items were up on shelves. On 7/15/25 at 10:48 AM, Regional Director of Operations Staff #1 stated that out of an abundance of precaution that they would be running the tray line out of the dining room, switch to plastic wear and terminally clean the kitchen.On 7/15/25 at 10:51 AM, the surveyor observed what was identified as sewage water by Staff #1 on the floor of the clean linen room. Laundry was circulating in the dryer and two staff members were folding laundry. During the observation Staff #3 stated that laundry was currently not being done in the building and that it was being sent out to be laundered. The surveyor asked about the laundry that was currently being dried and folded. The Nursing Home Administrator stated a few loads of laundry were brought back wet. On further observation, a closet-like area that contained two shelves of folded linen were noted with pooling water on the floor. The linen was not covered. Additionally, two carts in the clean laundry, in which the staff had just folded and placed laundry, were left uncovered and exposed to the sewer water on the floor. Staff #1 stated that all the linens would be re-washed and the room terminally cleaned after this was brought to his attention. On 7/15/25 at 11:21 AM, the surveyor observed a floor drain that had the cover removed in the hallway just outside room [ROOM NUMBER]. A foul odor was noted coming from the drain. The surveyor asked Environmental Service Staff EVS #8 is they could smell the odor. She stated she could. When asked how long the cover had been off EVS #8 Stated she was not aware. On further observation it was noted brown substance was being tracked down the hallway from the drain that was overflowing in the front entrance way and into the residential hallway.Interview on 7/15/25 at 2:20 PM with Maintenance Director staff #7 revealed that the concern was identified on Saturday 7/12/25 at 3:05 PM when he was contacted by the supervisor on duty that there was a backup in the kitchen where the water was not draining. A call was made to a plumbing company at that time and they were successful in clearing the identified clogged drains in the kitchen. On 7/14/25 the identified concerns from Saturday were found again, however, he stated that he came in at 9:00 AM to his assistant, Staff #6 trying to clear another drain in the front of the facility by the lobby. He further stated that at that time (7/14/25 at 9am) multiple drains were backing up throughout the facility including the laundry rooms.The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 8:15 PM on 7/15/25, after 2 initial plans were submitted at 6:09 PM and 7:23 PM, respectively. The plan included the assurance that a plumbing contractor unclogged the drain pipe and that the drain contents were no longer overflowing into the facility; All areas of the kitchen, laundry, to including clean linen room, and utility hallway, adjacent to the kitchen, have sewage water removed and the area sanitized; Any food items that had the potential to be contaminated were discarded and kitchen equipment that had the potential to be contaminated were sanitized; Linens in both clean and soiled that had the potential to be contaminated were re-washed. All floor drains that were open are now covered; And all current residents would be monitored for gastrointestinal symptoms for the next 72 hours.The facility plans for removal included the following: Education provided to the Environmental Staff, Kitchen Staff, and Maintenance Staff on infection control practices and cross contamination concern in regard to sewage exposure performed by the facility Educator and Nursing Supervisors. The education included training staff to pulse operations and immediately notify a supervisor to ensure a plan will be created and implemented to mitigate cross contamination. Education completed by 7/17/25. The Maintenance Director or Maintenance Assistant will snake line weekly to prevent drains from being clogged. A contracting plumbing vendor ran a camera to assess if there are further corrective actions needed to prevent drains from clogging. The reports will be reviewed for further action needed. Nursing Supervisors will perform rounds every shift for 2 weeks and then daily for 3 months to ensure drain lines are not overflowing. Any issue identified will immediately be communicated to the Maintenance Director and the Executive Director for appropriate actions. The Infection Control Coordinator or Food Service Director will observe the kitchen staff weekly for 3 months to ensure that there is no cross contamination of clean items. The Infection Control Coordinator or Environmental Service Director will observe laundry staff weekly for 3 months to ensure there is no cross contamination of clean linens. The results of the rounds and audits will be submitted to the Performance Improvement Committee for review and corrective action if needed. After determination of Immediate Jeopardy concerns, the Immediate Jeopardy was removed on 7/17/25 after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents.

Based on record review, and interview it was determined that the facility failed to provide a Resident's Representative the right to be involved in the vaccination consent process. This was found evident in 1 (Resident #73) of 5 residents reviewed for vaccinations. The findings include: On 7/24/25 at 9:02 AM, the surveyor reviewed Resident #73's medical record. The review revealed an evaluation titled, Physician's Certification of Incapacity to Make an Informed Decision completed by two providers dated 7/21/22 and 8/4/22. Both providers indicated the Resident #73 was unable to make a rational evaluation of the burdens, risks, and benefits of the treatment, or course of treatment. On further review it was noted that Resident #73's spouse was indicated on the Surrogate Identification Form. The surveyor reviewed the consent forms for the administration of the influenza (flu) vaccinations. In the 2022 flu season a telephone consent was obtained and documented by Resident #73's spouse. However, in the 2023 flu season, the consent form indicated the Resident had given consent and the form had Resident #73's signature, even though he/she was unable to give consent per the physician's evaluations. On 7/24/25 at 9:30 AM, the surveyor conducted an interview with the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that Resident #73's spouse should have been contacted to give consent for the 2023 flu vaccination and not the Resident.

Based on observations and interviews it was determined that the facility failed to provide a resident with a reasonable accommodation of need. This was found evident during one random observation on the survey for Resident #77. The findings include: On 7/16/25 at 8:56 AM, the surveyor observed that Resident was laying in bed awake and noted that his/her food tray was on the over-the-bed table next to Resident #77's bed. Resident #77 stated that his/her bed stopped working yesterday evening and that he/she was unable to raise the head of the bed up to eat. Resident #77 stated the bed has been fixed before but occasionally stops working. Resident #77 stated that he/she was told to hold off on eating until he/she could be set upright to eat. On 7/16/25 at 8:08 AM, the surveyor interviewed Resident #77's Geriatric Nursing Assistant (GNA) #13. GNA #13 stated that she was aware the Resident #77's bed was not working and she informed her Unit Manager. She confirmed that she instructed the Resident to wait to eat because he/she needed to be upright for safety concerns. On 7/16/25 at 8:29 AM, the surveyor conducted a follow up interview the GNA #13. She stated the plan was to get Resident #77 up to a chair for breakfast and that she was going to find another staff member to help. The surveyor observed Resident #77 still laying in bed and food not eaten. On 7/16/25 at 8:35 AM, the surveyor observed Resident #77 up in a wheelchair being wheeled into the activities room where his/her food was delivered after being re-heated. On 7/16/25 at 1:32 PM, the surveyor conducted an interview with the Regional Clinical Director of Operations Staff #5. During the interview the surveyor informed Staff #5 of the observation where Resident #77 had to wait over 35 minutes to eat his/her breakfast due to the controls on the bed not working from the night before.

Number of residents sampled: Number of residents cited: Based on review of facility investigation, resident medical records, and interviews, it was determined that the facility failed to ensure that a resident remained free from abuse. This was true for 1 (Residents #2) of 16 residents reviewed for abuse during the annual re-certification survey. The findings include:Nursing Practice Act: 10.27.19.02:D. A nurse may not engage in sexual misconduct. Sexual misconduct includes but is not limited to: (3) Solicitation of a sexual relationship, whether consensual or nonconsensual, with a client.On 7/16/2025 at 8:15 AM the facility reported incident (FRI) was reviewed. Staff #37, GNA (Geriatric Nursing Assistant) and Staff #38, RN (Registered Nurse) walked into the room on 10/6/2024 on evening shift and witnessed Staff#39, GNA touching Resident #2 in their vaginal area and kissing Resident #2's breast. Later the Administrator interviewed Staff #39, the GNA accused of the allegations. Staff #39, GNA stated that they cleaned Resident #2, and the Resident asked them to put barrier cream on their virginal area due to itching, which they did. Staff #39 also denied kissing Resident #2's breast. Staff # 39 did admit to giving Resident #2 a kiss on the lips.On 7/16/2025 at 9:29 AM, Resident #2 was interviewed about the October 2024 incident with Staff #39, GNA. Resident #2 stated that they initiated physical contact and consented to everything, specifically asking Staff #39 to apply cream to their vagina. Resident #2 denied Staff #39 kissing her breast but admitted Staff #39 kissed her on the lips.On 7/18/2025 at 8:30 AM, the facility policy was reviewed. The policy states, Employees shall not become romantically or sexually involved with a resident or a co-worker with whom he/she is in a supervisory position. Further record review revealed that Staff #39 was terminated on 10/11/2024 for violating the company's Standard of Conduct Policy.On 7/18/2025 at 10:05 AM the Administrator was asked about the FRI between Resident #2 and Staff #39. The Administrator recalled that Staff #39 was accused of inappropriate touching Resident #2, which Staff #39 denied, but admitted to kissing Resident #2 on the lips.

Based on medical record review, interview and policy review it was determined that the facility failed to acquire and document the appropriate consents and procedures prior to the implementation of a restraint. This was evident during the review of 1 of 3 residents (R-165) reviewed for restraints. The findings include:Review of the medical record for Resident #165 on 7/22/25 at 12:06 PM revealed this resident was admitted to the facility for rehabilitation post-acute hospital stay where a gastrostomy tube was placed secondary to the resident developing dysphasia (difficulty swallowing) after a stroke. An abdominal binder was placed on resident as well as a care plan was developed on 9/13/23. However, further record review revealed that the abdominal binder was placed on Resident #165 as early as 9/1/23.Further review of the consents form 'Physical restraint/Siderail consent Form' for the use of restraints revealed that consent for the use of the abdominal binder was not acquired from the family until 9/18/23. Additionally, according to the consent, the facility is to document what treatment /symptom the restraint device is being placed for and the healthcare provider that ordered the device. The potential benefits and risks are to be reviewed and identified prior to the implementation of the restraint as well. Regarding this abdominal binder, the medical condition, alternatives attempted and the potential risks and benefits were not identified related to Resident #165. Registered Nurse (RN), Unit Manager (UM) #43, was interviewed with the Director of Nursing (DON) on 7/23/25 at 10:54 AM. She was asked about the consent, the care plans and specifically Resident #165. She acknowledged at that time that the consent was not completed timely and that it was not filled out appropriately. The concern that a restraint was placed without the proper documentation and evaluations was reviewed at this time with the facility DON.

Based on record review and interviews it was determined the facility staff failed to conduct a thorough investigation for an incident of abuse. This was evident for 1 (#176) resident reviewed for 1 of 16 reports of abuse.The findings include:A facility reported incident of resident-to-resident abuse was reviewed on 7/17/25 at 12:31 PM.The report revealed that on 3/12/23 at 11:00 PM Resident #176 assaulted Resident #175. The facility Executive Director (ED) reported the incident and investigated. The investigation consisted of interviews that the ED conducted with staff.Staff #29 the Housekeeping Supervisor indicated she overheard screaming from a resident's room. She went to the room and observed Resident #175 who was standing next to the bed, struck Resident 176, who was lying in the bed. She sent Resident #175 out of the room, 2 nurses came to the room, and she informed them of what she observed. They walked Resident #175 to his/her room down the hall. The 2 nurses were not identified by Staff #29. -There were no interviews/statements from Staff #22 the RN (Registered Nurse) who was assigned to both residents at the time of the incident.-There was no statement from Staff #23 the nursing shift supervisor, to whom the incident was immediately reported as indicated on the incident investigation form.-Staff #33 the Geriatric Nursing Assistant (GNA) who was assigned to provide care to Resident #176 indicated only that she did not witness the incident.-Staff #36 the GNA who was assigned to provide care to Resident #175 indicated only that she did not witness the incident.-5 other staff working at the time of the incident all indicated only that they did not witness the incident. The investigation did not attempt to identify how the incident occurred including who last saw Resident #176, what s/he was doing, where s/he was, his/her behavior and mood, any warning signs or staff interaction with him/her and his/her response. The 2 nurses Staff #29 indicated came to the room and escorted Resident #176 to his/her room, were not identified and did not provide statements as to any pre or post incident behaviors and interventions they implemented including the residents' responses. In an interview on 7/18/25 at 9:43 AM Staff #29 was not able to recall the incident. She was reminded of the date and time of day and was provided with her interview witness statement but was still unable to recall the incident. Staff #23 was interviewed on 7/21/25 at 7:30 AM. She was provided with the residents' names, the date and time of the incident and a brief description of the events and asked to explain what had occurred that night. She shook her head and indicated that she did not remember the incident, nor the residents involved. She was asked what she would do as a supervisor, if a resident-to-resident assault occurred. She indicated that she would separate the residents, move one to another unit if possible, try to determine if 1:1 supervision is needed and call the Director of Nursing to report the incident. Staff #22 was interviewed on 7/21/25 at 3:32 PM. She recalled the incident but was unable to recall when asked if Resident #176 wandered much on the unit. She did remember she called the supervisor and the resident's family. When asked if she could recall when or where Resident #176 was seen by staff prior to the incident she stated, That's a long time ago, I'm not sure. When asked if she knew who walked with Resident #176 back to his/her room she indicated she wasn't sure, it could have been her and a GNA. On 7/21/25 at 4:03 PM - Interview with Staff #5 a Regional Director of Clinical Operations was asked if the facility conducted an RCA (Root Cause Analysis) regarding the incident. He was made aware that the surveyor was unable to find any documentation indicating what Resident #176 was doing prior to the incident - that there was no behavior documentation for night shift, and evening shift indicated no behaviors. It was unknown if the resident was wandering, or was asleep, or the circumstances leading up to the incident. He indicated that he was aware of that and that unfortunately there was no RCA conducted. In an interview on 7/23/25 at 9:42 AM the ED was made aware of the above concerns.Cross reference F 842.

Based on record review, and interviews, it was determined the facility failed to 1) notify the Ombudsman of resident's transfers, 2) provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer. This was found evident of 2 (Resident #10 & #141) of 4 residents reviewed for hospitalization 3. Failed to provide the resident/family/RP with discharge instructions. (#161) This was evident for 1 of 3 discharge records reviewed during the survey. The findings include: 1a) On 7/16/25 at 9:29 AM, the surveyor reviewed Resident #10’s medical record. The review revealed that Resident #10 was sent to the hospital on 4/25/25 and returned to the facility on 5/2/25. On 7/21/25 at 1:18 PM, the surveyor requested documentation to demonstrate that the Ombudsman was made aware of the hospitalization. On 7/21/25 at 1:42 PM, the surveyor conducted an interview with the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that during that time period no one at the facility was providing notices to the Ombudsman of transfers and discharges. 1b) On 7/22/25 at 7:03 AM, the surveyor reviewed Resident #141’s medical record. The review revealed that Resident #141 was hospitalized on [DATE]. On 7/22/25 at 7:56 AM, the surveyor requested documentation to demonstrate that the Ombudsman was made aware of the hospitalization. On 7/22/25 at 8:45 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that during that time period no one at the facility was providing notices to the Ombudsman of transfers and discharges. 2a) On 7/16/25 at 9:29 AM, the surveyor reviewed Resident #10’s medical record. The review revealed that Resident #10 was sent to the hospital on 4/25/25 and returned to the facility on 5/2/25. On 7/21/25 at 1:18 PM, the surveyor requested documentation to demonstrate that the Bed Hold policy was given to Resident #10’s Responsible Party (RP). On 7/21/25 at 1:46 PM, the Regional Clinical Director of Operations Staff #5 stated he was unable to find documentation that the written notice was sent to Resident #10’s Responsible Party (RP). 2b) On 7/22/25 at 7:03 AM, the surveyor reviewed Resident #141’s medical record. The review revealed that Resident #141 was hospitalized on [DATE]. On 7/22/25 at 7:56 AM, the surveyor requested documentation to demonstrate that that the Bed hold policy was given to Resident #141’s Responsible Party (RP). On 7/22/25 at 8:45 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 stated that he found documentation that stated the bed hold policy sent with the Resident to the hospital. Staff #5 was not able to provide evidence that a written notice was given to Resident #141’s RP. Next the survey reviewed the facility’s bed hold policy. The policy states, The resident and his/her surrogate decision-maker or court appointed legal representative will be provide written and/or verbal information regarding the bed-hold policy at the facility: Upon admission, At the time of transfer to the hospital, at the time of any therapeutic leave and if the bed-hold regulation were to change. 3. During the review of Resident #161’s medical record on 7/21/25 at 8:28 AM discharge planning revealed that there was no documentation of what was provided to the family/resident/representative (RP) at the time of discharge regarding planning, preparation and medications. Resident #161 was being discharged from the facility after rehabilitation from deconditioning and medication management after a kidney transplant. On 7/21/25 this surveyor requested any discharge planning and paperwork that was provided to the family/resident at discharge. On 7/22/25 at 6:42 AM the Regional Clinical Director notified this surveyor that there was no discharge paperwork in the record. The concern was reviewed with him at this time that there was no discharge planning and directions provided to the family of a resident with complex diagnosis' including gastrostomy tube feeding, wound care and anti-rejection medications needed for kidney transplant.

Based on interview, observation and record review, it was determined that the facility failed to develop/revise a comprehensive person-centered care plan specifically including measurable objectives-ideal healthy weight and timeframes to meet residents' significant weigh change concern. This was evident for 1 (Resident #64) out of 132 residents reviewed for care plan development to meet medical and psychosocial needs during an annual survey.The findings include: During a rounding on 07/15/2025 at 9:45 AM, Resident #64 stated I like to lose some weight. Observed the resident was wearing oversize clothes and seemed too small. Interview, on 7/16/25 at 1:50 pm, Resident #64 revealed that she came back from an emergency room visit due to a mental melt-down episode; feeling depressed and wanted to kill herself. The resident stated that I felt bad and looked at me I can not do anything for myself but getting big.Record Review, on 07/18/2025 at 11:00 AM, of Resident #64's record indicated 8/23/2024 the resident was admitted to this facility with diagnoses of mitochondrial metabolism disorders, seizures disorder, anxiety and depression disorders. The admission weight record showed 205lbs then her weight was sharply gained to 229lbs by November 2024. From the last weight measured 6/22/25 it increased to 257.3lbs/ BMI 41 as severe obesity.Mitochondrial Metabolism Disorders -A group of conditions that affect how mitochondria work in one's body. Mitochondria make energy in cells. When mitochondria can't produce enough energy that the body needs, it affects how a person's organs function. Specific Health Risks:Neurological: Developmental delays, seizures, encephalopathy, cognitive decline, and stroke-like episodes (MELAS). Metabolic: Lactic acidosis, diabetes mellitus, and other metabolic disturbances. Musculoskeletal: Muscle weakness, hypotonia, and exercise intolerance. Cardiovascular: Cardiomyopathy and arrhythmias. Organ Failure: Liver, kidney, and gastrointestinal dysfunction. Vision and Hearing: Impairment of vision and hearing. *Growth: Stunted growth and poor weight gain. Increased Risk of Infections: Some mitochondrial disorders can weaken the immune system, increasing susceptibility to infections. Medication Sensitivity: Individuals with mitochondrial disorders may be more susceptible to adverse effects from certain medications, including some antibiotics and drugs that affect mitochondrial function. Body Mass Index (BMI) is a calculation used to estimate body fat percentage and assess weight status. Healthy Weight: BMI between 18.5 and 24.9.Overweight: BMI between 25 and 29.9.Obesity: BMI of 30 or higher.Obesity is further classified into:Class 1: BMI 30 to 34.9.Class 2: BMI 35 to 39.9.Class 3 (Severe Obesity): BMI 40 or higher. Further record review found that Nutrition/Dietary Staff #17 noted on 1/31/2025 that the diet order as regular texture diet; finding 12.1% unhealthy weight gain since 8/2/2024 as clinically significant weight gained. At that time care planned to avoid significant weight change through the next review period. On 3/24/25 Staff #17 had a discussion with the family which they agreed to limiting concentrated sweets (cakes, cookies, pie, soda, juice) and starchy. Again on 4/30/2025 [NAME] Staff #16 documented that weigh gain 11.2% in the last 180 days and no specific weight control plans.The initial care plan was ineffective as Resident #64 continued to gain weight and no specific measurable care plan was developed.Observation of dining, on 07/18/2025 at 12:16 PM, Resident #64 was finishing a 2 layers cake and had a cup of juice from her tray. Interview, on 07/18/2025 at 2:35 PM, Staff #17 stated that she recognized the significant weight gained and obtained family support to limited sweets. She could not explain no other assessment or weight control was done. Additionally, Staff #16 documented 11.2 % weight gain in 180 days, no specific assessment or weight control was done. Both confirmed that they did not report to the physician nor revised a personal centered care plan to address the concern that was devesting Resident #64. Further interview, with Educator Staff #27 who stated that any greater than 5% weight change would trigger a significant condition change in the system and it had to report it to the medical staff and prompt the interdisciplinary team to revise the care plan to promote residents' weight control and well-being. During an interview, on 07/18/2025 at 4:33 PM, the administrator was made aware of the above findings, and he was expecting that the facility staff to follow-through to meet Resident #64's weight control & psychosocial needs instead of allowing significant weight gain.

Based on observation, interview and record review, it was determined that the facility failed to follow the facility's standard of oxygen care consistently. This was found evident of 1 out of (Resident #12) residents reviewed for respiratory care during an annual survey.Observation, on 07/15/2025 at 3:04 PM, Resident #12 was found on 2 liters of oxygen with nasal cannula in use and there was no label on the humidifier water bottle nor the oxygen nasal cannula tubing with a change date/time.Nasal cannula- a tubbing used to provide supplemental oxygen.Record review, on 07/16/2025 at 1:08 PM, of this resident's record indicated 1/18/25 the resident was admitted to this facility after a complicated hospitalization with diagnoses of new seizure disorder, heart attack, hypoxia, dysphagia and post medical diagnoses: intellectual disability, end of renal disease on hemodialysis MWF. The admission oxygen order was continuing oxygen 2-liter nasal canula and check every shift. Further review Futurecare Nursing Practice Manual/ Respirator Therapy of Oxygen Equipment Changing Schedule under procedure 2.- Replace equipment with newly labeled equipment displaying the date, time and the nurse's initials.Observation, on 07/22/2025 at 12:40 PM, Resident #12 resting in bed noted to have oxygen being delivered via nasal cannula, however, the oxygen nasal canula tubing was not labeled with a change date/time. Interview, on 07/23/2025 at 09:53 AM, Nursing Staff #18 reported that every time the oxygen tubing and oxygen humidifier pre-filled with sterile water change, both should have labeled. During the interview, on 07/23/2025 at 10:02 PM, met Unit Manager #19 at this resident's bedside, she witnessed and agreed that the oxygen tubing should have labeled the change date/time and the nurse's initials. The [NAME] Clinical Nurse Staff #5 was made aware of the above findings as a deficiency practice concern.

Based on the review of a complaint, medical record review and interview with facility staff, it was determined that the attending physician failed to review the full program of care at each visit, ensuring the medication ordered and documented in the progress notes were accurate. This was evident for 1 of 3 residents (161) reviewed for physician services. The findings include:Review on 7/21/25 at 8:28 AM revealed that Resident #161 was initially admitted to the facility for rehabilitation post hospitalization and needed medication management. Resident #161 was admitted on Cellcept and Tacrolimus, they are immunosuppressant medications used in organ transplant recipients to prevent rejection. Secondary to abnormal labs, Resident #161 was sent to the hospital on 7/8/24. On 7/18/24, Resident #161 was re-admitted to the facility. However, the record review revealed that although Attending staff #20 wrote in his notes that Resident #161 was receiving the Tacrolimus on readmission, the medication was never reordered and therefore, Resident #161, did not receive the medication from readmission to discharge.Interview on 7/21/25 at 11:20 AM with attending staff #20 regarding his progress notes addressing the medication and the physician orders. Physician Staff #20 stated that 'yes' Resident #161 should have been on the medication at readmission, and it was missed on the readmission orders. These findings were reviewed with the facility NHA, DON and Regional Clinical Director throughout the survey and again on 7/24/25.

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication without adequate monitoring. This was evident for 1 (Resident #14) of 5 Residents reviewed for unnecessary medications.The findings include:On 7/21/25 at 8 AM, the surveyor reviewed Resident #14's medical record. The review revealed that Resident #14 had three cardiovascular medications ordered in which administration instructions were based off of Resident #14's blood pressure and/or heart rate. The medication instructions were as follows:Amlodipine Besylate 10 mg, give one tablet by mouth one time a day for hypertension (high blood pressure), hold for systolic blood pressure (SBP) less than 110.Metoprolol Succinate Extended Release (ER) 25 mg, give one tablet by mouth one time per day for chronic heart failure (CHF), hold for heart rate less than 60.Hydralazine HCL 25mg give one table by mouth two times a day for hypertension, hold for blood pressure less than 110 or heart rate less than 60. Next the surveyor reviewed Resident #14's blood pressure and heart rate (pulse) documentation for the month of July.7/5/25- BP 163/80 HR 83 at 3:46 PM7/10/25- BP 130/67 HR 88 at 8:54 AM7/11/25 BP 126/64 HR 77 at 10AM7/11/25 BP 128/64 HR 74 at 8:07 PM7/19/25 BP 134/66 HR78 at 10:13 AM7/20/25 BP 112/58 HR 97 at 10:29 [NAME] 7/21/25 at 8:59 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the blood pressure and heart rates along with the cardiovascular medications. The DON stated that Resident #14 had an order for vitals (to include BP and HR) to be taken monthly. When asked if the blood pressure and heart rate are not taken prior to the administration of medications how would the staff know if they should administer per instructions. The DON explained that if there are parameters, then the PB and HR should be taken and when the order is written with parameters then there is an extra box that is checked to allow staff to enter the vitals. He further stated that if they are not marked on the Medication Administration Record (MAR) or vital sign documentation then the next place to look would be in the progress notes.The surveyor reviewed the July MAR with the DON. The review revealed that the medications were given 7 days in a row, from 7/12/25-7/18/25, without BP or HR documented in the medical record. The DON stated that any vitals taken to evaluate if the medications should have been given should have been documented at the time of administration.

Based on observation, interview and medical record review, it was determined that the facility's staff failed to track proper diet orders, to process the repeat insufficient proportion requests from residents and to honor residents' right to meet personal dietary proportion needs. This was evident for 1 (Resident #12) out of 2 residents reviewed for food during an annual survey.The findings include:Observation, on 07/15/2025 at 1:30 PM, Resident #12 finished everything on the lunch tray and yelled, I'm hungry and they did not bring enough food, Geriatric Nursing Assistant Staff #34 in the hallway stated that she notified the kitchen for additional food which it has been on-going for a while.Observation, on 07/16/2025 at 8:30 AM, this resident's main dish consisted of 3 parts of thin watery pureed food on a plate. Overheard this resident yelling out later, I'm hungry and need food. Observed the breakfast tray meal was completely finished by this resident. Record review, on 07/16/2025 at 01:08 PM, of this resident's record indicated that on 01/18/25 the resident was admitted to this facility after a complicated hospitalization with new diagnoses of seizure disorder, heart attack, hypoxia, dysphagia and post medical history included intellectual disability, end of renal disease on hemodialysis MWF. The admission diet order was pureed renal texture which was new to this resident at that time. The nutritional assessment was completed on 1/25/2025 and indicated that this resident's weight was 160.6 lbs; had 9.2% weight loss compared prior to hospitalization.Record review, on 07/17/2025 at 10:00 AM, of Resident #12's weight log: 01/23/2025 was167.42 lbs. then on 06/09/2025 was 163.79 lbs. The large portion meal and Renal product drink & before sleep snack were ordered on 04/29/25 and they were discontinued on 06/05/25 when this resident was hospitalized . After this surveyor's interventions, the large portion meal was finally re-ordered on 07/17/25 but not the Renal product drink and before sleep snack.(R) Renal product is a nutritionally complete and calorically dense formula that provides protein, vitamins and minerals specifically to meet the needs of people with chronic kidney disease (CKD) on dialysis, acute kidney injury (AKI), fluid restrictions due to CKD or AKI, or electrolyte restrictions.Interview, on 07/17/2025 at 10:22 AM, Dietitian Staff #17 stated that Resident #12 was not eating for a while, and she was not aware of the resident's complaints about the insufficient proportion of meal nor knowing that the large portions ordered was discontinued on 06/05/2025. Further interview with nursing Staff #18 who stated this resident was always hungry and asked for more food every meal since the resident was re-admitted on [DATE].On 07/17/2025 at 11:49 PM, an interview with the Regional Clinical Director of Operations, Staff #5, occurred. The discussion regarded the above findings which the facility's staff failed to track the resident's proper dietary orders. The inability to process the repeated insufficient proportions requested from the resident failed to honor the residents' right to meet their personal dietary needs.

Based on medical record, review of a complaint, and interview of facility staff, it was determined that the facility's Medical Director failed to ensure adequate implementation of resident care intervention and/or policy review. This was found evident for 1 (Resident #98) of 1 resident reviewed for insulin use. The findings include: On 7/16/25 at 12:32 PM, the surveyor interviewed Resident #98. During the interview Resident #98 described that when he/she was admitted to the facility he/she was prescribed a glucose monitoring device that was utilized to monitor blood glucose levels without the use of a finger stick. Resident #98 stated he/she was very happy with the use of the device but shortly after the device was ordered it was discontinued. On 7/23/25 at 11:35 AM, the surveyor reviewed Resident #98's medical record. The review revealed an order was placed for 3/27/24 for Resident 98 to have a continuous glucose monitoring device. On further review, Nurse Practitioner (NP) #42 documented, on 4/6/24 in a progress note, that the patient was seen for a follow-up. Patient and patient's daughter are upset that they cannot use the continuous glucose monitoring and now will need to utilize finger sticks. Resident #98 reports a lot of pain in his/her fingertips. On 7/24/25 at 6:06 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview the surveyor requested the facility's policy for continuous glucose monitoring devices. Staff #5 stated that the facility did not have a policy for the use of this device because it is typically utilized in home settings where patients can self manage the device. Staff #5 confirmed that Nurse Practitioner (NP) #42 wrote the order for Resident #98 to have the device due to the request of the family and that Resident #98 utilized the device for approximately 2.5 days. Staff #5 stated that the previous Director of Nursing (DON) did not request clinical oversight from the Regional Clinical Staff and the device was removed when it was made known to Regional Clinical Staff it sues. Staff #5 further stated that the Medical Director spoke to the provider and informed her the device could not be utilized in the building. The Surveyor asked Staff #5 for the education that was provided by the Medical Director. Staff #5 confirmed that the education was non-formal and there was no documentation. There was also no documentation that any education was provided to other providers. The surveyor reviewed the concern that the facility still did not have a policy or procedure written in regard to the use or non-use of continuous glucose monitoring devices and that there was no formal education to providers after the Medical Director was aware the device was implanted within the facility without a policy or procedure for use.

Based on record review and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records by:1) Failing to document the disposition of a discharged residents personal property. This was evident for 1 (#163) of 1 resident reviewed for Misappropriation of Property. 2) Failing to document resident behavior. This was evident for 1 (#176) resident reviewed for 1 of 16 abuse reports reviewed. The findings include:1) Resident #163's medical record was reviewed on 7/15/25 at 11:55 AM due to complaints which included but were not limited to an allegation that the resident's wheelchair was stolen and was replaced by the facility with a broken chair. The resident was admitted to the facility from an acute care hospital in Maryland. According to the hospital Discharge summary dated [DATE], he/she had resided in a Long Term Care facility in another state prior to the hospitalization. During an interview on 7/16/25 at 12:20 PM Staff #10 the Rehabilitation Supervisor was asked if Resident #163 came to the facility with his/her own wheelchair or if one was provided for his/her use while here. He indicated that rehab staff assess all new admissions to determine if and what type of assistive device the resident would need. He was unsure if Resident #163 came with their own wheelchair, but he would look into it.He returned at 1:30 PM and indicated that the resident likely did not come with a wheelchair and one was likely provided by the facility for his/her use.He also indicated that at some point the resident's wheelchair went missing and was replaced, that the resident did not like the replacement, and it was again replaced with a new wheelchair. He was unable to confirm if Resident #163 personally owned these wheelchair(s) or if they were owned by the facility. Review of Resident #163's medical record at approximately 1:45 PM revealed a Rehabilitation Treatment Encounter note was written on 12/3/24 regarding a replacement wheelchair. The note did not indicate if the wheelchair replaced a chair owned by the resident or the facility. Resident #163's census record revealed the resident was discharged from the facility on the same date the note was written. Further review of Resident #163's medical record on 7/16/25 at 1:45 PM revealed a personal inventory list dated 1/12/24 which included numerous clothing and personal items. Wheelchair was listed in the Acquired After Admission column and was dated 2/23/24. The inventory list was signed by Resident #163 and a staff member.Staff #5 a Regional Clinical Director of Operations was interviewed on 1/17/25 at 7:52 AM. He indicated that the wheelchair reflected in the Rehabilitation note on 12/3/24 was likely a facility wheelchair, that the resident was transferred to the hospital on [DATE] and a wheelchair would not have gone with him/her.He was made aware and confirmed that Resident #163's Inventory of Personal Items included but was not limited to a wheelchair which reflected the resident had their own personal wheelchair and that the inventory did not reflect the disposition of the resident's belongings when he/she was discharged from the facility.He indicated that he assumed someone came and picked up the resident's belongings after discharge but was not able to find documentation in the record of the disposition of Resident #163's personal items including the wheelchair, who the belongings were released to or when they were released. 2) A complaint and facility reported incident of a resident-to-resident abuse was reviewed on 7/17/25 at 12:31 PM.The report revealed that on 3/12/23 at 11:00 PM, during the change of shift from evening to night staff, Resident #176 went into Resident #175's room and struck Resident #175 who was lying in bed.Review of Resident #176's medical record on 7/18/25 at 10:47 AM revealed physician orders for Behavior Monitoring for: scratching and kicking, wandering on the unit, intermittent pacing, hitting/punching, and refusal of care.Resident #176's March 2023 Behavior Record revealed spaces for staff to document incidents of the resident Hitting/punching, Intermittent pacing, Kicking, Refusal of Care, Scratching, and wandering on the unit.In the spaces provided for 3/12/23 evening shift (3:00 PM - 11:00 PM) all behaviors were documented as 0 - the behavior did not occur, except for wandering which was blank.In the record for 3/12/23 night shift (11:00 PM - 7:00 AM) the spaces were blank - there was no documentation for any of the behavior monitoring areas. Staff #23 a nursing shift supervisor was interviewed on 7/21/25 at 7:30 AM. She was asked to explain what had occurred that night. She shook her head and indicated that she did not remember the incident, nor the residents involved. Staff #22 the RN (Registered Nurse) caring for both residents was interviewed on 7/21/25 at 3:32 PM. She recalled the incident but was unable to recall where Resident #175 was prior to the incident or if Resident #176 wandered much on the unit. On 7/21/25 4:03 PM an interview was conducted with Staff #5 a Regional Director of Clinical Operations. He was made aware that there was no behavior documentation for night shift, and evening shift indicated no behaviors. He confirmed that he was aware. In an interview on 7/23/25 at 9:42 AM the ED (Executive Director) indicated if he recalled correctly, Resident #176 had been wandering in the hallway. He returned a few minutes later and indicated that the incident occurred out of the blue and Resident #176 was not wandering and didn't have any prior behaviors. He was made aware of the above concerns at that time. Cross Reference F 610.

Based on observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 out of 3 observations of the laundry area. The findings include: On 7/15/25 at 10:51 AM, the surveyor observed the clean laundry room. The door to a linen closet was opened and linens were not covered. Additionally, two carts in the clean laundry room, in which the staff had just folded and placed laundry, were left uncovered and exposed to the sewer water on the floor. Staff #1 stated that all the linens would be re-washed and the room terminally cleaned after this was brought to his attention. On 7/18/25 at 10:51 AM, the surveyor again observed the door to a linen closet was opened and linens were not covered. The surveyor interviewed the Laundry Staff #40. Staff #40 stated that currently the clean laundry bin in the closet was prohibiting the door from closing but that she would be folding them next and after the bin was removed the the door would be closed. Next the surveyor went into the hallway where a mobile laundry cart was located. The linen was exposed, and the cover was draped over the top of the cart. Staff #40 stated that the linen cart should be covered but sometimes staff come down to get linen and forget to cover the linens after obtaining their supplies.

Number of residents sampled: Number of residents cited: Based on record review, and interview it was determined that the facility failed to document the rationale for non-administration of the influenza and pneumococcal immunization. This was found evident of 1 (Resident #66) of 5 residents reviewed for vaccinations during an annual survey. Influenza (flu) immunizations are usually offered during the flu season, which is considered October 1 through March 31 annually. The findings include: On 7/22/25 at 1:50 PM, the surveyor reviewed Resident #66's medical record. The review revealed that Resident #66 refused all vaccinations offered to him/her on 4/4/25. On Resident #66's influenza vaccination form it was documented that Resident #66 declined to have the influenza vaccination administered. Further on the form no rationale was given for the refusal even though the form asks for the reason to be indicated. The form was signed by the resident, indicating it was offered, and did not state that the refusal was due to the recently ending flu season. On further review the pneumococcal conjugate vaccine (PCV 20) form indicated that Resident #66 declined the vaccination. Again, no rationale for the refusal was provided even though the form asks for the reason. On 7/22/25 at 2:19 PM, the surveyor conducted an interview with the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that the rationale for refusal should be documented in the Resident's medical record.

Based on observations, interviews, and reviews of facility documents and medical records, it was determined that the facility staff failed to 1) ensure that the dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, and 2) store food in accordance with professional standards for food service safety, and 3) ensure meals were provided in a manner that maintained safe quality control temperatures to meet the individual needs of dialysis residents. This was evident for 2 (Residents #51 and #111) of 17 residents reviewed during an LTCSP recertification survey for food quality and kitchen practices. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1) An initial environmental kitchen food services inspection was conducted on 1/23/23 at 8:15 AM. Dishwasher temperature logs were not found/observed in the dishwashing machine area or any other area in the kitchen. A male dietary worker (staff #28) was asked about the dishwashing temperature log, and he responded, there is no log. On 1/24/23 at 9:30 AM a second tour of the kitchen was conducted. A dishwasher temperature log was not observed. There was an empty clear plastic envelope stuck on the dishwashing machine. The certified dietary manager (CDM) (staff #20) was asked to provide the January 2023 dishwashing machine water temperature log. She could not find it in her office. The surveyors left her office to observe the dishwashing machine in operation with two dietary workers emptying breakfast carts and stacking dishes and loading dishwashing trays for the dishwasher. The CDM came out of her office with a dishwashing temperature log with documented dishwashing temperatures for 1/23/23 she said that the dishwashing log got wet. She was asked to provide the December 2022 dishwashing log she checked in multiple binders and then proceeded to look at stacks of papers grouped by the preceding months. The stacks of paper had shown to have other temperature logs including the multiple refrigerators and freezer temperatures. Each group stack of temperature logs did not have a dishwashing water temperature log. No dishwashing log for December 2022, November 2022, or October 2022, and the September dishwashing log only had documented water temperatures for the last three dinner times for the month. The log for August 2022 was shown to be filled out appropriately. Observation of the dishwashing machine on 1/24/23 shown to be operating at a wash temperature greater than the minimum of 160 degrees Fahrenheit (F) and the rinse temperature was above the minimum temperature of 180 degrees F. The CDM was asked to provide a copy of the last county health department kitchen inspection. A review of the county health department kitchen inspection dated 10/18/22 revealed that the dishwasher was not in working order at the time of the inspection. On 2/7/23 at 9:32 AM, an inspection of the walk-in refrigerator/freezer revealed items stored on the floor of the refrigerator part of the walk-in. A netted 10-pound bag of onions and two juice boxes one on top of the other were on the floor. The CDM was not in the kitchen at the time of discovery. She returned a few minutes later and was informed of the stored food items found on the floor of the refrigerator. 31982 2) On 1/25/23 lunch trays were observed being delivered to the residents on Unit 2A at approximately 11:50 AM. On 1/25/23 at 12:49 PM the surveyor observed 2 meal trays on an overbed table beside bed B, Resident #111's bed. Resident #111 was not in the room. Resident #111's roommate and spouse, Resident #51 was lying in bed A. The meal tickets on the trays indicated that the trays belonged to Resident #111 and Resident #51. Both trays contained Beef Stroganoff, buttered noodles, cauliflower, chocolate pudding and Resident #111's tray also contained a bowl of soup. The food on the trays and utensils appeared untouched. Staff #36 a Licensed Practical Nurse was interviewed at that time and was asked why the trays were left on Resident #111's overbed table. She explained that Resident #111 was in dialysis and would return about 3:45 PM. When asked how Resident #111 was to get his/her lunch meal, she indicated that Resident #111 asked that it be kept at his/her bedside but that sometimes it was kept in the kitchen. She then went on to say that Resident #51's tray was also held at the bedside per Resident #111's request. She added that Resident #111 likes to eat their meals with Resident #51, that Resident #51 needs help with eating and Resident #111 did not want staff to feed Resident #51. She indicated that dialysis won't let the residents eat due to risk of upset stomach. When asked if she was familiar with the safe holding temperature for food, she stated: no. Staff #56 an Agency GNA (Geriatric Nursing Assistant) indicated she was caring for Residents #111 and #51 and that this was her first time working in this building. She indicated that Resident #111 and #51's breakfast trays came up at 8 AM and that Resident #111 asked to hold it till 11 AM and that they both ate that time. She added that Resident #111 asked that both lunch trays be held until he/she returned from dialysis. In an interview on 1/26/23 at 8:57 AM Resident #111 explained that there was an issue with meals on dialysis days, that he/she starts dialysis between 10AM & 12 PM on Monday, Wednesday and Friday, and Resident #51 received dialysis on Tuesday, Thursday and Saturday starting between 5-6 AM. He/She explained that he/she likes to eat his/her meals with Resident #51 and assist him/her with eating, so they eat their meals late in order to eat together. When asked why the trays were left in their room, she explained that there used to be a process in which a separate cart was sent from the kitchen with trays for the resident's receiving dialysis. He/she indicated that sometime last year the process stopped and that there is some kind of disconnect now. He/She explained that meals are often missing, and he/she has had to go to the other units looking for their trays. He/She explained that he/she requested that the trays be left in their room to ensure that he/she and Resident #51 would get their meals. Resident #111 indicated that while in dialysis on 1/25/23 2 ladies came and told him/her that they would be sending bagged meals, that there was an issue and that trays will no longer be sitting in their room as before. An interview was conducted on 2/3/23 at 10:10 AM with Staff #20 the Certified Dietary Manager and Staff #5 the Corporate Dietician. Staff #20 confirmed that she started with the facility on 1/10/23, was in orientation and had started in the facility on approximately 1/23/23. She was asked to explain the process for obtaining meals for the residents who go to dialysis. She indicated that some residents want breakfast prior to going to dialysis, a GNA will come down and pick up their tray. If they want it afterward, staff will call and pick it up when the resident returns. She went on to explain that a list of dialysis residents is sent to the kitchen the night before, that the tickets are pulled from the tray line for that meal. A GNA or transporter will pick up the resident's tray. She confirmed that this process had started about a week and a half ago. Staff #20 and #5 both confirmed that they did not find it acceptable for a lunch tray to be left at the bedside for several hours. They were made aware of the above concerns and that Resident #111 indicated that there was no other option if they and Resident #51 wanted to eat their lunch.

Based on observations, reviews of medical records, and staff interviews, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by;1) failing to screen tuberculosis (TB) for new admit residents, this was evident for 2 (Resident #125 and #142) of 5 residents TB screening reviewed; 2) failing to order contact precautions for a resident who diagnosis E. coli infection, this was evident for 1 (Resident #343) of 6 residents review for infection disease; 3) failing to follow infection control practices in residents' rooms, this was evident for 2 (Resident #2 and #205) of residents reviewed; 4) failing to implement Enhanced Barrier Precautions (EBP), and 5) failed to implement measures to prevent contamination of resident care products for 1 (#65) of 8 residents reviewed for Pressure Ulcer/Injury. These practices had the potential to affect all residents. The findings include: Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. Each resident must have a health assessment upon admission, including significant past or present infectious diseases and signs and symptoms of tuberculosis (TB). Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure (administering 2nd skin test within 1-3 weeks) is advisable for the initial testing of residents and employees. Each skin test should be administered and read by appropriately trained personnel and recorded (in mm induration) in the person's medical record. A record of all reactions of greater than or equal to 10 mm should be placed in a prominent location in order to facilitate the consideration of tuberculosis if the person develops signs or symptoms of tuberculosis, such as a cough of greater than 3 weeks' duration, unexplained weight loss, or unexplained fever. All persons with a reaction of greater than or equal to 10 mm should receive a chest radiograph to identify current or past disease. [Center for Disease Control and Prevention] Escherichia coli (abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals. E. coli are a large and diverse group of bacteria. Although most strains of E. coli are harmless, others can make you sick. Some kinds of E. coli can cause diarrhea, while others cause urinary tract infections, respiratory illness and pneumonia, and other illnesses. Contact precautions have been recommended for hospitalized patients colonized or infected with extended-spectrum ?-lactamase-producing Escherichia coli. [Center for Disease Control and Prevention] Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO (Multidrug-resistant organism). [Center for Disease Control and Prevention] 1a) On 01/25/23 at 01:45 PM, randomly selected 5 residents' medical records were reviewed for Immunization. Resident #125 was admitted to the facility on [DATE]. The resident's TB screening was done on 11/23/22. The test result was negative under the PCC (electronic medical record) immunization tab. However, no record was found for the second test. On 01/25/23 at 2:00 PM, Resident #142's medical record review revealed that the resident was admitted to the facility on [DATE]. However, there was no documentation of the TB screening under the resident's medical records (including electronic records and paper charts). During an interview with the Director of Nursing (DON) on 01/26/23 at 11:28 AM, the DON confirmed that the facility had screening new admission residents for TB with a 2-step skin test which would be documented under the PCC immunization tab. On 02/16/23 at 11:29 AM, the surveyor reviewed the facility's infection Control Manual of Tuberculosis Control Plan. The plan stated all residents shall receive a tuberculin skin test within 10 days following an initial admission unless the resident has had a documented negative skin test within the previous month, a previous positive test, history of preventive therapy or treatment of tuberculosis. No documentation of previous TB skin testing resident needed 2- step TB skin test. Above TB screening concerns were discussed with the DON on 2/16/23 at 11:15 AM. 2) A portion of investigating complaint MD00177483 on 2/13/23 at 11:54 AM revealed that Resident #343 was diagnosed with E. coli infection on 5/21/22 by blood culture. Further review of medical records revealed that Resident #343 had a contact precaution order from 5/24/22 to 5/28/22 without any indication listing. During an interview with the corporate Registered Nurse (Staff #3) on 2/13/23 at 3:47 PM, Staff #3 stated that Resident #343 already had had contact and droplet precaution for PUI (people under investigation) COVID-19 PCR pending results from 5/19/22 to 5/22/22. However, Staff #3 verified that no precautions were provided to the resident on 5/23/22 when he/she had already been diagnosed with E. coli infection. 3a) On 02/13/23 at 9:24 AM, the surveyor observed on the second floor of the nursing unit, 2A. room [ROOM NUMBER] door with three precautions signs (Enhanced Barrier Precaution, Contact precaution, and Droplet precautions) posted was opened. No active care or therapy was ongoing in the room. At 9:33 AM on 2/13/23, the surveyor observed that an agency Registered Nurse (RN # 43) administrated medication to Resident #19 without PPE (personal protective equipment). Right after the observation, RN #43 was interviewed. RN #43 said, I did not receive any report related to precaution, I will double-check on the order. She found only Enhanced barrier precautions without any detailed reasons. She also confirmed that she didn't have PPE when she entered the room. Further review of Resident #19's medical record revealed that the resident was under enhanced barrier precaution due to G-tube. 15701 3b) On 2/2/23 at 9:45 AM, wound nurse (staff #52) was observed to provide wound care to resident #8. There was a sign on resident #8's door indicating the resident was on Enhanced Barrier Precautions. The wound nurse performed a dressing change to a buttock wound without PPE to include a gown. Review of resident #8's medical record after wound round observation revealed a doctors order for Enhanced Barrier Precautions due to wounds. At 01:26 PM on 02/02/23 the director of nursing was informed of the wound nurse not wearing additional PPE during wound rounds for resident #8. 31982 3c) During Resident #65's dressing change procedure on 1/30/23 at 9:23 AM Staff #52 the Wound Nurse was observed spraying Skintegrity Wound Cleanser directly onto the resident's open sacral wound then wiping the wound with a 4 x 4 gauze pad and repeated this action a second time. The bottle was date labeled 1/30/23 in black marker but not labeled for Resident #65, nor did the resident have an order for its use. Staff #52 failed to protect the bottle of wound cleanser from becoming contaminated with potentially hazardous organisms by spraying it directly onto Resident #65's open wound exposing it to potential splash back. Staff #2 the Director of Nursing/Infection Preventionist and Staff #3 the Corporate Nurse were made aware of these findings on 2/16/23 at 8:52 AM. Cross reference F 686. 4) On 1/30/23 at 9:23 AM the surveyor observed Staff #52 the Wound Nurse, perform a dressing change to Resident #65's sacral wound. Resident #65 also had an indwelling urinary catheter. Prior to the dressing change, Staff #53 a GNA (Geriatric Nursing Assistant) washed and dried the resident's groin area, buttocks, and posterior thigh areas while Staff #52 held the resident in place to facilitate the process. Staff #53 then took Staff #52's place and assisted Resident #65 to remain on his/her left side as Staff #52 performed the dressing change. Afterward a clean brief was applied to Resident #65. Both staff were wearing gloves and surgical masks, Staff #52 was wearing a face shield. However, neither staff member wore a protective gown. Review of Resident #65's medical record on 1/30/23 at 11:12 AM revealed a physician order written 1/6/23 for Enhanced Barrier Precautions - wound/foley (urinary catheter) every shift. Resident #65's TAR (Treatment Administration Record) included the physicians order for Enhanced Barrier Precautions and was signed off for Day shift 1/30/23. Observation of Resident #65s room on 1/30/23 at 2:10 PM revealed a sign posted on the outside of the door which indicated Enhanced Barrier Precautions. 3 Carts labeled Isolation gowns, with drawers labeled for PPE (Personal Protective Equipment) were located in the hallway between rooms 209/211, 219/221, and 229/231. In an interview on 1/30/23 at 2:30 PM Staff #53 was asked what she does when a resident is on EBP she indicated wear a gown, gloves, N95 mask and a face shield. She confirmed that she did not wear a gown when providing care and assisting Staff #52 with Resident #65s dressing change earlier that the morning. When asked what Enhanced Barrier Precautions were for, she stated for infections then, precautions for if they have a cold or flu symptoms. The DON was asked for the Education In-Service Attendance Sheets for staff education for EBP. 2 sign in sheets dated 10/19/22 were provided. 1 sheet listed 11 Environmental Services (Housekeeping) staff, the other sheet listed 12 staff, 11 were identified as Nursing Department staff and 1 had no department identified. Both sheets revealed that the listed staff received EBP Education from Staff #54 The Regional Educator. Staff #52 and #53 were not listed on either attendance sheet. An interview was conducted with Staff #2 the Director of Nursing (DON)/Infection Preventionist (IP) on 2/2/23 at 1:31 PM. She indicated that she was the IP for the facility. However, Staff #54, the Regional Nurse Educator, was the facility's previous IP and provided the staff education regarding infection control. When asked about Enhanced Barrier Precautions she stated it's basically for PEGs (feeding tubes), wounds, HIV, MRSA (Methicillin Resistant Staph Aureus), or previous MRSA; put signs on doors to let them know to wear masks, gloves, and gowns. Any resident with wounds should have Enhanced Barrier Precautions. Unit Managers put signs up. When asked if audits were done for EBP, she indicated that Unit Managers did an audit at the beginning of the month to make sure the signs were still up. When asked if audits were done to ensure staff were following proper precautions, she indicated that she and the Unit Managers just watch on the floor, but don't document their findings. When asked who provided education to the staff regarding EBP she indicated the Regional Educator. She indicated that any staff who enter the resident's rooms should be educated. She was made aware that the education sign in sheets reflected that only 23 staff received EBP education, 11 of which were Environmental Services staff. She indicated that she had more sign in sheets somewhere on her desk but could not find them. Staff #2 was asked what education was provided to the EVS staff. She indicated that they were told what enhanced barriers were and about the signs then stated, I wasn't there so I can't say for sure. She indicated that approximately 20% of the staff in the facility were agency staff. She indicated that they were educated along with the facility staff and identified that 2 of the staff on the education sheets were possibly agency staff. She indicated that anyone providing care, touching the resident should put on a gown and gloves. She was asked how staff would know which resident was on EBP if there was a sign on the bedroom door. She indicated by the position of the EBP sign - a sign placed in the center would indicate that both residents were on EBP, a sign close to the hinged side of the door would indicate bed B, a sign close to the open side of the door would indicate bed A. She was made aware that Staff #52 and #53 were observed providing care to Resident #65 without Enhanced Barrier Precautions. An interview was conducted on 2/8/23 at 9:49 with Staff #54 the Regional Educator, Staff #55 the Regional RN was present. Staff #54 was asked to describe her role. She indicated that she came on board in May, that she was spread among 15 buildings, her responsibilities included new employee orientation, employee orientation, new hires, and skills fairs. She indicated that she tries to be in this facility as often as she can. She indicated that she did not attend the facility's QAPI (Quality Assurance, Performance Improvement) meetings. Staff #54 indicated the DON had the main role of education in the facility. When asked if she did facility training for Enhanced Barrier Precautions, Staff #54 indicated that she did some, and that she educated the department heads and risk managers in the morning meeting which included Unit Managers, supervisors and EVS staff. She indicated that the Unit Managers and the DON were responsible for educating their staff. She added that she was not here to cover staff. Staff #54 indicated that she was not sure if Staff #52 was present at the training she conducted adding that the wound nurse was generally not in the morning meeting. She indicated that the Administrator and the DON were responsible for ensuring that the rest of the staff were educated. The facility failed to provide any additional Education In-Service Attendance sheets to the surveyor.

Based on surveyor observation and interview with staff it was determined the facility staff failed to treat each resident with respect and dignity by 1) ensuring residents were treated with respect and dignity by labeling residents who required physical assistance with meals as feeders and this was evident for 11 residents listed on 2 of 3 posted staffing assignment boards in the facility, 2) identifying, labeling and posting the residents level of dependency on others on 1 of 3 nursing units in the facility, and 3) failing to have an effective process in place to assist the residents to obtain and wear personal clothing for 2 (#70 and #137) of 78 residents reviewed during an LTCSP recertification survey. The findings include: 1) A lunchtime meal test tray observation was conducted with the Food Service Director staff #20 in the 1st-floor unit on 2/3/23. A review of the unit staffing assignment board revealed the word feeders at the bottom left corner, with room numbers (indicating the residents requiring assistance with eating) listed across the row under each GNA assignment. On 2/3/23, an agency Licensed Practical nurse (LPN) was observed to be assisting with the delivery of meal trays to residents in their room. At 12:28 the LPN (staff #29) was in the hallway next to a food cart when she yelled out I don't know who the feeders are. The surveyor shared with the Food Service Director of the derogatory remark the LPN had shouted. For the next week on 2/6, 2/7, 2/8, and 2/9/23 on the 1st-floor staff assignment board and on the 2A unit remained the label Feeders on the boards to identify the nursing assistant assigned to assist the resident identified by room number and bed. On 2/9/23 at 8:34 AM an interview was conducted with the assistant unit manager (staff #36) of the 2A unit. She collaborated on the label feeders written on the assignment board and proceeded with a discussion related to maintaining residents' dignity in dining and labeling residents as feeders is considered a disrespectful term. On 2/9/23 at 8:40 AM the same conversation was held with the unit manager (Staff #9) on the 1st-floor nursing unit. He collaborated on the labeling of feeders written on the assignment board. A follow-up discussion was held with the unit manager at 9:30 AM. Questions related to agency staff and supervision related to the sufficient and competency survey task. He was informed of him of the surveyor's observation of the agency LPN (staff #29) on 2/3/23 shouting that she did not know who the feeders are. 31982 2) A dry erase staffing assignment board on Unit 2A was observed on 1/27/23 at 9:47AM. The board included the label Feeders and identified 6 residents by room and bed number. Staff #19 the 2A Unit Manager was interviewed at that time and indicated that Feeders referred to the residents who required staff to feed them. Additional observations of the 2A assignment board on 1/30/23 at 9:15 AM, 1/31/23 9:41 AM, 2/1/23 11:15 AM, 2/2/23 10:15 AM revealed the label feeders written at the bottom left corner with residents identified by room/bed numbers listed across the bottom of the board. These findings were reviewed with the Director of Nursing and the Corporate Nurse on 8/16/23 at 8:52 AM. 3) A. On 1/21/23 at 12:20 PM Resident #70 was observed sitting on the side of his/her bed eating lunch wearing a hospital gown. Review of the residents record at 12:33 PM revealed an inventory list which identified that the resident had 1 Pajama top and 1 Pajama pants. The record revealed that Resident #70 was admitted to the facility in October 2022. On 2/3/23 at 8:57 AM Resident #70 was observed sitting in a wheelchair in his/her room wearing a hospital gown and non-skid socks. When asked, the resident indicated that he/she will put on whatever they give him to wear. He/she was not sure if he/she had clothing in his/her closet. The 2 closets in the room were observed. The 1st closet had 4-5 empty hangers, bed and bath linens, incontinence briefs and hospital gowns piled in the bottom. 1 pair of balled up slipper socks was in the top drawer below the closet. The second closet was empty. 2) B. On 1/31/23 at 12:20 PM Resident #137 was observed propelling himself/herself in a wheelchair in the hallway and into their room wearing a hospital gown and nonskid socks. Observation of Resident #137's closet revealed that it contained no clothing. 1 sweatshirt was lying on the foot of the resident's bed. The resident indicated that they did not have any clothing with them because they had only been in the facility for 1 or 2 days. Review of Resident #137's medical record on 1/31/23 at 12:32 PM revealed the resident had been in the facility approximately 3 months. Resident #137's inventory of belongings list revealed no clothing items for Resident #137. Review of the facility policy/procedure for Clothing Inventory List included Notify Social Service of the resident needs clothing. An interview was conducted on 2/1/23 at 10:45 AM with Staff #45 a laundry worker. She was asked to explain the process for resident clothing. She indicated that clothing is brought to the receptionist desk by the family. The clothing is listed on an inventory sheet by the receptionist then the clothing and inventory sheet are sent to the laundry. She indicated that she was responsible for reconciling the inventory list with the clothing brought in and applying labels to the residents clothing. When asked what happened if a resident didn't have clothing, she explained that the facility had a rack of donated clothing, appropriate items would be picked out to give to the resident, labeled with their name and it became theirs. When asked how she would know if a resident needed clothing, she indicated that when she delivered the resident's laundry to their rooms she would see if someone was wearing a hospital gown or didn't have their own clothing. In an interview on 2/1/23 at 11:01 AM Staff #46 the Environmental Services Director confirmed that she supervised the laundry services. She was asked if the facility staff know the process for resident clothing inventory and labeling. She indicated that she provided education to facility staff in 2021 and 2022. Observation of Resident #137 and #70's rooms were made with Staff #19 the 2A Unit Manager on 2/15/23 at 8:49 AM. Resident #137s closet contained 2 thin fabric, black and white print, items of clothing folded on the floor of the closet. Staff #19 confirmed that no other items of clothing were present. When asked why Resident #137 had no other clothing staff #19 indicated she was not sure but stated sometimes we call family. During observation of Resident #70's room Staff #19 confirmed that there were several bed/bath linens and other items in the closet and that the closet contained no clothing. Staff #19 was made aware of the surveyors' prior observations and that the residents inventory lists revealed that Resident #137 had no clothing and that Resident #70 had 1 pair of pajamas but no other clothing. When asked what was done to obtain clothing for these residents, she indicated that if residents don't have clothing, the family would be called, if there was no family, then donated clothing could be obtained from the laundry. Staff #19 indicated that Resident #137 had no family. She was asked what had been done to obtain clothing for the resident. She indicated that nothing had been done. In an interview on 2/15/23 at 9:00 AM Staff #2 The Director of Nursing (DON) and Staff #3 the Corporate Nurse were made aware of the above findings. Staff #2 indicated that she did not understand why Resident #137 had no clothing, that she had gone to the laundry and gotten 2 outfits - 2 tops and 2 pair of pants, for the resident soon after his/her admission. She confirmed that she did not add the clothing to Resident #137's inventory list nor have the clothing labeled for the resident.

Based on surveyor observation, interview with the facility's staff and the resident, it was determined that the facility failed to ensure the residents' environment was free from accident hazards. The findings include: While interviewing resident #1 on 04/6/12, observation revealed that in room #107 there was an excessive accumulation of items which pose an unreasonable threat to the health and safety of the residents in the area. The items consist of, but not limited to, multiple cardboard boxes piled to the ceiling, paper(s), multiple food items that required refrigeration, personal care equipment stored on the floor beside the bed, decorative items, etc. There was only limited space for the resident on her bed due to the amount of personal care items, paper(s), linens, and food items. Interviews with the facility staff confirmed the items belong to resident #1. The accumulation of furnishings and decorative items in a health facility in this manner has the potential to promote health hazards, and harm to occupants of the facility.

Based on medical record review and staff interviews, it was determined that the facility nursing staff failed to provide adequate supervision and assistance resulting in the fracture of a resident's right proximal humerus. The facility also failed to maintain an accident free environment. The findings include: 1)Resident #48 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to medical record, the resident is not safe to transfer from sit/stand without assistance due to visual deficit in addition to other diagnoses. The resident is completely dependent on the staff for all activities of daily living (ADLs). Medical record review revealed that the resident is a fall risk of 16. (A fall risk assessment is a tool used to calculate a residents risk for falls). According to the facility, a score above 15 places a resident in the ' high ' fall risk category. Surveyor review of the facility investigation on 1/19/12, revealed that, on 12/9/11 at 8:45 AM, the assigned Geriatric Nursing Aide (GNA) left the resident seated on the toilet and proceeded to change the resident's bedding. According to medical record and staff interview on 1/19/12, it was revealed that the resident was left alone in the bathroom. Facility investigation documentation revealed GNA reported hearing a loud noise and reentered the bathroom to find that the resident fell into the bathroom wall resulting in a left eye laceration with bleeding, and right shoulder swelling, with the final [DIAGNOSES REDACTED]. Further review of the medical record revealed a Care Plan for ADL dependence related to blindness and dementia as evidenced by unable to complete tasks without assistance. The Care Plan, last revised on 10/11/11 states, the resident is assisted by staff for ADLs daily. Extended review of medical record revealed resident had eighteen falls since July 29 2011. Further review of the resident's medical record revealed [REDACTED].S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) completed on 10/01/2011, scored the resident a (3) for self performance, for moving on and off the toilet, meaning that extensive assistance is required, resident involved in activity, staff provided weight bearing support and (2) for support defined as one person physical assist with the activity. Further review of resident's medical record revealed progress notes from Rehab and Nursing which indicate that the resident has a history of attempting to get up from seated positions without facility staff present and would benefit from close supervision. The medical record further revealed that the resident required 1:1 assistance for all ADLs, (one person extensive assist). Resident Care Plan also includes; resident to be on a bed alarm and chair alarm. Interview with the Director of Nursing (DON) on 1/20/12 revealed that there are no toilet alarms in bathrooms. Interview with the MDS coordinator, Administrator and DON on 1/20/2012 at 12:00 PM revealed that " The GNA used poor judgment to leave the resident on the toilet:. Interview with the second floor nurse manager on 1/20/2012 at 11:00 AM revealed that " it was routinely known by staff to stay with the resident". 2) Based on surveyor and facility staff observation and interview with facility staff, it was determined the facility failed to maintain an accident free environment. The findings include: During the medication administration pass observation on 1/18/12 on Unit 1A, the Certified Medication Aide (CMA) and Licensed Practical Nurse (LPN #1) left the medication cart unlocked and unattended while they administered the medications. Both acknowledged this when they returned to the cart. On 1/20/2012 at 10:06 AM and 10:30 AM on Unit 1A, LPN #2 was observed leaving two medication carts unlocked and unattended. One was located outside room 103 and the other outside room 107. This was observed by the surveyor and Registered Nurse (RN #1) who approached the LPN and instructed him to lock the carts.